1. Jacqueline Jacques, ND, FTOS

2. What is Lean Body Mass  Muscle  Bone

3. When we lose lean mass we lose health  Medical term is sarcopenia  A syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death  Sarcopenia is a powerful predictor of late-life disability Report of the European Working Group on Sarcopenia in Older People

4. What is Sarcopenia  Between 20 - 80 years of age, there is approximately a 30% reduction in muscle mass  Sarcopenia very likely begins in early adulthood with atrophy and loss of type II muscle fibers  There is a decline in both muscle fiber size and number  There can also be increasing fat mass

5. What is Sarcopenia  Recent estimates indicate that approximately 4 5% of the older U.S. population is affected by s arcopenia. That equated to 18 million people in 2010 The Healthcare Costs of Sarcopenia in the United States. Journ al of the American Geriatric Society 52:80–85, 2004.)  The risk of disability is 1.5 to 4.6 x higher with sarcopenia than in persons with normal muscle  Costs around $26 Billion per year to the US health care system (and rising)

6. Sarcopenic Obesity  Sacropenic Obesity is a subset of Sarcopenia State in which fat mass is preserved or increased relative to a loss of lean mass.  There is proportionally an increase in fat mass as compared to lean mass. These subjects can also be considered ‘fat frail’ who suffer from increased weakness from sarcopenia and the requirement to carry additional weight from obesity

7. Sarcopenic Obesity  One worsens the other: Muscle and fat are both metabolically active, the latter producing TNF-a, IL-6 and adipokines all of which have a direct catabolic effect on the former, and promote insulin resistance. Creates a vicious cycle…v

9. Causes

10.  Major factors considered to be involved include genetic heritability nutritional status (protein intake, energy intake, and vitamin D status) physical activity hormonal changes (declines in serum testosterone and growth hormone) insulin resistance, atheroscelorosis and changes in circulating pro-inflammatory cytokines

11. Causes: Weight Loss… MethodNumber of Study groups Mean of study groups 25% or greater loss of FFM < 25% FFM loss LCD1517%213 LCD & EX619%15 LCD & Drugs328%12 VLCD429%31 VLCD & Ex516%14 BPD1530%96 RYGB430%31 LAGB1517%213 Chaston TB, & Dixon JB. Int J Obes (Lond). 2007;31:743-50. Percentage of FFM loss with various methods of weight loss

12. Casues: Vicious Cycle

14. Consequences

15. Metabolic Risks of Sarcopenia  A loss in muscle mass is related to metabolic problems such as insulin resistance, type 2 d iabetes and obesity (including lean obesity)  The combination of more body fat and lower muscle leads to increased insulin resistance This is a set up for poor cardiometabolic health

18. Am J Clin Nutr 2005;81:953–63.

20. Exercise  Resistance training is the most effective exercise for slowing the rate of loss of muscle mass and maintaining or improving muscle strength.

21. Exercise  Resistance Training: Reduces falls Improves muscle strength Improves ability too complete ADLs Has been studied to improve QOL  It is also preventive  Overall total activity is also very important but harder to measure

22. Exercise  AHA Guidelines are often used in sarcopenia: All sedentary adults should participate in resistance training activities 2 to 3 days per week. Individuals who are younger than 50 years should perform 1 set of 8 to 12 repetitions of 8 to 10 different exercises. Individuals who are 50 to 60 years old or who have CVD should perform 1 set of 10 to 15 repetitions of 8 to 10 different exercises at a lighter weight.

23. Protein  Recommended Dietary Allowance (RDA) for healthy adults (0.8 g/kg/day). Though many over age 50 do not achieve this  There needs to be a post-prandial rise in blood AAs to stimulate protein synthesis Low intake hampers this As we age, more AAs are taken up by the liver and never get into circulation

24. Protein  Current recs may be too low to stimulate muscle synthesis in older adults  Studies have indicated that levels of 30g/meal can produced protein synthesis similar to younger people -Paddon-Jones D, Sheffield-Moore M, Zhang XJ, et al. Amino acid ingestion improves muscle protein synthesis in the young and elderly. Am J Physiol Endocrinol Metab. 2004;286:E321-E328.  An expert panel recommended a total protein intake of 1 to 1.5 g/kg/day with equal amounts of protein consumed at breakfast, lunch, and dinner -J.E. Morley et al., JAMDA, 2010. 11: p. 391-396

25. Protein after bariatric surgery  Protein intake should be individualized, assessed, and guided by an RD, in reference to gender, age, and weight  A minimal protein intake of 60 g/d and up to 1.5 g/kg (0.7g/pound) per day should be adequate;  Higher amounts of protein—up to 2.1 g/kg (1 gram/pound) per day—need to be assessed on an individualized basis From the 2013 TOS Guidelines

26. Protein after bariatric surgery  “Recommendations for protein intake are variable but studies suggest higher protein levels (80–90 g/d) are associated with reduced loss of lean body mass.  Protein intake is generally reduced following surgery and adequate intake can be facilitated through the use of protein supplements” From the 2013 TOS Guidelines

27. Branched Chain Amino Acids (BCAAs)  The amino acids valine, leucine and isoleucine  Nearly 25% of all whey protein is made up of BCAAs - one reason why a lot of people recommend whey  They help both to decrease muscle loss and promote muscle synthesis  Good to supplement both with increased weight loss and with exercise

28. Leucine  One of the 3 branched chain amino acids  As we already discussed, branched-chain amino acids regulate muscle protein synthesis and help prevent loss  Leucine is the principal branched-chain amino acid responsible for the anabolic effect on muscle protein synthesis.

29. Leucine  Studied range is 3 to 12 grams/day  May be more effective for protein synthesis if co-administered with whey Combination seems to give higher/faster rises in serum amino acids

30. HMB  Beta-hydroxy-beta-methylbutyrate (HMB) is the active metabolite of leucine.  May be more effective (than leucine) in untrained individuals  Levels of 3g/day together with mild resistance training significantly increased LMB in elderly men in 8 weeks. Also resulted in fat loss. -Vukovich MD, et al. Body composition in 70-year-old adults responds to dietary beta-hydroxy-beta- methylbutyrate similarly to that of young adults. J Nutr. 2001;131:2049–2052

31. Vitamin D  Vitamin D deficiency appears to be an independent risk for sarcopenia; Muscle loss/weakenss Bone loss Increased risk for falls and hip fracture  Fall prevention has been observed at levels starting at 700iu/day

32. Vitamin D  In studies, anti-fall efficacy started with achieved 25-OH D levels of at least 60 nmol/L (24 ng/ml)  Anti-fracture efficacy started with achieved 25-OH D levels of at least 75 nmol/L (30 ng/ml)  Higher levels may give a better result -H.A. Bischoff-Ferrari, Best Pract Res Clin Rheumatol, 2009. 23(6): p. 789-795

33. Other Tx  Nutrition: Creatine – related to amino acids. 95% of creatine is stored in muscle ○ May improve muscle strength and energy – allowing people to do more exercise and thus promote more lean mass ○ Typical doses are around 5 grams. Be cautions if you have kidney disease ot take medication for diabetes EPA – from fish oil. Can help prevent muscle break down

34. Other Tx  Drug: Testosterone Estrogens DHEA Growth hormones Angiotensin-converting enzyme inhibitors

36. Conclusions  Whenever you lose weight, you will lose lean mass  It is important to work hard to preserve lean mass as it will continue to decline with age  Maintaining health lean mass is important not just for strength, both for overall lifelong health