ASUHAN GIZI SARKOPENIA PADA LANSIA Anugrah Novianti SGz

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ASUHAN GIZI SARKOPENIA PADA LANSIA Anugrah Novianti, SGz, M. Gizi PROGRAM STUDI ILMU GIZI

ASUHAN GIZI SARKOPENIA PADA LANSIA Anugrah Novianti, SGz, M. Gizi PROGRAM STUDI ILMU GIZI FAKULTAS ILMU-ILMU KESEHATAN

Sarcopenia • Sarcopenia is the loss of muscle mass and strength that occurs as

Sarcopenia • Sarcopenia is the loss of muscle mass and strength that occurs as people age. It is difficult to know exactly how many older people experience sarcopenia, since different clinicians define it differently. • This gradual loss of muscle is perceived by most of us as "normal. "

Cont. . . • The implication is that there must be factors that influence

Cont. . . • The implication is that there must be factors that influence the varying degrees with which different individuals experience sarcopenia. Some of these factors may be beyond our control—“good genes, ” for example—but others may have to do with diet and lifestyle, factors that are in our control (at least more so than our genetic material).

Cont. . . Regrettably, poor diet is one of the most common problems practitioners

Cont. . . Regrettably, poor diet is one of the most common problems practitioners encounter when treating older adults. Many individuals in this population have low nutrient intakes, for a variety of reasons that range from physical deficits to economic hardship.

Cont. . . Dental problems in the elderly make them more likely to choose

Cont. . . Dental problems in the elderly make them more likely to choose softer foods that often lack protein; delayed gastric emptying can reduce appetite; hormonal changes may cause longer-lasting feelings of satiety. On top of that, meat is more expensive than foods rich in starch, and for this reason individuals who are living on a fixed income may tend to fill up on cheap, processed carbohydrates. Lack of physical strength may also make packaged, processed foods more appealing.

HOW NUTRITION AND OTHER FACTORS RELATE TO SARCOPENIA

HOW NUTRITION AND OTHER FACTORS RELATE TO SARCOPENIA

Nutrition And Ageing In comparison with younger ages, older adults eat more Low food

Nutrition And Ageing In comparison with younger ages, older adults eat more Low food intakes and monotonous slowly, diets putthey older are people lessat risk of having inadequate nutrient intakes hungry and thirsty, consume smaller meals, and they snack less. Food intake falls by around 25% between 40 and 70 years of age.

Novel Insights on Nutrient Management of Sarcopenia in Elderly • Van Kan (2009) has

Novel Insights on Nutrient Management of Sarcopenia in Elderly • Van Kan (2009) has investigated the prevalence of sarcopenia in the population aged 60– 70 years: in this age group, the prevalence ranged from 5 to 13% but increased to 11– 50% in subjects aged >80 years. Sarcopenia becomes responsible not only for the reduction of mobility and the level of autonomy of the elderly, but also for their ability to maintain good health.

PROTEIN Protein is considered a key nutrient in older age Recommended protein intakes may,

PROTEIN Protein is considered a key nutrient in older age Recommended protein intakes may, therefore, need to be raised in older people in order to maintain nitrogen balance and to protect them from sarcopenic muscle loss However, whilst amino acid supplementation has been shown to increase lean mass and improve physical function

RECOMMENDED AMOUNT OF PROTEIN INTAKE FOR HEALTHY ELDERLY • Older people should have an

RECOMMENDED AMOUNT OF PROTEIN INTAKE FOR HEALTHY ELDERLY • Older people should have an average intake of protein of 1. 2/g/kg/day of body weight/day.

RECOMMENDATIONS IN PROTEIN INTAKE IN THE COURSE OF ACUTE AND CHRONIC PATHOLOGY • The

RECOMMENDATIONS IN PROTEIN INTAKE IN THE COURSE OF ACUTE AND CHRONIC PATHOLOGY • The majority of elderly patients who present an acute or chronic disease have an increased need for protein intake (1. 2 to 1. 5 g/kg body weight/day), while patients with critical illnesses or severe malnutrition have a need of protein equal to 2 g/kg body weight/day.

VITAMIN D • An association between vitamin-Ddeficient osteomalacia and myopathy has been recognised for

VITAMIN D • An association between vitamin-Ddeficient osteomalacia and myopathy has been recognised for many years, but the role of vitamin D, and the extent to which it has direct effects on normal muscle strength and physical function remains controversial. • At the genomic level, binding of the biologically active form of the vitamin (1, 25 -dihydroxyvitamin D) results in enhanced transcription of a range of proteins, including those involved in calcium metabolism. • Much of the epidemiological literature is consistent with the possibility that there are direct effects of vitamin D on muscle strength. • However, the evidence is not always consistent as some observational studies find no association between vitamin D status and physical function, and supplementation studies have not always resulted in measurable improvements in function

Vitamin D • Vitamin D deficiency is common among geriatric patients (2– 60%). Vitamin

Vitamin D • Vitamin D deficiency is common among geriatric patients (2– 60%). Vitamin D is hydroxylated in the liver to 25 (OH) D. • However the activity of hydroxylation by the kidney may decrease with age, in parallel with the decline in renal function. Consequences are the following: a low level of vitamin D, renal failure, and a low intake of calcium may result in mild secondary hyperparathyroidism. Increased levels of parathyroid hormone (PTH) cause an increase in bone turnover that is associated with bone loss, predominantly cortical; secondary hyperparathyroidism has been proposed as the main mechanism through which vitamin D deficiency contributes to the pathogenesis of hip fracture.

Cont… • Many studies have shown that low levels of 1, 25 -(OH) D

Cont… • Many studies have shown that low levels of 1, 25 -(OH) D and 25(OH) D are associated with lower muscle strength, increased body instability, falls, and disability in older subjects. • In addition, studies on vitamin D supplementation in elderly subjects with vitamin D deficiency showed an improvement in physical function and isometric knee extension versus placebo. • Suggests that vitamin D supplementation (800– 1000 IU) daily was associated with improvements of muscle strength and balance. In conclusion, in vitamin D deficient sarcopenic subjects, dietary vitamin D supplementation (800– 1000 IU daily) could be promising and interesting for treatment of sarcopenia.

ANTIOXIDANT NUTRIENTS • Damage to biomolecules such as DNA, lipid, and proteins may occur

ANTIOXIDANT NUTRIENTS • Damage to biomolecules such as DNA, lipid, and proteins may occur when reactive oxygen species (ROS) are present in cells in excess. • In older age, an accumulation of ROS may lead to oxidative damage and contribute to losses of muscle mass and strength. • There have been few studies of older adults to determine how antioxidant supplementation affects muscle strength, and the benefits of supplementation remain uncertain. Since ROS have both physiological and pathological roles, interventions based on simple suppression of their activities may be unlikely to improve age-related declines in muscle mass and function

Antioxidant • Oxidative stress has been implicated as a central mechanism in the pathogenesis

Antioxidant • Oxidative stress has been implicated as a central mechanism in the pathogenesis of sarcopenia. • Several studies have shown the positive effects of vitamin E in reversing muscle damage during extensive muscle contraction (exercise) in healthy men. Vitamin E supplementation at a dose of 800 IU for 28 days resulted in lowering the expression of oxidative stress markers after a downhill run in both young and older men. • Indicating that vitamin E promotes adaptation against exercise induced-oxidative stress and reduced muscle damage

LONG-CHAIN POLYUNSATURATED FATTY ACIDS (LCPUFAS) • Sarcopenia is increasingly recognised as an inflammatory state

LONG-CHAIN POLYUNSATURATED FATTY ACIDS (LCPUFAS) • Sarcopenia is increasingly recognised as an inflammatory state driven by cytokines and oxidative stress; ol. Since eicosanoids derived from 20 -carbon polyunsaturated fatty acids are among the mediators and regulators of inflammation, this raises the possibility that variations in intake of n-3 and n-6 LCPUFAs, and their balance in the diet, could be of importance. • Consistent with this finding, a number of studies of patients with rheumatoid arthritis have shown that supplementation with fish oil resulted in improved grip strength.

LONG-CHAIN OMEGA-3 FATTY ACIDS • The ability of the skeletal musculature to use amino

LONG-CHAIN OMEGA-3 FATTY ACIDS • The ability of the skeletal musculature to use amino acids to build or renew constitutive proteins is gradually lost with age and this is partly due to a decline in skeletal muscle insulin sensitivity.

FOODS AND DIETARY PATTERNS • One problem with the existing evidence base is that

FOODS AND DIETARY PATTERNS • One problem with the existing evidence base is that dietary components are often highly correlated with each other. This may help to explain why the effects of supplementation with single nutrients may be less than that predicted by the observational evidence. It also means that from observational data it may be difficult to understand the relative importance of the influences of different nutrients on sarcopenia. • “Healthy” diets, characterised by greater fruit and vegetable consumption, wholemeal cereals, and oily fish, have been shown to be associated with greater muscle strength in older adults • Intervention studies that take a food-based or “whole diet” approach are likely to change intakes of a range of nutrients and, therefore, have the potential to be more effective than single nutrient supplementation studies in preventing age-related losses in muscle mass and strength.

DIET AND EXERCISE Resistance exercise training interventions have been shown to be effective in

DIET AND EXERCISE Resistance exercise training interventions have been shown to be effective in increasing muscle strength and improving physical function in older adults. A further issue in understanding a possible protective role for diet in sarcopenia is, therefore, the potential for interactions between diet and exercise, and the extent to which interventions that combine supplementation and exercise training may be more effective than changing nutrient intake alone. The interactive effects of diet and exercise on physical function have been studied most extensively in relation to protein/amino acid supplementation.

LIFELONG NUTRITION AND SARCOPENIA Firstly, the health of older people is influenced by events

LIFELONG NUTRITION AND SARCOPENIA Firstly, the health of older people is influenced by events throughout their lives, and achievement of optimal function may, therefore, depend on lifelong exposure to a healthy diet and lifestyle. A second consideration is that muscle mass and strength achieved in later life are not only determined by the rate of muscle loss, but also reflect the peak attained in early life (figure 1). Thus, factors that influence growth, such as variations in early nutrition, may contribute to muscle mass and strength in older age.

Cont. . . A key finding, that highlights the importance of lifecourse influences, is

Cont. . . A key finding, that highlights the importance of lifecourse influences, is that low weight at birth predicts lower muscle mass and strength in adult life.

Cont. . . Existing evidence indicates the potential importance of diets of adequate quantity

Cont. . . Existing evidence indicates the potential importance of diets of adequate quantity and quality, to ensure sufficient intakes of protein, vitamin D, and antioxidant nutrients. However, muscle mass and strength achieved in later life are not only determined by the rate of muscle loss, but also reflect the peak attained earlier in life, and efforts to prevent sarcopenia also need to recognise the potential effectiveness of interventions earlier in the lifecourse. Optimising diet and nutrition throughout life may be key to preventing sarcopenia and promoting physical capability in older age.

 • The balance between muscle protein anabolism and catabolism is vitally important to

• The balance between muscle protein anabolism and catabolism is vitally important to maintaining skeletal muscle mass, particularly in older adults who lose muscle mass as a consequence of aging and/or illness • Sarcopenia is further classified into either primary or secondary categories. Primary sarcopenia, when no specific etiologic cause can be identified, is progressive and associated with the impact of aging.

Next to the intrinsic, age-related processes, a multitude of extrinsic and behavioral factors can

Next to the intrinsic, age-related processes, a multitude of extrinsic and behavioral factors can aggravate the development and/or progression of sarcopenia, leading to secondary sarcopenia, such as disuse and lack of physical activity, malnutrition, chronic inflammation, and comorbidity.

MALNUTRITION AND SARCOPENIA ARE PREVALENT AMONG OLDER ADULTS Many older adults are malnourished or

MALNUTRITION AND SARCOPENIA ARE PREVALENT AMONG OLDER ADULTS Many older adults are malnourished or at high risk for malnutrition due to many factors. Decreased appetite and food intake, poor dentition, an increased frequency and severity of acute and chronic medical conditions, multiple medications, social and economic challenges, and cognitive decline all play a role in the etiology of malnutrition among older adults.

 • Age-associated loss of muscle mass is characterized by a 3– 8% decline

• Age-associated loss of muscle mass is characterized by a 3– 8% decline per decade after the age of 30 years with further decline in adults 60 years of age and older. • With aging, the loss of muscle mass is accompanied by an increase in body fat. On average, adults can experience annual losses of 0. 23 kg of muscle and gains of 0. 45 kg of fat between 30 and 60 years of age. Acute illness and injury can accelerate age-related changes in body composition

MALNUTRITION SARCOPENIA SYNDROME AND CLINICAL OUTCOMES • In many patient populations, malnutrition and sarcopenia

MALNUTRITION SARCOPENIA SYNDROME AND CLINICAL OUTCOMES • In many patient populations, malnutrition and sarcopenia are present in parallel. • This leads us to coin the proposed clinical syndrome of Malnutrition-Sarcopenia Syndrome (MSS). • Patients with malnutrition and/or sarcopenia are at risk of increased morbidity and mortality, decreased quality of life and functioning and increased rehospitalization, length of hospital stay, and healthcare costs. Importantly, malnutrition and sarcopenia are associated with increased mortality

Thank You

Thank You