Nutrition sarcopenia and frailty a complex relationship in economics

While there is consensus on the definition of frailty, there is no agreement on . Many recognize frailty, yet it is difficult to quantify and diagnose, contributing to . Although frailty is distinguished from malnutrition and sarcopenia, the .. The relationship between nutrition and frailty: Effects of protein intake. Nutrition, sarcopenia and frailty: a complex relationship. Juergen M. Criteria for the phenotypic definition of frailty developed by Fried et al (). The general. Clinical and pathophysiological relationships in sarcopenia and frailty. described with multiple causes, inter-relationships and complex pathways proposed. The most striking difference with the Fried definition of frailty was that any variable . synthetic response to both feeding and exercise, termed anabolic resistance.

Both are consistently associated with increased risk of incident disability, falls, hospitalization and mortality. These syndromes have only recently been applied to groups with chronic respiratory disease. However, early findings have sparked interest in the field, particularly those relating to frailty that appears highly prevalent, 16 a strong predictor of poor outcome, 21 and provides important information for care planning, for example, in relation to lung transplant listing.

We provide an overview of the common approaches and assessment of these syndromes from gerontology, summarize studies examining sarcopenia and frailty in people with chronic respiratory disease and explore the relationships between these syndromes and markers of skeletal muscle weakness.

Finally, we propose potential areas for future research.

Relationship between tongue strength, lip strength, and nutrition related sarcopenia

Reference and citation lists of all identified articles were hand-searched, and authors in the topic area were contacted to identify additional studies. We limited the review to studies defining sarcopenia as a syndrome, in line with an international consensus definition, and excluded studies where sarcopenia was defined on the basis of low muscularity or low fat-free mass alone see the study by Schols et al. A geriatric syndrome is a term used to describe common conditions, occurring as a result of impairments across multiple physiological systems, which ultimately lead to vulnerability, poor reserve and significant morbidity and mortality.

It is without a doubt a common and complex medical condition, with multiple causative factors, and the potential for huge personal and financial cost. Estimates also suggest that at least 1 million Hoover et al. The variation in prevalence may be due to inconsistencies in measuring frailty and the population being measured. Using the cumulative deficit model, Song et al. Based on this comparison, it is worth contrasting the 2 methods of diagnosis in generalizable samples to determine the potential for overestimation with different criteria.

Differences in prevalence are also noted by medical condition and location within the healthcare sector where diagnosis is made. With the presence of a chronic disease, rates of frailty also increase significantly.

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Although frailty is not unique to older adults, frailty rates increase with age Collard et al. Statistics Canada predicts that bynearly 1 in 4 Canadians will be over age 65 years, thus leading to increases in frailty prevalence StatsCan With a large proportion of the population at risk, screening and assessing frailty in a reliable manner is important Muscedere et al.

Early identification and treatment of frailty and pre-frailty is important for attenuating the progression of complications or preventing the exacerbation of conditions Fried et al. Interventions for preventing or minimizing the effects of frailty in older adults include physical activity, nutrition, and lifestyle changes Artaza-Artabe et al. Several definitions of malnutrition and their common concepts are outlined in Fig.

A sample of definitions of malnutrition and their overlapping characteristics. Sarcopenia and frailty were also considered in this terminology Cederholm et al.

Sarcopenia is the gradual and general loss of skeletal muscle mass and performance, accompanied by risk of adverse outcomes Cruz-Jentoft et al.

An additional concern is with older adults who are obese but also meet criteria for sarcopenia, a condition defined as sacropenic obesity Baumgartner In the ESPEN statement, frailty is discussed as a state of susceptibility with limited physiological reserve capacity Cederholm et al. As with pre-frailty, mal nutrition risk, which is rarely defined, is a commonly used term Bales Nutrition risk is listed as a step in the nutrition care process, followed by diagnosis ESPEN terminologywhich suggests that the malnourished are a subset of those nutritionally at risk.

Others have suggested it is the presence of risk factors known to lead to impaired nutritional status if left unchecked Council on Practice ; Keller ; Rijk et al. Similar to frailty and pre-frailty is the view that nutrition risk is not as detrimental as malnutrition and earlier identification results in easier or more successful treatment Brotherton et al.

A variety of valid and reliable screening tools are available, often specific to a healthcare setting or population. Prevalence of malnutrition and nutrition risk As nutrition risk is conceptualized to precede malnutrition Keller it should be more common.

However, prevalence of risk is elusive not only due to the different tools and populations assessed, but also as tools designed for screening are sometimes referred to as assessment tools Bales Malnutrition diagnosis in the community is believed to be relatively uncommon, although focus has been placed predominately on the older adult population or specific disease states e. Health implications of malnutrition Being malnourished while in hospital has been shown to independently increase mortality, length of hospital stay LOSrates of infection, impair wound healing, and increase risk of readmission, all of which affect patient flow and ultimately healthcare costs Allard et al.

Canadian research also demonstrates that most patients remain in the nutritional state in which they were admitted or decline further while in hospital; a similar pattern is observed 30 days after discharge, leading to readmission Allard et al. In the community, nutrition risk may lead to increased number of visits to the General Practitioner BAPEN Malnutrition Advisory Groupmore hospital visits, and increased risk of falling, among other complications Visvanathan et al.

Frailty and malnutrition concept and prevalence overlap Correspondence in the constructs of frailty and malnutrition, particularly the phenotype concept of frailty, is evident. Shrinkage or weight loss, exhaustion, weakness, and slowness are all symptoms consistent with malnutrition and also represent 4 of the 5 Fried criteria Fried et al. Jeejeebhoy highlighted this overlap in his review of the consistencies and differences among malnutrition, sarcopenia, cachexia, and frailty.

This review highlighted that the loss of body tissues contribute to a phenotype common to each of these syndromes, although etiology of this loss of tissue varies with the condition Jeejeebhoy Those who have loss of body tissue because of inadequate food intake or increased requirement are malnourished and thus tissue accretion will result with refeeding.

In clinical practice the reality is that for many older adults these conditions overlap in their occurrence and causes, and treatment should be multifactorial. As malnutrition and frailty share risk factors, it is anticipated that many individuals will present with both frailty and malnutrition. In the community, nutritional risk in older adults increases the risk of frailty and associated consequences, including risk of hospitalization and loss of independence Bollwein et al.

Most studies have focused on community-dwelling older adults, and there is a need to understand the overlapping prevalence within populations such as hospitalized patients, younger adults vulnerable to frailty, and those with high risk of chronic disease.

More focus should be placed on understanding and reversing the effects of pre-frailty, as this is the population that may receive the most benefit from intervention. Frailty and pre-frailty should also be examined across all populations and healthcare settings. Consistent terminology and assessment tools are required to gain a clear picture of the overlap in prevalence of malnutrition and frailty with direction for potential interventions. The 2 main models for conceptualizing frailty phenotype and cumulative deficit form the basis for many screening and assessment tools created to date Clegg et al.

Many of these tools use inconsistent terminology, yet there is overlap in characteristics such as weight loss, weakness, etc. For the cumulative deficit model, primary and ambulatory care can use existing electronic medical record data to identify key risk factors while long-term care can use the interRAI Minimum Data Set Muscedere et al.

Key frailty and malnutrition assessment tools and their overlapping characteristics. Contrary to nutrition tools, there is a minimal distinction between frailty screening identification of potential risk and assessment diagnosis of condition tools.

The feasibility of the tool within the target setting should always be considered. A recent review offers a broad understanding of frailty tools in various healthcare settings and highlights that the setting often determines the tool that is utilized Muscedere et al. Screening for pre-frailty should be incorporated into various clinical environments. Nutrition assessment and screening tools Different definitions of malnutrition have led to various diagnostic frameworks.

ESPEN has also released very minimal malnutrition diagnostic criteria out of the desire to have simple, objective measures that can be used in a variety of contexts and clinical populations Cederholm et al. Since this set of diagnostic criteria was released, there has been criticism Bahat et al.

Further, these diagnostic criteria are focused on the phenotype and do not include inadequate food intake, which is the root cause of malnutrition. These tools provide a more comprehensive view of malnutrition including food intake; risk factors for food intake; function; and body mass or composition. In addition to these diagnostic methods, a variety of nutrition screening tools exist.

These tools are designed so non-nutrition professionals, such as admission nurses, can quickly and sufficiently identify if a patient is at mal nutrition risk. All screening tools result in false positives and negatives, and diagnostic methods are required to confirm malnutrition.

Sarcopenia and frailty in chronic respiratory disease

In a review of published studies, Annweiler and colleagues [ 21 ] discuss the reasons for the divergence in study findings, some of which may be due to methodological differences, including a lack of consideration of confounding influences in some studies. Further evidence is needed, particularly as vitamin D insufficiency is common among older adults [ 24 ]. Antioxidant Nutrients There is increasing interest in the role of oxidative stress in aetiology of sarcopenia, and markers of oxidative damage have been shown to predict impairments in physical function in older adults [ 25 ].

Damage to biomolecules such as DNA, lipid, and proteins may occur when reactive oxygen species ROS are present in cells in excess. The actions of ROS are normally counterbalanced by antioxidant defence mechanisms that include the enzymes superoxide dismutase and glutathione peroxidase, as well exogenous antioxidants derived from the diet, such as selenium, carotenoids, tocopherols, flavonoids, and other plant polyphenols [ 1525 ].

In older age, an accumulation of ROS may lead to oxidative damage and contribute to losses of muscle mass and strength [ 15 ].

A number of observational studies have shown positive associations between higher antioxidant status and measures of physical function [ 10 ]. Importantly these associations are seen both in cross-sectional analyses and in longitudinal studies, such that poor status is predictive of decline in function.

The observed effects are striking. For example, among older men and women in the InCHIANTI study, higher plasma carotenoid concentrations were associated with a lower risk of developing a severe walking disability over a follow-up period of 6 years; after taking account of confounders that included level of physical activity and other morbidity, the odds ratio was 0.

Inverse associations have also been described for vitamin E and selenium status and risk of impaired physical function [ 10 ]. There have been few studies of older adults to determine how antioxidant supplementation affects muscle strength, and the benefits of supplementation remain uncertain [ 27 ]. 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 [ 28 ].

However, low antioxidant intakes and status are common [ 629 ], and this remains an important question to be addressed. Since eicosanoids derived from carbon polyunsaturated fatty acids are among the mediators and regulators of inflammation [ 13 ], 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.

There is some observational evidence to support an effect of n-3 LCPUFA status on muscle function, as higher grip strength was found in older men and women who had greater consumption of oily fish [ 31 ]—one of the richest sources of n-3 LCPUFAs in the UK diet.

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 [ 13 ]. In a recent randomised controlled trial, supplementation of older adults with n-3 LCPUFA eicosapentaenoic and docosahexaenoic acids resulted in an enhanced anabolic response to amino acid and insulin infusion.

Whilst these novel data suggest that the stimulation of muscle protein synthesis by n-3 LCPUFA supplementation could be useful for the prevention and treatment of sarcopenia [ 32 ], further evidence is needed to establish the therapeutic potential of n-3 LCPUFAs in inflammatory conditions [ 13 ].

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.

Nutrition and Sarcopenia: A Review of the Evidence and Implications for Preventive Strategies

It also means that from observational data it may be difficult to understand the relative importance of the influences of different nutrients on sarcopenia. In turn, since diets are patterned, high fruit and vegetable consumption may be indicators of other dietary differences which could be important for muscle function, such as greater consumption of oily fish and higher intakes of vitamin D and n-3 LCPUFAs [ 33 ].

The cumulative effects of nutrient deficiencies have been described by Semba et al. This emphasises the importance of the quality of diets of older adults, as well as the quantity of food consumed, to ensure that intakes of a range of nutrients are sufficient. Compared with the evidence that links variations in nutrient intake and status to physical function, much less is known about the influence of dietary patterns and dietary quality in older age.

Data from studies of younger adults appear to be consistent with this finding.