assessment della malnutrizione e bilancio ......protein and energy supplementation in elderly people...
TRANSCRIPT
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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: [email protected]
Congresso Nazionale Società Italiana di Gerontologia e Geriatria
Milano, 21-24 Novembre 2012
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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
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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
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INACTIVITY ± INFLAMMATION ± ANOREXIA
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-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)
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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
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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)
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INACTIVITY ± INFLAMMATION - ANOREXIA
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• 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)
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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
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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
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2115
cancer patients
15%
obesity
15%
sarcopenic obesity
SURVIVAL
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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
* §
* §
*
*
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§
-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
*
*
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CROSS-TALK BETWEEN FAT
AND MUSCLE DURING
INACTIVITY AND AGING
POSITIVE
ENERGY
BALANCE
INFLAMMATION
REDOX UNBALANCE
MUSCLE
ATROPHY
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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
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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
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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
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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
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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
≈
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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.
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ANABOLIC RESISTANCE OF AGEING
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INCREASED PROTEIN REQUIREMENT
• INACTIVITY
• AGEING
• ACUTE AND CHRONIC DISEASE STATES WITH ACTIVATION OF SYSTEMIC INFLAMMATION
ANABOLIC RESISTANCE
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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.
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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
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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
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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
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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
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-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
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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).
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• INACTIVITY
• SYSTEMIC
INFLAMMATION
ANABOLIC
RESISTANCE
MUSCLE
ATROPHY
INCREASED
FAT MASS
METABOLIC VICIOUS CYCLE IN AGEING AND CHRONIC DISEASES
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EXERCISE +
ENERGY BALANCE
• INACTIVITY
• SYSTEMIC
INFLAMMATION
ANABOLIC
RESISTANCE
MUSCLE
ATROPHY
INCREASED
FAT MASS
PROTEIN
INTAKE