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1 The Prevalence and Diagnosis of Sarcopenia in Taiwan Who is the candidate of sarcopenia? Wen-Yuan Lin, MD,MS, PhD China Medical University China Medical University Hospital What is Sarcopenia( 肌少症 ) 肌少症 : 指因老化而導致的肌肉質量力量與功能流失 Involuntary loss of skeletal muscle mass that occurs with advancing age in 1997 Atrophy and loss of individual muscle cells linked to diminished synthesis of muscle proteins and function of mitochondria in 2003 Significant Changes of Body Composition with aging J Nutr 1997; 127: 990S-1S; Mech Ageing Dev 2003; 124: 歲後肌肉質量逐年下降年過 40 歲後, 會以每 10 年減少 8% 速度降低年過 70 歲後, 會以每 10 年 15% 加速流失. 維持肌肉質量 / 瘦肉組織的重要性瘦肉組織 (Lean Body Mass,LBM) LBM 佔人體約 75% 的重量 ( 肌肉佔 LBM 的大部分 ) 肌肉 Lean Body Mass 器官瘦肉組織 ( 即扣除脂肪及水分 ) 骨骼 LBM 下降造成免疫力降低, 並增加併發症發生率 1. Grimby G, Saltin B. Clin Physiol. 1983;3: Janssen I. J Appl Physiol. 2000;89:81 3. Grimby GB et al. Acta Physiol Scand. 1982;115: Larsson L et al. J Appl Physiol. 1979;46: Flakoll P et al. Nutrition. 2004;20: Baier S et al. J Parenter Enteral Nutr. 2009;33: Demling. Eplasty. 2009; 9: e9. Epub 2009 Feb 3. 1

2 Use it or loseit 什麼是肌少症 (Sacropenia)? 肌少症 : 漸進性的肌肉質量減少, 及肌肉功能 ( 肌力及生理活動 ) 降低, 可能造成提高疾病發生率生活品質降低甚至死亡的併發症 (Syndrome). 肌少症是由歐盟肌少症工作小組 EWGSOP(European Working Group on Sarcopenia in Older People) 於 2010 年所提出的定義. 歐盟肌少症工作小組 (EWGSOP) 是由以下四個單位所組成 : 1. 歐洲老年醫學會 (EUGMS) 2. 歐洲腸道靜脈營養學會 (ESPEN) 3. 歐洲區國際老年病和老年醫學協會 (IAGG-ER) 4. 國際老化興營養學會 (IANA) Source: J Nutr Health Aging Aug-Sep 1. Sarcopenia: European consensus on definition and diagnosis; Report of the European Working Group on Sarcopenia in Older People Cruz-Jentoft A.J. et al. Age & Ageing 2010;1-12. 依據 EWGSOP2010 定義 Skeletal Muscle Loss( 骨骼肌流失 ) 肌肉蛋白的量由合成及分解的速度所共同決定, 當分解速度增加合成速度降低時, 便發生肌肉萎縮 (muscle wasting) Sarcopenia: 老年相關, 沒有特別病因 Cachexia: 慢性發炎導致肌肉質量加速流失的情形 Wasting: 指因飲食攝取不足所致的肌肉重量減少, 合併軟組織減少, 進展速度最快肌少症症狀常會伴隨在其他疾病中在營養不良營養不良肥胖型少肌症肥胖型少肌症惡病質惡病質衰弱等病患也常見到肌少症症狀肥胖型少肌症 : 脂肪組織入肌肉中, 如 : 活動量低但體重過重的老年人惡病質 : 伴隨其他重症疾病所造成嚴重體重下降, 如 : 癌症病人衰弱 : 因外傷或疾病造成體重下降, 同時併發其他器官功能性損傷的病患營養不良 : 蛋白質及熱量攝取不足體重過重但是肌肉質量低重度營養不良 1. Sarcopenia: European consensus on definition and diagnosis; Report of the European Working Group on Sarcopenia in Older People Cruz-Jentoft A.J. et al. Age & Ageing 2010;1-12. Different kinds of weight loss Weight loss Cachexia Anorexia Malab sorption Sarcopenia Hyper metabolism ± ± ± Lean tissue Fat tissue Appetite = Anemia Yes ± ± No No Proteolysis Yes No No Yes Yes CRP = = = = Vitamin A = = = = Albumin ± ± = = MORLEY JE et al Nutrition 2008; 24:

3 Mechanisms of sarcopenia. Mechanisms of Sarcopenia Cruz-Jentoft A J et al. Age Ageing 2010;39: The Author Published by Oxford University Press on behalf of the British Geriatrics Society. Clin Geriatr Med 27 (2011) Etiological sarcopenia mechanisms and their consequences Rev Andal Med Deporte. 2011;4(4): Age-related sarcopenia Nutrition-related sarcopenia Activity-related sarcopenia Disease-related sarcopenia SARCOPENIA categories by cause Primary sarcopenia No other cause evident except ageing Secondary sarcopenia Results from inadequate dietary intake of energy and/or protein, as with malabsorption, gastrointestinal disorders, or use of medications that cause anorexia Can result from bed rest, sedentary lifestyle, deconditioning, or zero-gravity conditions Associated with advanced organ failure (heart,lung,liver, kidney, brain), inflammation disease, malignancy or endocrine disease CRUZ-JENTOFT AJ et al.. Age Ageing 2010; 39: 造成老年人瘦肉組織減少的三大主因長期臥床或活動量低使蛋白質合成能力蛋白質合成能力下降 1. Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; Tortora GJ, Derrickson B. Principles of Anatomy and Physiology. 12th ed. Hoboken, NJ: John Wiley and Sons; Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; Kortebein P et al. JAMA. 2007;297:

4 長期臥床或活動量低使肌肉質量肌肉質量下降蛋白質攝取不足造成瘦肉組織減少 1. Wardlaw GM, Kessel M. Perspectives in Nutrition. 5th ed. New York, NY: McGraw-Hill; Tortora GJ, Derrickson B. Principles of Anatomy and Physiology. 12th ed. Hoboken, NJ: John Wiley and Sons; Grimby G, Saltin B. Clin Physiol. 1983;3: Kortebein P et al. JAMA. 2007;297: Paddon-Jones D et al. J Clin Endocrinol Metab. 2004;89: Paddon-Jones D. Presented at: 110th Abbott Nutrition Research Conference; June 23-25, 2009; Columbus, Ohio. 1. Demling. Eplasty. 2009;9:e9. Epub 2009 Feb 3. Consequences of Sarcopenia (Low Muscle Mass) (1)functional status 較差 New Mexico Elder Health Survey:3~4 倍 selfreportedphysical disability. (Am J Epidemiol 1998;147(8): ) NHANES: 女性, 增加 3.8 倍 having functional limitations ( J Am Geriatr Soc 2002;50(5): ) Health ABC:80% to 90% more likely to have mobilityimpairmentlowest/highest quintile (Int J Obes Relat Metab Disord 2004;28(2):234 41) Consequences of Sarcopenia (2) falls 機會高 New Mexico Elder Health Survey: odds ratio (OR) for fallsin men at 2.58 (95% CI, ), in women at 1.28(95% CI, )(Am J Epidemiol 1998;147(8): ) MINOS study: Relative appendicular muscle mass (RASM =ASMM by DXA/Height), the OR per SD lower RASM for fall was 1.31(95% CI, ) Predicted Median Life expectancy by Age and Gait Speed Studenski,et al. JAMA. 2011;305(1):50-58 J Am Geriatr Soc 52:80 85,

Diagnosis and Stage of Sarcopenia(EWGSOP) The European Working Group on Sarcopenia in Older People (EWGSOP) A.J. Cruz-Jentoft et al. Age and Ageing 2010; 39: 412 423 Cruz-Jentoft et al.

5 Diagnosis and Stage of Sarcopenia(EWGSOP) The European Working Group on Sarcopenia in Older People (EWGSOP) A.J. Cruz-Jentoft et al. Age and Ageing 2010; 39: Cruz-Jentoft et al.age and Ageing 2010; 39: Definition of Sarcopenia (Muscle Mass, 肌肉量 ) 1.ASMI= ASM/ht^2 (Appendicular skeletal muscle/ height^2) by Baumgartner 2. TSMI=TSM/ht^2 (Total skeletal muscle/height^2) 3. SMI%(Skeletal muscle index=skeletal muscle mass/body mass x 100) by Jasssen 2sd below gender specific mean of young population; gender specific lowest 20% Cruz-Jentoft et al. Age and Ageing 2010; 39: Muscle Strength and Function Measurement 附註 - 肌肉質量肌力及行動能力測量方式 1. Sarcopenia: European consensus on definition and diagnosis; Report of the European Working Group on Sarcopenia in Older People Cruz-Jentoft A.J. et al. Age & Ageing 2010;1-12. Cruz-Jentoft et al. Age and Ageing 2010; 39:

握力計與握力器 (Muscle Strength ) Low Muscle Strength by BMI 身體功能 (Physical Performance) Short Physical Performance Battery (SPPB) Repeated chair stands (0-4) Balance testing (0-4) 8 walk

6 握力計與握力器 (Muscle Strength ) Low Muscle Strength by BMI 身體功能 (Physical Performance) Short Physical Performance Battery (SPPB) Repeated chair stands (0-4) Balance testing (0-4) 8 walk (0-4) Repeated chair stands Guralnik JM, et al. J Gerontol Med Sci 1994; 49(2):M85-M94 Balance testing 8 (2.44 meter) walk(gait Speed) Tandem gait Semi-tandem stand Side-by-side stand 6

7 Death Rate According to Individual Performance Tests-Age and Sex adjusted Cruz-Jentoft et al.age and Ageing 2010; 39: EWGSOP-suggested algorithm for sarcopenia case finding in older individuals. 利用快速篩檢流程, 找出肌少症患者 Cruz-Jentoft A J et al. Age Ageing 2010;39: The Author Published by Oxford University Press on behalf of the British Geriatrics Society Sarcopenia: European consensus on definition and diagnosis; Report of the European Working Group on Sarcopenia in Older People Cruz-Jentoft A.J. et al. Age & Ageing 2010;1-12. Sarcopenia(muscle mass+/-muscle strength and physical performance) Baumgartner s Davison ASMI < -2 s.d. below the mean of a cohort of young adults Two lower quintiles of muscle mass Janssen SMI(skeletal muscle index) < -2 s.d. below the mean of a cohort of young adults Newman Different definitions of Sarcopenia Residual 20 th percentile +/- low muscle function or strength or performance 7

8 Epidemiology of Sarcopeniaamong the Elderly in New Mexico ASMI= Appendicular skeletal muscle mass (kg/height 2 (m 2 ) being less than two standard deviations below the sex-specific means of the Rosetta Study reference data for young adults aged years SMI=skeletal muscle mass/body mass x100 Skeletal muscle mass (Kg)=0.401xH 2 /R+3.825x Sex-0.071x age Sarcopenia was defined as the SMI of 2 standard deviation or more below the normal sex specific means for young persons. Sarcopenia I: -1~-2SD Sarcopenic II:<-2SD Baumgartner et al. Am J Epidemiol 1998; 147: Janssen et al. J Am Griatr Soc ;50: Prevalence of and Risk Factors for Sarcopenia in Elderly Chinese Men and Women (Hong Kong) Prevalence of and Risk Factors for Sarcopenia in Elderly Chinese Men and Women (Hong Kong) Lau et al.journal of Gerontology: MEDICAL SCIENCES Copyright 2005 by The Gerontological Society of America. 2005;60A(2): Lau et al.journal of Gerontology: MEDICAL SCIENCES Copyright 2005 by The Gerontological Society of America. 2005;60A(2): Prevalence of sarcopenia and sarcopenic obesity in Korean adults: the Korean sarcopenic obesity study Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: the EPIDOS (EPIDemiologie de l OSteoporose) Study Healthy body composition Purely sarcopenic Purely obese Sarcopenicobese 57.1% 6.9% 33.3% 2.8% Kim et al. International Journal of Obesity (2009) 33, healthy women aged 75 y/o in the EPIDOS (EPIDemiologie de l OSteoporose) Study in 5 French cities (Amiens, Lyon, Montpellier, Paris, and Toulouse) from 1992 to 1994 Obesity:percentage body fat (% fat mass =fat mass/body weight X100) was above the 60th percentile of the present study sample Sarcopenia: ASMI ( ASM/height2) was 2 SDs below the mean of a reference population from the Rosetta Study. Rolland et al. Am J Clin Nutr 2009;89:

9 Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: the EPIDOS (EPIDemiologie de l OSteoporose) Study Associated Factors and Health Impact of Sarcopenia in Older Chinese Men and Women: A Cross-Sectional Study Oliveria et al. Am J Clin Nutr 2009;89: Lee JSW et al. Gerontology 2007;53: Associated Factors and Health Impact of Sarcopenia in Older Chinese Men and Women: A Cross-Sectional Study The prevalence of sarcopenia in Taichung Elderly Health Study (TEHS), Age 65 y/o 50% 40% years years >85 years 43.2% 38.5% 30% 20% 14.6% 26.7% 21.4% 17.5% 10% 0% 6.8% 8.1% 7.4% Men Women Total Lee JSW et al. Gerontology 2007;53: Definition of sarcopenia (EWGSOP, 2010) Presence of both low muscle mass + low muscle function (strength or performance) *Skeletal muscle mass index (SMI): Appendicular skeletal muscle mass/height 2 (kg/m 2 ); Cutoff point from a Japanese study which consisted of 529 young adults (Sanada K. et al, 2007) unpublished. Treatment of Sarcopenia 1. Exercise: resistance exercise (strength training) 2. Adequate protein intake is necessary( instead of 0.8gm/Kg) 3. 營養品的補充 : DHEA, Leucine, β-hydroxyβmethylbutyrate 4. VitD, especially for VitD deficient patients 5. AIIA,ACEI for heart failure patient 6. Pharmacologic intervention: testosterone, growth hormone, GnRH 7. Myostatin regulation: Follistatin, anitibody 運動處方 -FITT PRO Frequency: 每天 Intensity: Moderate intensity( 中度 ) Type: aerobic + strength training( 有氧肌力訓練 ) Time: at least 30min/ time(30 分鐘 ) Progression: depends( 進度 ) 9

10 Sarcopenia. Exercise as a treatment strategy Aust Fam Physician Mar;35(3): Summary of important points Sarcopenia is largely responsible for the loss of muscle strength, and contributes to a decline in physical function, disability, loss of independence, morbidity and mortality. Biological and lifestyle factors underlie this condition, with reduced physical activity readily modifiable. Resistance exercise is a simple, inexpensive, readily accessible, and effective countermeasure. Once or twice weekly training of the major muscle groups at a moderate intensity is sufficient for improvement. 其他建議 1. Adequate Protein Intake,vitamin D are important for maintaining LBM and muscle health 2. HMB(β-Hydroxy β-methylbutyric acid; a metabolite of the essential amino acid leucine) supplement play some role in protein losing patient 3. Pharmacological therapies for sarcopenia mandate more evidence LEUCINE increases protein synthesis in old healthy men 20 healthy males 70 y.o * BMI 25 Oral protein supplementation WITHOUT or WITH LEUCINE FSR (%/hour) Control Leucine RIEU et al. J Physiol 2006; 575 : Clinical Nutrition News in A.S.P.E.N Mar. 2. Douglas Paddon-Jones and Blake B. Rasmussen. Curr Opin Clin Nutr Metab Care Jan; 12(1):

11 New food pyramid for seniors Thank you for your attention 11

( ) [3] 流行病學 %-13% 80 11%-50% [4] %-7.3% ( 2.5%-6.5% 5.4%-8.2%) [5] 評估與測量方法 [3] 1. X (Dual energy X-ray absorptionmetry, DXA) (Bio-impeda

( ) [3] 流行病學 %-13% 80 11%-50% [4] %-7.3% ( 2.5%-6.5% 5.4%-8.2%) [5] 評估與測量方法 [3] 1. X (Dual energy X-ray absorptionmetry, DXA) (Bio-impeda 前言 40 8% 70 15% [1] 40 10-15% 70 25-40% [2] 定義 1989 Irwin Rosenberg 台中慈濟醫院家庭醫學科 sarcopenia, pathophysiology, treatment (Sarcopenia) (European Working Group on Sarcopenia in Older People, EWGSOP) 2010 (low

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