ESPEN endorsed recommendationProtein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group
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New insights in aging and declining muscle function
The natural aging process is associated with gradual and progressive loss of muscle mass, muscle strength, and endurance, i.e., a condition called sarcopenia [1]. Such changes have been considered inevitable consequences of aging. This concept has recently been challenged, as new study results suggest that mitochondrial dysfunction, reduced insulin sensitivity, and reduced physical endurance are related, at least in part, to physical inactivity and to increases in adiposity rather than to aging
Changing protein intake and protein needs in older adults
Compared to younger adults, older adults usually eat less, including less protein [4], [5]. In Europe, up to 10% of community-dwelling older adults and 35% of those in institutional care fail to eat enough food to meet the estimated average requirement (EAR) for daily protein intake (0.7 g/kg body weight/day), a minimum intake level to maintain muscle integrity in adults of all ages [6]. At the same time, many older adults need more dietary protein than do younger adults [7], [8]. An imbalance
Dietary protein intake
There are many reasons older adults fail to consume enough protein to meet needs—genetic predisposition to low appetite, physiological changes and medical conditions that lead to age- and disease-associated anorexia, physical and mental disabilities that limit shopping and food preparation, and food insecurity due to financial and social limitations (Fig. 1) [5].
Dietary protein needs
There are also many reasons older adults have higher protein needs (Fig. 2). Physiologically, older adults may develop resistance to the positive effects of dietary protein on synthesis of protein, a phenomenon that limits muscle maintenance and accretion; this condition is termed anabolic resistance [12], [13]. Mechanisms underlying anabolic resistance and the resultant need for higher protein intake are: increased splanchnic sequestration of amino acids, decreased postprandial availability of
Consequences of malnutrition and negative nitrogen balance
In older adults, age- or disease-related malnutrition leads to negative nitrogen balance and ultimately to frailty and primary or secondary sarcopenia [1], [21]. These conditions can result in disability, and eventually to loss of independence, falls and fractures, and death [7]. Primary (age-related) and secondary (disease-related) sarcopenia are difficult to distinguish in older adults because of the high prevalence of chronic disease in this population—92% after age 65 years, and 95% after
Physical activity and exercise can maintain or enhance muscle mass
Loss of muscle mass with aging is primarily due to decreased muscle protein synthesis rather than to increased muscle protein breakdown. While the basal level of post-absorptive myofibrillar protein synthesis may decline with age, this decline is minimal [30]. Inactivity with consequent anabolic resistance are major contributors to the development of sarcopenia [30]. This concept is supported by the observation that immobilization induces resistance of muscle to anabolic stimulation [31].
Protein requirements without and with chronic diseases or conditions
Older adults are expected to benefit from increased dietary protein intake, especially those with anorexia and low protein intake along with higher needs due to inflammatory conditions such as heart failure, COPD, or CKD undergoing dialysis [40]. Further research is needed to identify and develop tools that can precisely define protein needs in older individuals with chronic conditions. Research is likewise needed to determine whether increased protein intake can measurably improve functional
Optimal protein or amino acid type and amount
A wide range of factors can affect the amount of dietary protein needed by an older person -digestibility and absorbability of protein in foods consumed, whether chewing capacity is normal or impaired, protein quality and amino acid content, sedentary lifestyle (including immobilization or inactivity due to medical condition), and presence of stress factors (inflammation and oxidative stress).
Sarcopenic obesity and protein intake
Sarcopenic obesity is a deficiency of skeletal muscle tissue mass relative to fat tissue (Table 3). Obesity and inactivity contribute to decreased muscle mass and to lower muscle quality, especially with aging [69]. Lower muscle quality is attributed in part to infiltration of fat into the muscle, which affects both muscle strength and muscle function [70]. Intramyocellular lipid accumulation also reduces synthesis of muscle proteins [71].
Working definitions of sarcopenic obesity have been used
Concerns about negative effects of higher protein intake in older adults
While the benefits of increased dietary protein are acknowledged for maintenance of muscle health in older adults, health professionals often express concern that high-protein diets will stress and worsen declining kidney function in this population. However, evidence shows that many healthy older adults have preserved kidney function [79], [80], [81]. On the other hand, those older adults who are unhealthy are more likely to develop mild kidney insufficiency or CKD. For such individuals with a
Conclusions
If the increasing life expectancy over the past two centuries continues at the same rate through the 21st century, many babies born since 2000 will celebrate their 100th birthdays [86]. In fact, average lifespan has increased 7–10 years in just 3 decades [86].
What distinguishes a generally healthy, long-lived person today? A study of Japanese centenarians (100 years or older) found that those who remained autonomous, i.e., performed activities of daily living, had good cognition, and had good
Conflict of interest
None.
Acknowledgments
The authors thank Dr. Cecilia Hofmann (C. Hofmann & Associates, Western Springs, IL, USA) for her capable assistance with writing, reference management, and editing.
Work by Nicolaas E. P. Deutz for this article was supported by Award Number R01HL095903 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of this authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of
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