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Problemi nutrizionali: dalla valutazione nutrizionale alla
dietoterapia Stefania Maggi
Firenze, 21 Ottobre 2017
CORSO FORMATIVO SIGG-ECM Trattamento del paziente anziano complesso con Diabete Mellito
The management of T2DM in the elderly is challenging
Ageing, diabetic microvascular and macrovascular complications, hyperglycaemia, hypoglycaemia, multiple morbidity and lack of social support are risk factors for the geriatric syndromes
T2DM=type 2 diabetes mellitus.
Araki A, Ito H. Geriatr Gerontol Int. 2009;9:105–114.
Increased mortality
Ageing
Diabetes complications
Comorbidity
Lack of social support
Hyperglycaemia
Hypoglycaemia
Risk factors
Depression
Disability
Malnutrition
Urinary incontinence
Cognitive impairment
Falling
Geriatric syndromes
Health Status Comorbidity Index (CIRS)
Drug use History,medical visit, Lab/Rx diagnostics
Cognitive, Functional, Mood, Motility
Barthel, ADL IADL, Tinetti
SPMSQ, MMSE, GDS
Social evaluation Social Network - Cohabitation Nursing Homes - Income
Private vs public: home-care, long-term care services
1) Clinical profile 2) Pathological Risk 3) Residual skills
Individual (personalized) Care Plan
Comprehensive Geriatric Assessment - CGA MULTIDIMENSIONAL ASSESSMENT
Biological Risk Mini Nutritional Assessment
Risk of pressure sores Exton-Smith
Older individual vs adult: redistribution of fat and muscle
Woman 25 yrs
Woman 81 yrs FFM (> limbs)
Myosteatosis Myofibrosis
Increase FM
Man 40 yrs
Man 70 yrs
EWGSOP Working Definition of Sarcopenia
LOW MUSCLE MASS
LOW PHYSICAL PERFORMANCE
LOW MUSCLE STRENGTH
OR SARCOPENIA
SEVERE SARCOPENIA
PRE-SARCOPENIA
AND
EWGSOP Working Definition of Sarcopenia
Cruz-Jentoft AJ et al. Sarcopenia: European consensus on definition and diagnosis. Report of the European
Working Group on Sarcopenia in Older People. Age Ageing 2010
Case finding Subject >65 years
Usual gait speed
No sarcopenia
Muscle mass
Grip strength
No sarcopenia
Sarcopenia
NORMAL
NORMAL
SLOW
LOW
LOW
NORMAL
Diabete e sarcopenia The Health, Aging, and Body Composition Study
(1840 soggetti età 70-79 aa, diabetici e non, seguiti per 3 anni)
Park SW et al, Diabetes Care 2007
***
***
*** p<0.001; * p< 0.05
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
Forza muscolare (Nm)
*
Variazione a 3 anni nella forza estensione ginocchio e nella qualità
del muscolo, in base alla presenza/assenza di diabete al basale
*
Aggiustato per: sesso, età, razza, BMI, forza/qualità muscolare al basale, variazioni in massa magra AAII, attività
fisica, CAD, ictius, scompenos cariaco, arteriopatia periferica, artrosi del ginocchio, neoplsie, depresione, ipovisus,
insufficienza renale, livelli di citochine
Yoon JW et al, Diabetes Metab J 2016
Diabete e performance fisica Korean Longitudinal Study of Health and Aging: 269 maschi > 65 anni
Diabete e cadute (Study of Osteoporotic Fractures: 9249 donne, età >66 anni-follow-up 7,2 anni)
Scwartz AV et al, Diabetes Care 2002
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
70-74 aa 75-79 aa 80-84 aa >84 aa
No diabete
Diabete non insulino-trattato
Diabete insulino-trattato
Incidenza cadute
/persona/anno
* p<0.05 vs non diabetici; § p<0.05 vs diabetici non insulino-trattati
*
*
*
* * §
* §
* §
* §
Complex relationship between frailty, sarcopenia and nutrition
Adapted from Walston J, et al. J Am Geriatr Soc. 2006;54:991-1001.
Oxidative Stress
Free radicals
Chronic Diseases (diabetes,
CHF, HTN, Cancer)
Frailty
CRP IL-6
TNFα
Inflammation
Neuroendocrine deregulation
Triggers Physiology Outcomes
Age-related changes in nutrition and body composition
IGF-1 DHEA-S Cortisol
IR
Sarcopenia
Neurocognition
Anemia
Sarcopenia and Frailty Overlap
Fried LP, et al. J Gerontol A Biol Sci Med Sci. 2001;56:M146-M156.
Cruz-Jentoft A, et al. Age Ageing. 2010;39:412-423.
Bauer JM, et al. Exp Gerontol. 2008;43:674-678.
DIAGNOSTIC CRITERIA
FRAILTY – FRIED SARCOPENIA – EWGSOP*
• Weight loss
• Self-reported exhaustion
• Weakness
• Slow walking speed
• Low physical activity level
• Decreased skeletal muscle mass
• Decreased muscle strength
• Reduced physical performance
Sarcopenia Frailty Strength
Functionality
*EWGSOP=European Working Group on Sarcopenia in Older Persons
Heterogeneity in the health status of older adults and the paucity of evidence from clinical trials represent a challenge for generalized treatment recommendations
Hubbard RE, et al. J Gerontol A Biol Sci Med Sci. 2010;65:377-381
Maintaining optimal BMI in diabetic older patients
Underweight and obesity are associated with frailty
Modified from Gill TM, Arch Intern Med 2006
51.5% 58.3% 63.9%
40.1% 24.9% Dead 4.2% Dead 4.9% Dead 13.1%
11.9% 23%
Robust Pre-Frail Frail
FRAILTY IS REVERSIBLE
Nutrition and exercise can reverse frailty
Binder EF, et al. J Am Geriatr Soc. 2002;50:1921-1928.
Potential reversibility of many features is a characteristic that distinguishes frailty syndrome from the effects of aging.
Biological plausibility of the combined effect
Biolo, 1997
Effect of resistance exercise + nutrition (protein) on muscle protein synthesis
Functional categories of older people with diabetes
• Category1: Functionally independent
• This category is characterized by people who are living independently have no important impairments of activities of daily living (ADL ), and who are receiving non or minimal caregiver support
Controlling blood
glucose levels
Healthy Eating:
Regular carbohydrate
High in fibre
Low in fat (particularly
saturated fat)
Low in added sugar
Adequate energy
/protein/fluids/vits and
mins
http://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/nhanes_analytic_guidelines_dec_2005.pdf
Daily caloric intake decrease with age
• 1321 kcal/d in men • 629 kcal/d in women
Age (y)
Men Women
n = x
0
1000
1500
2000
2500
3000
all ages 20 – 39 40 – 59 >60
kcal/d
ay
Mean decrease in caloric intake between age 20-80 years
At least 1400 kcal/day are needed to cover
micronutrient needs
A well-balanced diet above 1400 kcal/day meets most micronutrient needs
(Mediterranean Diet)
Campbell WW et al.. Am J Clin Nutr. 2008;88:1322-1329
• Vitamin E: 15 mg/day for adults > 70 years
• Vitamin C: 90 mg/day for men > 70 years; 75 years for women
• Vitamin D: 20 µg/day for adults > 70 years
• Folate: 400 µg/day for adults > 70 years
• Vitamin B12: 2.4 µg/day for adults > 70 years
The optimal protein intake for older adults is at least 1.2 g/kg/day (and up to 1.5 g/kg/day) – a level higher than the standard adult RDA (if
not CKD) .
Cat
abol
ism
A
nabol
ism
10 g
Total Protein 90 g
maximum rate of protein synthesis
15 g 65 g
A skewed daily protein distribution fails
to maximize potential for muscle growth
Distribution of protein intake
is relevant: IRREGULAR intake does not maximize protein synthesis
Cat
abol
ism
A
nabol
ism
30 g 30g 30 g
Repeated maximal stimulation of protein synthesis increase / maintenance of muscle mass
~ 1.2 g/kg/day
Distribution of protein intake
is also relevant: REGULAR intakes maximize protein synthesis
Total Protein 90 g
maximum rate of protein synthesis
Functional categories of older people with diabetes
• Category 2: Functionally dependent
• This category represents those
individuals who, due to loss of function, have impairments of ADL.
• This increases the likelihood of
requiring additional medical and social care .
• Such individuals living in the
community are at particular risk of admission in HOSPITAL
Category 2: Functionally dependent
Low energy and protein intake increases risk of frailty
IN CHIANTI Study 802 participants > 65 years
Bartali B, et al. J Gerontol A Biol Sci Med Sci. 2006;61:589-593. Bartali B, et al. J Nutr.
2003;133:2868-2873. Beasley JM, et al. J Am Geriatr Soc. 2010;58:1063-1071.
Significant association between diagnosis of frailty and:
• Low protein intake
• Daily energy intake < 21 kcal/kg body weight
Women Health Initiative (WHI)
strong, independent, dose-responsive, lower risk of incident frailty in older women with higher protein intake
Fra
ilty
rela
tive
ris
k
Adjusted Risk of Frailty Compared with Lower Quintile of Protein Intake
Oral Nutrition Supplements (ONS)
Definition The modification of food and fluid
by fortifying food with a mix of:
macronutrients (protein, carbohydrate and fat)
micronutrients (vitamins, minerals and trace elements)
ONS increase overall nutrition intake by: Being an extra nutrition to regular meals Changing meal patterns
NICE: Guiding principles for improving the systems and processes for ONS - 2012
http://www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf
Ready-made nutritional supplements are energy dense
and generally contain between 1 and 2.4 kcal/ml and
a balance of micronutrients.
• These individuals are characterized by a significant medical illness and have a life expectancy reduced to less than 1 year – Decision to be made with
patient, family, caregivers about nutritional support
Functional categories of older people with diabetes Category 3:end of life care
Conclusioni
• La nutrizione rappresenta una parte integrante della gestione del paziente diabetico indipendentemente dall’età
• Molti anziani sono malnutriti per i cambiamenti legati all’età nel senso del gusto e dell’olfatto, per la disfagia, le scadenti condizioni del cavo orale, i disturbi fisici e cognitivi, i problemi socio-economici
• Alcuni anziani con diabete sono in sovrappeso o obesi e questo aumenta il rischio di declino fisico e di fragilità (obesità sarcopenica).
• La perdita di peso in un paziente anziano, però, può aumentare il rischio di perdita di massa ossea e muscolare, e portare a deficit nutrizionali. Quindi strategie che associano l’esercizio fisico alla dieta sono essenziali affinchè il paziente perda peso e migliori la performance fisica, riducendo quindi il rischio cardiovascolare e metabolico
• Se le richieste nutrizionali non sono soddisfatte con la dieta abituale in un anziano fragile, diverse strategie possono essere messe in atto, quali supplementazioni di proteine, Vitamina B12, Vitamina D e calcio