Nutritional interventions that may help combat sarcopenia and frailty include protein, essential amino acids, vitamin D, and antioxidants. While protein supplementation shows some promise, the evidence is inconsistent due to variations in study design and populations. Essential amino acid and vitamin D supplementation appear to improve muscle mass and strength, especially in deficient individuals, but more research is still needed. Overall, the evidence suggests protein and vitamin D have the most potential to treat and prevent sarcopenia, but better designed studies are required to provide definitive conclusions.

1. Nutritional interventions in
sarcopenia and frailty
Dr Mary Hickson
Research Dietitian, Imperial College
Healthcare NHS Trust
Adjunct Professor, Imperial College
London
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2. Impact of Nutrition
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4. Nutrients implicated
• Protein and essential amino acids (EAA)
• Vitamin D
• Dietary fat - Alpha linoleic acid
• Alcohol
• Antioxidants
• Minerals
• Acid-base load
4
Welch A. Nutritional
influences on age-related
skeletal muscle loss.
Proceedings of the
Nutrition Society (2014),
73, 16–33

5. Dietary fat / α-linoleic acid
• Fatty acids source of energy for resting and working
muscle
• Integral component of myocellular membranes
• Influences inflammation and insulin resistance
• Different fatty acids could affect membrane function
• Animal models: high dietary fat muscle hypertrophy
• N-3 FA augments muscle protein anabolism
• PUFA: Associated with muscle mass
• α-linoleic acid (with resistance training): No effect on
muscle mass or performance
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6. Alcohol
• Excess alcohol is related to muscle damage
– Reduced rates of protein synthesis and breakdown,
– Loss and redistribution of ribosomal RNA,
– Increased RNase activities
– Membrane damage
– Altered Ca2+ regulation
– Generation of free radicals
• Few studies looking at alcohol and sarcopenia
• Little evidence of association
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7. Antioxidants
• Oxidative stress potentially muscle loss
• Antioxidant nutrients could oxidation in muscle
• Antioxidants = Vits C, E, Carotenoids, Cu, Mn, Se, Zn
• Some evidence that lack of these micronutrients (and
Fruit and Veg) are associated with functional
limitations
• Vit E and C supplementation (with resistance
exercise) improved lean mass more than resistance
exercise alone
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8. Minerals
• Magnesium status has effects on muscle
performance
• Low serum Mg associated with lower
muscle strength
• Longitudinal study showed Mg, Fe, P, Zn
all associated positively with lean mass
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9. Acid-base load
• Tendency for slight blood pH decrease with age
due to decreasing function of the kidneys (lower
excretion of H+)
• Diet can also influence metabolic acidosis
• Acidogenic foods:
– Meat, fish, eggs, cereals, dairy
• Alkalinogenic foods:
– Fruit and vegetables
• Overall balance is acid-base load
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10. Acid-base load
• Metabolic acidosis potentially accelerates
protein breakdown
• Two studies: both showed alkaline diet favoured
muscle mass retention.
• The alkaline effect of diet was about half as
important as the effect of age on muscle loss
• Eat more fruit and veg!
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11. What is the evidence?
• Systematic Reviews of RCT
• Cruz-Jentoft A et al. Prevalence of and
interventions for sarcopenia in ageing adults: a
systematic review. Report of the International
Sarcopenia Initiative. Age and Ageing 2014; 43:
748–759
• Bibas et al. Therapeutic Interventions for Frail
Elderly Patients: Part I. Published Randomized
Trials. Progress in cardivascular diseases 2014;
57: 134-143
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12. Main findings
• Protein – 5 studies - no consistent effect
• EAA – 2 studies - very limited evidence –
some effect on muscle mass and function
• HMB – 4 studies - Limited evidence -
Some effects on muscle mass and
function
• Fatty acids – 1 study – no effect
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13. Protein supplementation
• With and without resistance training
• With and without energy supplement
• With and without additional vitamins and
minerals
• Different populations
• Blinding mixed
• Adherence 44-98%
• Only some assessed dietary intake13

14. • Protein supplemented 13-40g/d
• Up to 1.4g/kg-bw/d
• Some evidence that supplements reduced
spontaneous food intake
• Difficulties recruiting; community dwelling
= 4-9% recruitment rate
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15. Protein – no consistent effect?
• Clear well defined populations
• Four arm studies nutrition +/- exercise
• Standardised outcome measures
• Timing of nutritional supplement*
• Baseline nutritional status*
• Assessment of spontaneous food intake
• Protein in relation to requirement (g/kg-bw/d)
• Recruitment
• Adherence
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16. Protein requirements
• 1.0-1.2g/kg bw/d
– 60kg person increase from 48g/d to 72g/d
• 1.2-1.5g/kg bw/d (risk of malnutrition, ill)
– 60kg person = 90g/d
• 25-30g/meal to stimulate anabolism
– suggests minimum of 75-90g/day
• Pulse feeding – majority (80%) of protein at one
meal to overcome effect of splanchnic
sequestration
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17. 17
The
Splanchnic
bed

18. Essential amino-acids
• Anabolic stimulus for muscle
• Only two studies
• One in healthy women and one in
sarcopenic women
• Different EAA supplements
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19. EAA profiles
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0
0.5
1
1.5
2
2.5
3
Dillon
Kim

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40.7
43.5
41
45.2
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40
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placebo suppl
LeanBodyMass(kg)
baseline
3 months
p<0.05
Dillon EL et al. Amino Acid
Supplementation Increases Lean
Body Mass, Basal Muscle Protein
Synthesis, and Insulin-Like Growth
Factor-I Expression in Older
Women. J Clin Endocrinol Metab.
2009, 94(5):1630–1637

21. 21
Kim et al. Effects of
Exercise and Amino Acid
Supplementation on Body
Composition and Physical
Function in Community-
Dwelling
Elderly Japanese
Sarcopenic Women: A
Randomized Controlled
Trial. JAGS 60:16-23, 2012

22. EAA future studies
• Agreement on EAA profile
• Adherence
• Acceptability
• Is leucine the key?
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90-95%
conversion
5-10%
conversion
Essential Branched Chain AA

24. β-hydroxy β-methylbutyrate
(HMB)
24 Eley 2008

25. HMB dose
• 3g/d HMB
• = 60g leucine/d
• = >600g of high-quality protein sources
(eggs, dairy and meat) daily
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26. Animal work
26
Wilson et al. Journal
of the International
Society of Sports
Nutrition 2012, 9:1
Changes in fat mass among control and HMB conditions in
young and older F344 rats.

27. HMB
• More consistent dose – 2-3g/d HMB (but
one with arginine and lysine)
• Generally free-living older adults
• One – bedrest study
• More consistent improvements in muscle
mass
• Less consistent improvements in strength
and function
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28. Arginine and lysine
• Lysine requirement estimated at 30mg/kg
per day for maintenance in non-elderly
healthy adults (≈2g/d)
• Some evidence that older adults intake is
lower, particularly women.
• Key AA in muscle – needed for growth and
maintenance
• Arginine shown to stimulate whole-body
protein synthesis28

29. Protein seems important
• Amount - 1.2g/kg-bw/day (Bauer, 2013)
• Type - ? AA content
• Timing – even or pulse?
• Exercise
• Nutritional status
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30. Vitamin D and muscle
• Deficiency: Symptoms = muscle weakness,
pain, and gait impairments.
• Vitamin D receptor on muscle tissue?
• Observational studies positive relationship
between vitamin D and muscle function.
• Vitamin D supplementation trials on muscle
function show effect on strength.
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Effect of Vit D
supplementation
on global
muscle strength
(grip or lower limb)
Mean diff = 0.17
95% CI: 0.031, 0.31
P=0.017
I2=77.67%
Total subjects =
5533
Beaudart, J Clin
Endocrinol Metab
99: 4336–4345,
2014

32. 32
Beaudart, J Clin
Endocrinol Metab
99: 4336–4345,
2014
Mean diff = 0.06 (P=0.52)
I2=3.34%
Effect of Vit D on muscle mass

33. 33
Beaudart, J Clin
Endocrinol Metab
99: 4336–4345,
2014
Mean diff = 0.06 (P=0.66)
I2=0.0%
Effect of Vit D on muscle power

34. Vitamin D
• Modest but significant effect on muscle
strength
• Greatest effect in vit D deficient or
insufficient states
• Inconclusive data on power and mass
• Critical to assess baseline vit D status and
supplement vit D with other intervention.
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35. 35
Fuller et al. Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 6, Nov 2011
HMB/Arg/Lys and Vit D
>30ng/mL
HMB/Arg/Lys and Vit D
<30ng/mL
control

36. Key points
• Protein and vitamin D seem to have the most
potential in treating and/or preventing sarcopenia
• Evidence is currently hampered by design issues
• Lack of agreement on the most appropriate
outcomes
• Baseline nutritional status is important
• Supplements need to be on top of recommended
requirements
• Other aspects of diet are under researched
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