LEAN BODY MASS AFTER BARIATRIC

SURGERYJacqueline Jacques, ND, FTOS

What is Lean Body Mass

Muscle Bone

When we lose lean mass we lose health Medical term is sarcopenia A syndrome characterized by progressive

and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death

Sarcopenia is a powerful predictor of late-life disability

Report of the European Working Group on Sarcopenia in Older People

What is Sarcopenia

Between 20 - 80 years of age, there is approximately a 30% reduction in muscle mass

Sarcopenia very likely begins in early adulthood with atrophy and loss of type II muscle fibers

There is a decline in both muscle fiber size and number

There can also be increasing fat mass

What is Sarcopenia

Recent estimates indicate that approximately 45% of the older U.S. population is affected by sarcopenia. That equated to 18 million people in 2010

The Healthcare Costs of Sarcopenia in the United States. Journal of the American Geriatric Society 52:80–85, 2004.)

The risk of disability is 1.5 to 4.6 x higher with  sarcopenia than in persons with normal muscle

Costs around $26 Billion per year to the US health care system (and rising)

Causes

Causes

Causes

Major factors considered to be involved include genetic heritability nutritional status (protein intake, energy intake,

and vitamin D status) physical activity hormonal changes (declines in serum

testosterone and growth hormone) insulin resistance, atheroscelorosis and

changes in circulating pro-inflammatory cytokines

Causes: Weight Loss…

Method Number of Study groups

Mean of study groups

25% or greater loss

of FFM

< 25% FFM loss

LCD 15 17% 2 13

LCD & EX 6 19% 1 5

LCD & Drugs 3 28% 1 2

VLCD 4 29% 3 1

VLCD & Ex 5 16% 1 4

BPD 15 30% 9 6

RYGB 4 30% 3 1

LAGB 15 17% 2 13

Chaston TB, & Dixon JB. Int J Obes (Lond). 2007;31:743-50.

Percentage of FFM loss with various methods of weight loss

Casues: Vicious Cycle

Consequences

Consequences

Metabolic Risks of Sarcopenia

A loss in muscle mass is related to metabolic problems such as insulin resistance, type 2  diabetes and obesity (including lean obesity)

 The combination of more body fat and lower muscle leads to increased insulin resistanceThis is a set up for poor cardiometabolic health

Treatment and Prevention

Exercise

Resistance training is the most effective exercise for slowing the rate of loss of muscle mass and maintaining or improving muscle strength.

Exercise

Resistance Training:Reduces fallsImproves muscle strengthImproves ability too complete ADLsHas been studied to improve QOL

It is also preventive Overall total activity is also very

important but harder to measure

Exercise AHA Guidelines are often used in

sarcopenia:All sedentary adults should participate in

resistance training activities 2 to 3 days per week. Individuals who are younger than 50 years should

perform 1 set of 8 to 12 repetitions of 8 to 10 different exercises.

Individuals who are 50 to 60 years old or who have CVD should perform 1 set of 10 to 15 repetitions of 8 to 10 different exercises at a lighter weight.

Protein

Recommended Dietary Allowance (RDA) for healthy adults (0.8 g/kg/day).Though many over age 50 do not achieve this

There needs to be a post-prandial rise in blood AAs to stimulate protein synthesisLow intake hampers thisAs we age, more AAs are taken up by the liver

and never get into circulation

Protein Current recs may be too low to stimulate muscle

synthesis in older adults Studies have indicated that levels of 30g/meal can

produced protein synthesis similar to younger people

- Paddon-Jones D, Sheffield-Moore M, Zhang XJ, et al. Amino acid ingestion improves muscle protein synthesis in the young and elderly. Am J Physiol Endocrinol Metab. 2004;286:E321-E328.

An expert panel recommended a total protein intake of 1 to 1.5 g/kg/day with equal amounts of protein consumed at breakfast, lunch, and dinner

- J.E. Morley et al., JAMDA, 2010. 11: p. 391-396

Protein after bariatric surgery Protein intake should be individualized,

assessed, and guided by an RD, in reference to gender, age, and weight

A minimal protein intake of 60 g/d and up to 1.5 g/kg (0.7g/pound) per day should be adequate;

Higher amounts of protein—up to 2.1 g/kg (1 gram/pound) per day—need to be assessed on an individualized basis

From the 2013 TOS Guidelines

Protein after bariatric surgery “Recommendations for protein intake

are variable but studies suggest higher protein levels (80–90 g/d) are associated with reduced loss of lean body mass.

Protein intake is generally reduced following surgery and adequate intake can be facilitated through the use of protein supplements”

From the 2013 TOS Guidelines

Branched Chain Amino Acids (BCAAs) The amino acids valine, leucine and

isoleucine Nearly 25% of all whey protein is made

up of BCAAs - one reason why a lot of people recommend whey

They help both to decrease muscle loss and promote muscle synthesis

Good to supplement both with increased weight loss and with exercise

Leucine One of the 3 branched chain

amino acids As we already discussed,

branched-chain amino acids regulate muscle protein synthesis and help prevent loss

Leucine is the principal branched-chain amino acid responsible for the anabolic effect on muscle protein synthesis.

Leucine

Studied range is 3 to 12 grams/day May be more effective for protein

synthesis if co-administered with whey Combination seems to give higher/faster

rises in serum amino acids

HMB Beta-hydroxy-beta-methylbutyrate (HMB) is

the active metabolite of leucine. May be more effective (than leucine) in

untrained individuals Levels of 3g/day together with mild

resistance training significantly increased LMB in elderly men in 8 weeks. Also resulted in fat loss.

- Vukovich MD, et al. Body composition in 70-year-old adults responds to dietary beta-hydroxy-beta-methylbutyrate similarly to that of young adults. J Nutr. 2001;131:2049–2052

Vitamin D

Vitamin D deficiency appears to be an independent risk for sarcopenia;Muscle loss/weakenssBone lossIncreased risk for falls and hip fracture

Fall prevention has been observed at levels starting at 700iu/day

Vitamin D

In studies, anti-fall efficacy started with achieved 25-OH D levels of at least 60 nmol/L (24 ng/ml)

Anti-fracture efficacy started with achieved 25-OH D levels of at least 75 nmol/L (30 ng/ml)

Higher levels may give a better result- H.A. Bischoff-Ferrari, Best Pract Res Clin

Rheumatol, 2009. 23(6): p. 789-795

Other Tx

Nutrition:Creatine – related to amino acids. 95% of

creatine is stored in muscle○ May improve muscle strength and energy –

allowing people to do more exercise and thus promote more lean mass

○ Typical doses are around 5 grams. Be cautions if you have kidney disease ot take medication for diabetes

EPA – from fish oil. Can help prevent muscle break down

Other Tx

Drug:TestosteroneEstrogensDHEAGrowth hormonesAngiotensin-converting enzyme inhibitors

Conclusions

Conclusions

Whenever you lose weight, you will lose lean mass

It is important to work hard to preserve lean mass as it will continue to decline with age

Maintaining health lean mass is important not just for strength, both for overall lifelong health