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• W1980291647 abstract "Sarcopenia and frailty are now in the front line of geriatric research. Sarcopenia, initially defined as an age-related loss of muscle mass, is now considered a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk for adverse outcomes such as physical disability, poor quality of life, and death.1Cruz-Jentoft A.J. Baeyens J.P. Bauer J.M. et al.Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.Age Ageing. 2010; 39: 412-423Crossref PubMed Scopus (7159) Google Scholar, 2Landi F. Liperoti R. Fusco D. et al.Sarcopenia and mortality among older nursing home residents.J Am Med Dir Assoc. 2012; 13: 121-126Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar Changes in muscle mass have shown to be poor predictors of clinical outcomes,3Newman A.B. Kupelian V. Visser M. et al.Strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort.J Gerontol A Biol Sci Med Sci. 2006; 61: 72-77Crossref PubMed Scopus (1103) Google Scholar, 4Manini T.M. Clark B.C. Dynapenia and aging: An update.J Gerontol A Biol Sci Med Sci. 2012; 67: 28-40Crossref PubMed Scopus (491) Google Scholar and in intervention studies, changes in muscle mass do not show a clear direct relation with muscle strength and physical performance.5Nass R. Pezzoli S.S. Oliveri M.C. et al.Effects of an oral ghrelin mimetic on body composition and clinical outcomes in healthy older adults: A randomized trial.Ann Intern Med. 2008; 149: 601-611Crossref PubMed Scopus (200) Google Scholar, 6Kim H.K. Suzuki T. Saito K. 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.J Am Geriatr Soc. 2012; 60: 16-23Crossref PubMed Scopus (328) Google Scholar Frailty is a syndrome of decreased reserve and resistance to stressors that results in an increased risk for adverse outcomes. Although the word frailty has been used in geriatric medicine for quite a long time,7Parfentjev I.A. Frailty of old age and bacterial allergy.Geriatrics. 1956; 11: 260-262PubMed Google Scholar and defining an older subject as frail seems to be easy to agree on in practice, a good definition is still lacking.8Abellan van K.G. Rolland Y.M. Morley J.E. et al.Frailty: Toward a clinical definition.J Am Med Dir Assoc. 2008; 9: 71-72Abstract Full Text Full Text PDF PubMed Scopus (418) Google Scholar, 9Rodriguez-Manas L, Feart C, Mann G, et al. Searching for an operational definition of frailty: A Delphi method based consensus statement. The Frailty Operative Definition-Consensus Conference Project. J Gerontol A Biol Sci Med Sci 2012 Apr 16. [Epub ahead of print]Google Scholar Physical frailty is closely related to sarcopenia.10Bauer J.M. Sieber C.C. Sarcopenia and frailty: A clinician’s controversial point of view.Exp Gerontol. 2008; 43: 674-678Crossref PubMed Scopus (168) Google Scholar, 11Jeejeebhoy K.N. Malnutrition, fatigue, frailty, vulnerability, sarcopenia and cachexia: Overlap of clinical features.Curr Opin Clin Nutr Metab Care. 2012; 15: 213-219Crossref PubMed Scopus (128) Google Scholar, 12Cooper C. Dere W. Evans W. et al.Frailty and sarcopenia: Definitions and outcome parameters.Osteoporos Int. 2012; 23: 1839-1848Crossref PubMed Scopus (214) Google Scholar Fried’s criteria, the most widely used definition of phenotypic frailty, are able to predict falls, impaired mobility, activities of daily living disability, hospitalization, and death.13Fried L.P. Tangen C.M. Walston J. et al.Frailty in older adults: Evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156Crossref PubMed Google ScholarUnderstanding intervention studies in a setting where definitions of the conditions that are treated, and the biomarkers and tools to be used are still evolving is, not surprisingly, confusing.1Cruz-Jentoft A.J. Baeyens J.P. Bauer J.M. et al.Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.Age Ageing. 2010; 39: 412-423Crossref PubMed Scopus (7159) Google Scholar, 14Cesari M. Fielding R.A. Pahor M. et al.Biomarkers of sarcopenia in clinical trials: Recommendations from the International Working Group on Sarcopenia.J Cachexia Sarcopenia Muscle. 2012; 3: 181-190Crossref PubMed Scopus (179) Google Scholar, 15Brass E.P. Sietsema K.E. Considerations in the development of drugs to treat sarcopenia.J Am Geriatr Soc. 2011; 59: 530-535Crossref PubMed Scopus (31) Google Scholar, 16Chumlea W.C. Cesarit M. Evans W.J. et al.International working group on sarcopenia.J Nutr Health Aging. 2011; 15: 450-455Crossref PubMed Scopus (62) Google Scholar, 17Vellas B. Cestac P. Moley J.E. Editorial: Implementing frailty into clinical practice: We cannot wait.J Nutr Health Aging. 2012; 16: 599-600Crossref PubMed Scopus (66) Google Scholar In fact, because sarcopenia and frailty are complex geriatric syndromes, it can be expected that complex interventions will be needed.18Cruz-Jentoft A.J. Landi F. Topinková E. et al.Understanding sarcopenia as a geriatric syndrome.Curr Opin Clin Nutr Metab Care. 2010; 13: 1-7Crossref PubMed Scopus (377) Google Scholar, 19Inouye S.K. Studenski S. Tinetti M.E. et al.Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept.J Am Geriatr Soc. 2007; 55: 780-791Crossref PubMed Scopus (1113) Google Scholar At this time, three different, and probably nonexclusive, approaches are rapidly developing: exercise, nutrition, and drugs. The latest is still in the slow line, as several trials have failed to show a pharmacologic effect of different approaches, except when compensating a deficit (eg, androgens, vitamin D). More basic science is still needed to develop new molecular approaches, and some of these new drugs are already starting clinical trials in humans.15Brass E.P. Sietsema K.E. Considerations in the development of drugs to treat sarcopenia.J Am Geriatr Soc. 2011; 59: 530-535Crossref PubMed Scopus (31) Google Scholar, 20Sakuma K. Yamaguchi A. Novel intriguing strategies attenuating to sarcopenia.J Aging Res. 2012; 2012: 251217Crossref PubMed Scopus (40) Google ScholarExercise has shown to be beneficial for a number of diseases and conditions, and it is no surprise that it benefits muscle function. This is quite evident for athletes, and it was good to find out that even extremely old and frail individuals can benefit.21Fiatarone M.A. O’Neill E.F. Ryan N.D. et al.Exercise training and nutritional supplementation for physical frailty in very elderly people.N Engl J Med. 1994; 330: 1769-1775Crossref PubMed Scopus (2267) Google Scholar, 22Serra-Rexach J.A. Bustamante-Ara N. Hierro V.M. et al.Short-term, light- to moderate-intensity exercise training improves leg muscle strength in the oldest old: A randomized controlled trial.J Am Geriatr Soc. 2011; 59: 594-602Crossref PubMed Scopus (128) Google Scholar Exercise seems to improve muscle mass and function, and reduce the risk for disability-related outcomes in older people, both living in the community and in nursing homes.23Candow D.G. Forbes S.C. Little J.P. et al.Effect of nutritional interventions and resistance exercise on aging muscle mass and strength.Biogerontology. 2012; 13: 345-358Crossref PubMed Scopus (60) Google Scholar, 24Peterson M.D. Sen A. Gordon P.M. Influence of resistance exercise on lean body mass in aging adults: A meta-analysis.Med Sci Sports Exerc. 2011; 43: 249-258Crossref PubMed Scopus (363) Google Scholar, 25Bird M.L. Hill K. Ball M. et al.Effects of resistance- and flexibility-exercise interventions on balance and related measures in older adults.J Aging Phys Act. 2009; 17: 444-454Crossref PubMed Scopus (57) Google Scholar This fact is once again confirmed by one of the two trials performed by Tieland et al26Tieland M. Dirks M.L. van der Zwaluw N. et al.Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 713-719Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar and reported in the October 2012 issue of this journal. This is a randomized, controlled trial with an excellent design in frail older people (defined by Fried’s criteria) living in the community, with higher number of subjects than other trials performed in this population. Subjects were able to comply with a long-term (24 weeks) twice-a-week program of resistance exercise and showed improvements in the main outcome measure (muscle mass) and in some secondary outcomes (ie, leg strength and physical performance). It is interesting to note that the main variable that changed to make the Short Physical Performance Battery significant (ie, >1-point improvement) was chair rise, which is the element more directly linked to leg strength, with no apparent change in gait speed or balance.Nutritional intervention seems to be relevant to improve frailty and sarcopenia.23Candow D.G. Forbes S.C. Little J.P. et al.Effect of nutritional interventions and resistance exercise on aging muscle mass and strength.Biogerontology. 2012; 13: 345-358Crossref PubMed Scopus (60) Google Scholar, 27Malafarina V. Uriz-Otano F. Iniesta R. et al.Effectiveness of nutritional supplementation on muscle mass in treatment of sarcopenia in old age: A systematic review.J Am Med Dir Assoc. 2013; 14: 10-17Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 28Robinson S. Cooper C. Aihie S.A. Nutrition and sarcopenia: A review of the evidence and implications for preventive strategies.J Aging Res. 2012; 2012: 510801Crossref PubMed Scopus (146) Google Scholar, 29Bartali B. Frongillo E.A. Bandinelli S. et al.Low nutrient intake is an essential component of frailty in older persons.J Gerontol A Biol Sci Med Sci. 2006; 61: 589-593Crossref PubMed Scopus (352) Google Scholar However, nutrition is a complex issue, and the precise role of each element or aspect of usual diet and nutritional interventions on outcomes in frailty and sarcopenia is still mostly unknown. Of course, energy intake needs to be sufficient, and most experts agree nowadays that the recommended 0.8 mg/kg body weight for protein intake is inappropriate for elderly individuals if frailty and disability are to be prevented.30Morley J.E. Do frail older persons need more protein?.J Am Med Dir Assoc. 2012; 13: 667-668Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The amount, timing, distribution, quality, and composition of protein supplements, alone or as part of wider nutritional interventions, to improve outcomes in frailty and sarcopenia have been actively explored in recent years. Tieland’s group31Tieland M. van de Rest O. Dirks M.L. et al.Protein supplementation improves physical performance in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 720-726Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar brings new evidence with a well-designed trial that explores the effects of a simple protein supplement in muscle mass and function. Importantly, this trial is negative in its main outcome measure (ie, protein supplements do not increase muscle mass), something that seems not to be unusual in recent trials. However, and importantly, protein supplements show a significant effect in physical performance, which is probably more relevant than muscle mass from a patient and societal perspective. This seems to be mediated through a (borderline) increase in leg strength. The exercise trial adds some relevant information: Exercise seems to be needed, together with proteins, to increase muscle mass.26Tieland M. Dirks M.L. van der Zwaluw N. et al.Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 713-719Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar The optimistic assertion by the authors that an “increase in skeletal muscle mass in the protein- as opposed to the placebo-supplemented group, will likely allow a further increase in muscle strength and performance as time progresses” will still have to be proved, considering the weak relation between muscle mass and strength in this population.26Tieland M. Dirks M.L. van der Zwaluw N. et al.Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 713-719Abstract Full Text Full Text PDF PubMed Scopus (378) Google ScholarTaken together, both trials bring some answers that may be transferred to usual clinical practice. If you can engage your patient in a resistance exercise program, this would be the best approach, because exercise has some effect on muscle mass and function that does not depend on adding proteins (provided, of course, that sufficient amounts of proteins and energy are provided, which may be done with usual diet). Nutritional intervention in patients who exercise may have some role in improving some outcomes, although more research is needed about who needs what. If exercise is not feasible for any reason (a not so unusual clinical scenario, and a familiar one in nursing homes), adding proteins to the diet may improve patients’ outcomes, even if the effect of protein on muscle mass is unclear. Complex interventions (eg, adding other nutrients, including vitamin D, and changing the amount or composition of proteins) are now in clinical trials, which may give us further insight in future months.However, many questions are still open to research. The weak correlation between muscle mass and strength may be because of measurement issues (usual measurement properties of DXA and other techniques used to assess muscle mass have not been properly assessed in older populations) or other aspects of muscle physiology (muscle quality and shape, neuromuscular or hormonal issues) more relevant to muscle function. Head-to-head comparisons of different doses and distributions of protein supplements in well-designed clinical trials are needed, and timing of protein intake in relation with exercise, a fact that seems to be relevant in muscle protein accretion, would have to be reassessed, to confirm whether findings in small trials are confirmed in frail and sarcopenic populations. Tieland does not report on timing of protein to exercise, and this may be difficult to understand when exercise is performed only twice a week. The interaction between different types and doses of exercises and different nutritional interventions needs to be understood in the future.Sarcopenia and frailty are opening a door to one of the basic aims of gerontology: preventing or reverting disability. In the October 2012 issue, this journal published two pieces of high-quality research on this topic. Let’s hope for more. Sarcopenia and frailty are now in the front line of geriatric research. Sarcopenia, initially defined as an age-related loss of muscle mass, is now considered a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk for adverse outcomes such as physical disability, poor quality of life, and death.1Cruz-Jentoft A.J. Baeyens J.P. Bauer J.M. et al.Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.Age Ageing. 2010; 39: 412-423Crossref PubMed Scopus (7159) Google Scholar, 2Landi F. Liperoti R. Fusco D. et al.Sarcopenia and mortality among older nursing home residents.J Am Med Dir Assoc. 2012; 13: 121-126Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar Changes in muscle mass have shown to be poor predictors of clinical outcomes,3Newman A.B. Kupelian V. Visser M. et al.Strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort.J Gerontol A Biol Sci Med Sci. 2006; 61: 72-77Crossref PubMed Scopus (1103) Google Scholar, 4Manini T.M. Clark B.C. Dynapenia and aging: An update.J Gerontol A Biol Sci Med Sci. 2012; 67: 28-40Crossref PubMed Scopus (491) Google Scholar and in intervention studies, changes in muscle mass do not show a clear direct relation with muscle strength and physical performance.5Nass R. Pezzoli S.S. Oliveri M.C. et al.Effects of an oral ghrelin mimetic on body composition and clinical outcomes in healthy older adults: A randomized trial.Ann Intern Med. 2008; 149: 601-611Crossref PubMed Scopus (200) Google Scholar, 6Kim H.K. Suzuki T. Saito K. 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.J Am Geriatr Soc. 2012; 60: 16-23Crossref PubMed Scopus (328) Google Scholar Frailty is a syndrome of decreased reserve and resistance to stressors that results in an increased risk for adverse outcomes. Although the word frailty has been used in geriatric medicine for quite a long time,7Parfentjev I.A. Frailty of old age and bacterial allergy.Geriatrics. 1956; 11: 260-262PubMed Google Scholar and defining an older subject as frail seems to be easy to agree on in practice, a good definition is still lacking.8Abellan van K.G. Rolland Y.M. Morley J.E. et al.Frailty: Toward a clinical definition.J Am Med Dir Assoc. 2008; 9: 71-72Abstract Full Text Full Text PDF PubMed Scopus (418) Google Scholar, 9Rodriguez-Manas L, Feart C, Mann G, et al. Searching for an operational definition of frailty: A Delphi method based consensus statement. The Frailty Operative Definition-Consensus Conference Project. J Gerontol A Biol Sci Med Sci 2012 Apr 16. [Epub ahead of print]Google Scholar Physical frailty is closely related to sarcopenia.10Bauer J.M. Sieber C.C. Sarcopenia and frailty: A clinician’s controversial point of view.Exp Gerontol. 2008; 43: 674-678Crossref PubMed Scopus (168) Google Scholar, 11Jeejeebhoy K.N. Malnutrition, fatigue, frailty, vulnerability, sarcopenia and cachexia: Overlap of clinical features.Curr Opin Clin Nutr Metab Care. 2012; 15: 213-219Crossref PubMed Scopus (128) Google Scholar, 12Cooper C. Dere W. Evans W. et al.Frailty and sarcopenia: Definitions and outcome parameters.Osteoporos Int. 2012; 23: 1839-1848Crossref PubMed Scopus (214) Google Scholar Fried’s criteria, the most widely used definition of phenotypic frailty, are able to predict falls, impaired mobility, activities of daily living disability, hospitalization, and death.13Fried L.P. Tangen C.M. Walston J. et al.Frailty in older adults: Evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156Crossref PubMed Google Scholar Understanding intervention studies in a setting where definitions of the conditions that are treated, and the biomarkers and tools to be used are still evolving is, not surprisingly, confusing.1Cruz-Jentoft A.J. Baeyens J.P. Bauer J.M. et al.Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.Age Ageing. 2010; 39: 412-423Crossref PubMed Scopus (7159) Google Scholar, 14Cesari M. Fielding R.A. Pahor M. et al.Biomarkers of sarcopenia in clinical trials: Recommendations from the International Working Group on Sarcopenia.J Cachexia Sarcopenia Muscle. 2012; 3: 181-190Crossref PubMed Scopus (179) Google Scholar, 15Brass E.P. Sietsema K.E. Considerations in the development of drugs to treat sarcopenia.J Am Geriatr Soc. 2011; 59: 530-535Crossref PubMed Scopus (31) Google Scholar, 16Chumlea W.C. Cesarit M. Evans W.J. et al.International working group on sarcopenia.J Nutr Health Aging. 2011; 15: 450-455Crossref PubMed Scopus (62) Google Scholar, 17Vellas B. Cestac P. Moley J.E. Editorial: Implementing frailty into clinical practice: We cannot wait.J Nutr Health Aging. 2012; 16: 599-600Crossref PubMed Scopus (66) Google Scholar In fact, because sarcopenia and frailty are complex geriatric syndromes, it can be expected that complex interventions will be needed.18Cruz-Jentoft A.J. Landi F. Topinková E. et al.Understanding sarcopenia as a geriatric syndrome.Curr Opin Clin Nutr Metab Care. 2010; 13: 1-7Crossref PubMed Scopus (377) Google Scholar, 19Inouye S.K. Studenski S. Tinetti M.E. et al.Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept.J Am Geriatr Soc. 2007; 55: 780-791Crossref PubMed Scopus (1113) Google Scholar At this time, three different, and probably nonexclusive, approaches are rapidly developing: exercise, nutrition, and drugs. The latest is still in the slow line, as several trials have failed to show a pharmacologic effect of different approaches, except when compensating a deficit (eg, androgens, vitamin D). More basic science is still needed to develop new molecular approaches, and some of these new drugs are already starting clinical trials in humans.15Brass E.P. Sietsema K.E. Considerations in the development of drugs to treat sarcopenia.J Am Geriatr Soc. 2011; 59: 530-535Crossref PubMed Scopus (31) Google Scholar, 20Sakuma K. Yamaguchi A. Novel intriguing strategies attenuating to sarcopenia.J Aging Res. 2012; 2012: 251217Crossref PubMed Scopus (40) Google Scholar Exercise has shown to be beneficial for a number of diseases and conditions, and it is no surprise that it benefits muscle function. This is quite evident for athletes, and it was good to find out that even extremely old and frail individuals can benefit.21Fiatarone M.A. O’Neill E.F. Ryan N.D. et al.Exercise training and nutritional supplementation for physical frailty in very elderly people.N Engl J Med. 1994; 330: 1769-1775Crossref PubMed Scopus (2267) Google Scholar, 22Serra-Rexach J.A. Bustamante-Ara N. Hierro V.M. et al.Short-term, light- to moderate-intensity exercise training improves leg muscle strength in the oldest old: A randomized controlled trial.J Am Geriatr Soc. 2011; 59: 594-602Crossref PubMed Scopus (128) Google Scholar Exercise seems to improve muscle mass and function, and reduce the risk for disability-related outcomes in older people, both living in the community and in nursing homes.23Candow D.G. Forbes S.C. Little J.P. et al.Effect of nutritional interventions and resistance exercise on aging muscle mass and strength.Biogerontology. 2012; 13: 345-358Crossref PubMed Scopus (60) Google Scholar, 24Peterson M.D. Sen A. Gordon P.M. Influence of resistance exercise on lean body mass in aging adults: A meta-analysis.Med Sci Sports Exerc. 2011; 43: 249-258Crossref PubMed Scopus (363) Google Scholar, 25Bird M.L. Hill K. Ball M. et al.Effects of resistance- and flexibility-exercise interventions on balance and related measures in older adults.J Aging Phys Act. 2009; 17: 444-454Crossref PubMed Scopus (57) Google Scholar This fact is once again confirmed by one of the two trials performed by Tieland et al26Tieland M. Dirks M.L. van der Zwaluw N. et al.Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 713-719Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar and reported in the October 2012 issue of this journal. This is a randomized, controlled trial with an excellent design in frail older people (defined by Fried’s criteria) living in the community, with higher number of subjects than other trials performed in this population. Subjects were able to comply with a long-term (24 weeks) twice-a-week program of resistance exercise and showed improvements in the main outcome measure (muscle mass) and in some secondary outcomes (ie, leg strength and physical performance). It is interesting to note that the main variable that changed to make the Short Physical Performance Battery significant (ie, >1-point improvement) was chair rise, which is the element more directly linked to leg strength, with no apparent change in gait speed or balance. Nutritional intervention seems to be relevant to improve frailty and sarcopenia.23Candow D.G. Forbes S.C. Little J.P. et al.Effect of nutritional interventions and resistance exercise on aging muscle mass and strength.Biogerontology. 2012; 13: 345-358Crossref PubMed Scopus (60) Google Scholar, 27Malafarina V. Uriz-Otano F. Iniesta R. et al.Effectiveness of nutritional supplementation on muscle mass in treatment of sarcopenia in old age: A systematic review.J Am Med Dir Assoc. 2013; 14: 10-17Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 28Robinson S. Cooper C. Aihie S.A. Nutrition and sarcopenia: A review of the evidence and implications for preventive strategies.J Aging Res. 2012; 2012: 510801Crossref PubMed Scopus (146) Google Scholar, 29Bartali B. Frongillo E.A. Bandinelli S. et al.Low nutrient intake is an essential component of frailty in older persons.J Gerontol A Biol Sci Med Sci. 2006; 61: 589-593Crossref PubMed Scopus (352) Google Scholar However, nutrition is a complex issue, and the precise role of each element or aspect of usual diet and nutritional interventions on outcomes in frailty and sarcopenia is still mostly unknown. Of course, energy intake needs to be sufficient, and most experts agree nowadays that the recommended 0.8 mg/kg body weight for protein intake is inappropriate for elderly individuals if frailty and disability are to be prevented.30Morley J.E. Do frail older persons need more protein?.J Am Med Dir Assoc. 2012; 13: 667-668Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The amount, timing, distribution, quality, and composition of protein supplements, alone or as part of wider nutritional interventions, to improve outcomes in frailty and sarcopenia have been actively explored in recent years. Tieland’s group31Tieland M. van de Rest O. Dirks M.L. et al.Protein supplementation improves physical performance in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 720-726Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar brings new evidence with a well-designed trial that explores the effects of a simple protein supplement in muscle mass and function. Importantly, this trial is negative in its main outcome measure (ie, protein supplements do not increase muscle mass), something that seems not to be unusual in recent trials. However, and importantly, protein supplements show a significant effect in physical performance, which is probably more relevant than muscle mass from a patient and societal perspective. This seems to be mediated through a (borderline) increase in leg strength. The exercise trial adds some relevant information: Exercise seems to be needed, together with proteins, to increase muscle mass.26Tieland M. Dirks M.L. van der Zwaluw N. et al.Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 713-719Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar The optimistic assertion by the authors that an “increase in skeletal muscle mass in the protein- as opposed to the placebo-supplemented group, will likely allow a further increase in muscle strength and performance as time progresses” will still have to be proved, considering the weak relation between muscle mass and strength in this population.26Tieland M. Dirks M.L. van der Zwaluw N. et al.Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial.J Am Med Dir Assoc. 2012; 13: 713-719Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar Taken together, both trials bring some answers that may be transferred to usual clinical practice. If you can engage your patient in a resistance exercise program, this would be the best approach, because exercise has some effect on muscle mass and function that does not depend on adding proteins (provided, of course, that sufficient amounts of proteins and energy are provided, which may be done with usual diet). Nutritional intervention in patients who exercise may have some role in improving some outcomes, although more research is needed about who needs what. If exercise is not feasible for any reason (a not so unusual clinical scenario, and a familiar one in nursing homes), adding proteins to the diet may improve patients’ outcomes, even if the effect of protein on muscle mass is unclear. Complex interventions (eg, adding other nutrients, including vitamin D, and changing the amount or composition of proteins) are now in clinical trials, which may give us further insight in future months. However, many questions are still open to research. The weak correlation between muscle mass and strength may be because of measurement issues (usual measurement properties of DXA and other techniques used to assess muscle mass have not been properly assessed in older populations) or other aspects of muscle physiology (muscle quality and shape, neuromuscular or hormonal issues) more relevant to muscle function. Head-to-head comparisons of different doses and distributions of protein supplements in well-designed clinical trials are needed, and timing of protein intake in relation with exercise, a fact that seems to be relevant in muscle protein accretion, would have to be reassessed, to confirm whether findings in small trials are confirmed in frail and sarcopenic populations. Tieland does not report on timing of protein to exercise, and this may be difficult to understand when exercise is performed only twice a week. The interaction between different types and doses of exercises and different nutritional interventions needs to be understood in the future. Sarcopenia and frailty are opening a door to one of the basic aims of gerontology: preventing or reverting disability. In the October 2012 issue, this journal published two pieces of high-quality research on this topic. Let’s hope for more." @default.
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• W1980291647 title "Perspective: Protein and Exercise for Frailty and Sarcopenia: Still Learning" @default.
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