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