Tuesday, August 01, 2023

Muscle and Successful Aging

By Viviane Knight

Most of my clients (myself included), fear the possible loss of their independence in aging as a result of a catastrophic fall. Just as concerning, but not as openly talked about, is the fear of not being able to meet their own needs of everyday tasks such as chores around the house, showering, and driving, often called the activities of daily living or ADL’s.

Most adults achieve their peak muscle mass sometime during their late 30s to early 40s, and it is normal to gradually lose muscle size and power as we age.

However, the extreme frailty often associated with aging is anything but normal.

Sadly, the outcome of frailty increases after a fall. It’s the chicken vs the egg dilemma: weakness and loss of mass increase our risk of falling and each fall becomes progressively harder to recover from, thus facilitating frailty.

Muscle as a measurable marker of aging

Dr. William Evans, adjunct professor of Human Nutrition, and researcher at the University of California, Berkeley was the first to describe sarcopenia, the accelerated loss of muscle mass (or quality), muscle strength and muscle function. Given that approximately 40–50% of the population over 80 years of age suffers from sarcopenia, this condition has been recognized as a major aging ailment.

The formal diagnosis of sarcopenia must be comprehensively based on these three aspects: muscle mass, muscle strength, and muscle function. I’ll provide a brief overview of all three:

Muscle function can be easily assessed with a questionnaire, called the SARC-F screening test, developed by Theodore Malmstrom and John Morley in 2013. In the SARC-F (Strength, Assistance with walking, Rise from a chair, climb stairs, and Falls) questionnaire, each of the five components has 2 possible points for a total of 10 points. A total score of ≥4 points indicates that the risk of sarcopenia is increased.

SARC-F Screening Test for Sarcopenia

Component

Strength

Assistance with
walking

Rise from a
chair


Climb stairs


Falls


Question

How much difficulty do you have in lifting & carrying 10lbs?

How much difficulty do you have walking across a room?

How much difficulty do you have transferring/rising from a chair or a bed?

How much difficulty do you have climbing a flight of 10 stairs?

How many times have you fallen in the past year?

Scoring

None - 0
Some - 1
A lot or unable - 2

None - 0
Some - 1
A lot, use aids, or unable - 2

None - 0
Some - 1
A lot or unable without help - 2

None - 0
Some - 1
A lot or unable - 2

None - 0
1 to 3 falls - 1
4 + falls - 2

Muscle strength can be easily determined using two easy, cost-efficient tests: Handgrip strength and Gait speed.

It has been found to be a robust predictor of the overall state of strength among different age groups. The association between handgrip strength, frailty and mortality has been observed in multiple populations ranging from hospitalized older female patients to healthy middle-aged men followed for 30 years. Everyday activities such as opening jars, carrying grocery bags, pulling/pushing doors and turning doorknobs become exceedingly difficult with low handgrip strength.

In general, lowered handgrip strength increases with age in both men and women. Because of the hormonal effect of menopause, as well as structural and mechanical changes at the cellular level, there is increased muscle tissue degeneration and reduction of bone density, for which women have a significantly lower handgrip strength than men. Therefore, the parameters that determine the strength of the handgrip are defined by age (60 to 64; 65 to 69; 70 and over) and gender, as well as by hand used.

The test is done using a hand-held dynamometer, usually by a physical or occupational therapist. The patient squeezes the dynamometer with all their strength, typically three times with each hand. An average score is then calculated using the measurements from both hands.

Reference values for dynamometry by age group and gender.

Age group

Male right hand

Male left hand

Female right hand

Female left hand

60-64

41

33

25

20

65-69

41

33

23

20

70+

32

30

20

19

It is important to emphasize that having lower than reference value grip strength does not necessarily mean that a person is in poor health, but his or her quality of life is impaired on some level.

However, even the smallest recommended daily amount of physical activity reduces the risk of developing disability, improves muscle, bone, and joint strength, and contributes to an overall better quality of life. The second test for muscle strength is Gait or Walking speed. Evaluating gait speed involves allowing the subject to walk a short distance, selecting the maximum step speed within the timed distance, and calculating the average step speed in m/s. This test can be administered by your doctor or more often done in physical therapy setting. The following chart stratifies the results and potential implications.

Muscle mass is the final assessment of the three

Why is the Functional model of health so important?

And is considerably more complicated, being calculated with complex algorithms and costly. There are a multitude of ways to assess your muscle mass amount, most of which require a clinical or hospital setting: dual energy X-ray absorptiometry (DEXA), computed tomography (CT), bioelectrical impedance assessment (BIA), deuterated water (D2O), ultrasound (US) and magnetic resonance imaging (MRI) scans.

Muscle mass is the final assessment of the three

And is considerably more complicated, being calculated with complex algorithms and costly. There are a multitude of ways to assess your muscle mass amount, most of which require a clinical or hospital setting: dual energy X-ray absorptiometry (DEXA), computed tomography (CT), bioelectrical impedance assessment (BIA), deuterated water (D2O), ultrasound (US) and magnetic resonance imaging (MRI) scans.

None of these methods measure skeletal muscle mass amount directly, and each method becomes less accurate if body water content or hydration level changes, a condition that is quite common in many illnesses.

Hydration levels do vary even in healthy individuals over the course of a few hours, so it is a confounding variable for sure. Dehydration directly impacts muscle mass/weight because muscle is 70-75% water. Currently, MRI represents the most advanced and accurate technique for the study of body composition, and assessment of muscle mass. Even more accurate are serial, or many MRI measurements of an individual taken over a period of time. Below are MRI scans of the hip region of both male and female, young and older.

A is a young male. B is an older male. C is a young female. D is and old female. Arrow points to muscle.

Back to Dr. Evans….

Dr. Evans believes that muscle mass is a prominent, measurable marker of healthy aging. He states:

"Muscle mass is strongly related to things like how fast you walk, your grip strength, and your fall and fracture risk. In fact, it appears that in older adults, muscle mass is more strongly correlated to the risk of a hip fracture than is their bone density.”

Wait, what did he just say?

That bone density may not be as important as the amount of muscle on your body when it comes to preventing a fall. *
(*I just want to qualify that this my interpretation in my own words.)

Dr. Evans goes on to say:

“In very old adults, bone density is often low, but muscle mass is variable between individuals.”

The image to the left is of the upper thigh muscle of two men close in age. Extremes of muscle amount are obvious between the sedentary 74-year-old and a 70-year-old triathlete, validating Dr. Evans’ quote above.

There does exist a simple at home assessment of muscle mass – that is measuring the circumference of your calf muscle. The calf circumference measurement is not as accurate as an MRI scan (or a substitute) but can alert you to a potential risk for developing sarcopenia.
The only equipment needed is a tape measure. Here are the steps:

1. Plant your foot firmly on the floor, while in a seated position.
2. Wrap the tape measure around the widest part of your calf, typically the center of your muscle, and record the measurement.
3. Take two more readings of the same calf.
4. Do the same procedure on the other calf, recording the three measurements.
5. Take the average of the six measurements and compare them to the chart below.

Average Calf Circumference Chart

Age Group

50-59

60-69

70-79

80+

Men, avg calf circumference

15.6 inches

15.4 inches

14.9 inches

14.2 inches

Women, avg calf circumference

15.2 inches

15.1 inches

14.4 inches

13.9 inches

If there is cause for concern in any of these test results, please seek the advice of your physician for your next steps.

As of this writing, there are no FDA-approved medications for the treatment of sarcopenia. However, the effects of exercise and nutritional interventions on patients with sarcopenia have been examined in numerous studies and have shown to be of tremendous benefit.

Exercise, especially resistance/strength training

The established link between inactivity and loss of muscle mass, strength, and function strongly suggests that physical activity should be both protective of, and a treatment for sarcopenia. A range of exercise interventions, such as strength or resistance training, functional training, balance training, as well as aerobic training, all have been used. Study after study has found that regular exercisers live as much as a decade longer and more independently, than sedentary folks.

All forms of exercise have their rightful place at the table of successful aging.

However, progressive resistance/strength training (PRT), in which participants exercise against an increasing external load, has been shown to have positive effects on muscle strength and muscle function.

In a meta analysis of 121 clinical trials that included 6700 people, researchers found that PRT could help people:

  • Gain muscle strength
  • Walk faster
  • Get out of a chair more quickly
  • ​Go up steps more easily
  • Have less arthritis pain
  • ​Enhanced daily activities like cooking or bathing more easily

Cautuion, too much exercise, too soon, can increase the risk of injury, so it’s important to start slow. Talk to your doctor before beginning a new workout program, especially if you have other health conditions. Your doctor can give you general recommendations for an exercise plan that is best for you.

A research paper has shown that after doing PRT training for 12 weeks, two times per week, people in an assisted living facility over the age of 90 improved their strength, power and muscle mass -it’s never too late to begin a resistance exercise program. I often hear that folks are afraid of hurting their back, or something else from exercise. We know that exercise does not worsen osteoarthritis. We also know that everyone will experience some back pain or shoulder pain, etc. within their lives. In my opinion, the risk of sarcopenia and frailty outweighs the risks of performing exercise under proper guidance.

Try taking a class geared towards seniors at your local gym, community center, or online. Additionally you can seek the assistance of a certified fitness trainer. Many gyms offer complimentary orientation sessions to new members which include an introduction to the strength equipment. As a general recommendation, exercises to work your leg muscles specifically, should be of top priority – including your calf muscles.

Peter Attia, MD states in his book ‘Outlive’, “Think of strength training as a form of retirement saving. Reaching older age with enough of a “reserve” of muscle can protect us from injury and allow us to continue to pursue the activities we enjoy.” I second that and practice it myself.

Nutrition for preserving and building muscle

Our nutrient needs change throughout our lifespan. Protein is the most valuable nutrient for building and repairing muscle fibers. Currently, the recommended dietary allowance (RDA) for protein is 50 grams of protein per day or 0.8 gram per kilogram (g/kg) of body weight a day for men and women 19 and older, whichever is greater.

It is important to note that the original RDA recommendations were made based on studies conducted in young healthy adults and do not take into account the many physiological changes that occur with aging. Additionally, these recommendations were based on the premise of preventing deficiency as opposed to, promoting optimal health, which is of greater importance in the older population.

The often cited scientific research paper ‘Nutrition for Sarcopenia’ by Hidekatsu Yanai in the Journal of Clinical Medicine Research, suggests that an optimal dietary protein intake is 1.0 - 1.2 g/kg (body weight)/day was recommended to prevent sarcopenia or maintain current muscle mass. For a 150 lb woman, that is 68-81 g of total protein per day.

For those with sarcopenia, protein needs are even higher at 1.2 - 1.5 g/kg a day, because muscle growth is dependent upon an adequate, consistent supply of the amino acid building blocks.

Using the above example, that same 150 lb woman should consume between 81 to 100 grams high quality protein per day.

To put this into some perspective, a 6-ounce serving of non-fat Greek yogurt has 18 grams; a half-cup of 1% fat cottage cheese, 14 grams; a 3-ounce serving of skinless chicken breast, 28 grams; a half-cup of lentils, 9 grams; and a cup of skim milk, 8 grams.

Yes, increasing protein will take deliberate effort on your part.

To figure out how much protein you need, take your body weight in pounds and multiply it by 0.45. This gives you your body weight in kilograms. Next, multiply that number by the g/kg/day protein amount you desire to eat (i.e. 1.0-1.2, or 1.2 to 1.5).

Collectively, the scientific data indicate that both the total daily protein amount and the patterns of intake are important to maximally stimulate muscle growth and maintain muscle mass and function in older adults.

The research strongly suggests that spreading out protein consumption equally over your meals is optimal to keep you in a consistent muscle protein maintainence state. Practically speaking, this means rethinking what you eat at breakfast, when protein intake tends to be lowest. “Oatmeal or a bagel isn’t enough; people should think of adding a non-fat Greek yogurt, 2-3 eggs or a few turkey sausages,” says Dr. Elena Volpi, a professor of geriatrics and cell biology at the University of Texas Medical Branch in Galveston, Texas.

Alternatively, a protein smoothie is also appealing, as you can sip it as you go about your morning. Often, my easy fix is to add a scoop of whey protein isolate in my blender bottle to a cold cup of coffee in the warmer months.

Here’s a recipe for a ‘real food’ smoothie you may like:

“Dessert for Breakfast” Smoothie
(Gluten-free, vegetarian) 1 SERVING
Ingredients:
½ cup 1 percent milk
½ cup plain low-fat Greek yogurt
1 tablespoon unsweetened cocoa powder
1 ½ tablespoons peanut butter
1 small banana (can use frozen)
1 tablespoon avocado
2 teaspoons hemp seeds
Handful of ice (or more, based on preference)
Dash of cinnamon

To prepare:
Place all ingredients in a blender and blend until smooth.
Nutritional information: 440 calories, 25g protein, 22g fat, 44g carbohydrates, 7g fiber, 308mg calcium, 989mg potassium, 198mg sodium, 1.16 mcg B12, 1.12g leucine, 11mg vitamin C

Lunch protein amount is better, but often not optimal either Dr. Volpi states. For example, a study in Nutrition Journal focused on older German adults who got about the same amount of protein each day. It revealed that those who concentrated their protein grams at lunch and dinner were significantly more likely to be frail than those who ate protein at every meal. Uneven protein distribution throughout the day was also associated with slower walking speed and fatigue, the study found.

When it comes to positively impacting sarcopenia, it’s not just how much protein you eat, but also the source of your protein. Not all protein is created equal, and the type of protein you eat seems to play a role in preventing muscle loss.

Dietary protein is made up many types of amino acids. Our body can make some amino acids on its own, but some must be obtained from protein-rich foods. Of the 20 total amino acids, certain ones are considered “essential” and others are “nonessential”. We need them both.

The amino acid leucine has specifically been shown to trigger muscle protein synthesis. Leucine is classified as one of the ‘essential’ amino acids, which means our bodies cannot produce it, so we must get it from food sources.

Leucine is found in highest amounts in animal foods, including beef, lamb, poultry, fish, eggs, milk and products made with milk. It’s also found in soybeans and, to a lesser extent, other beans, nuts and seeds.

While animal protein is inarguably a natural part of the human diet, it is not the only food humans should be eating. An abundance of anthropological and nutrition science research indicates that the optimal human diet includes whole sources of both plant and animal foods—not just meat

Animal versus plant protein is a hotly debated topic at the moment, filled with strong emotions. Please note that this post does not discuss the implications of eating animal protein from an ecological or moral perspective, nor does it imply that animal protein is the only way to fulfil daily protein requirements in preserving muscle mass.

The old saying “too much of a good thing is a bad thing” holds true with almost every nutrient, including protein. While protein is vitaly important, it is a delicate balance. Providing too much protein can cause issues like dehydration and in those with kidney disease, it can further kidney damage.

To end on a less science-nerdy note…

Happily and thankfully, there are many examples of fully functional, independent living 80, 90 and 100+ year olds. You may have some in your own family! Dan Buettner describes centenarians and super-centenarians in his book “The Blue Zones”.

The highest concentrations of centenarians reside around the world in Sardinia, Italy, Okinawa, Japan, Ikaria, Greece, the Nicoya peninsula in Costa Rica and Loma Linda, California.

Centenarians focus on eating what they grow, tending to their homes, gardens and livestock, and spending time with family and friends. Additionally, they practice a strong religious faith and have purpose for each day.

There is limited information on the relationship between health care and centenarian health in the Blue Zones. Health care as we know it in the United States, as administered by a doctor and/or medicines, does not seem to be their focus – rather, a healthy, active lifestyle takes the top priority.

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