Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: the Framingham Heart Study

Sarcopenia, obesity, and inflammation--results from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors study

BACKGROUND

Age-related body-composition changes are associated with health-related outcomes in elders. This relation may be explained by inflammation and hemostatic abnormalities.

OBJECTIVES

Our objectives were to evaluate the relation between body-composition measures [body mass index (BMI), total fat mass, and appendicular lean mass (aLM)] and C-reactive protein (CRP), interleukin 6 (IL-6), and plasminogen activator inhibitor 1 (PAI-1) and to explore the effect of obesity and sarcopenia on CRP, IL-6, and PAI-1 concentrations.

DESIGN

The data are from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study baseline visit (n = 286; mean age = 66.0 y). Total fat mass and aLM were assessed with a dual-energy X-ray absorptiometry scan. Linear regressions were performed between body-composition measures and CRP, IL-6, or PAI-1 concentrations. The effect of sarcopenia and obesity (defined as the percentage of fat mass) on CRP, IL-6, and PAI-1 concentrations was evaluated with the use of analyses of covariance.

RESULTS

CRP and IL-6 were positively associated with both BMI [beta = 0.027 (P = 0.03) and beta = 0.048 (P < 0.001), respectively] and total fat mass [beta = 0.049 (P < 0.001) and beta = 0.055 (P < 0.001), respectively] and were inversely associated with fat-adjusted aLM [beta = -0.629 (P = 0.002) and beta = -0.467 (P = 0.02), respectively]. PAI-1 was positively associated with both BMI (beta = 0.038, P = 0.005) and total fat mass (beta = 0.032, P = 0.007). No significant interaction was found between either obesity or sarcopenia and CRP, IL-6, and PAI-1 concentrations. Obesity remained significantly associated with high CRP and IL-6 concentrations after adjustments for sarcopenia.

CONCLUSIONS

CRP and IL-6 are positively associated with total fat mass and negatively associated with aLM. Obesity-associated inflammation may play an important role in the age-related process that leads to sarcopenia. The relation of inflammation with sarcopenia was not independent of any of the considered obesity indexes.

Role of endocrine-immune dysregulation in osteoporosis, sarcopenia, frailty and fracture risk

Osteoporosis, a key predictor of hip fractures can be treated using a variety of safe and effective interventions. Nevertheless, optimally effective strategies for the prevention of hip fractures must also incorporate efforts to address a broad range of other potentially reversible factors. Hyperthyroidism, anticonvulsants, caffeine and smoking may decrease bone mass and increase fracture risk at any age. In older individuals it is important to also consider additional risk factors, including long-acting benzodiazepines, poor vision and sarcopenia. The presence of sarcopenia, an age-related decline in muscle bulk and quality enhances the risk of frailty and possibly also hip fracture, particularly if associated with diminished functional mobility, lower quadriceps strength and poor balance or body sway. In this review we examine evidence which indicates the presence of endocrine-immune dysregulation in both osteoporosis and sarcopenia. Post-menopausal declines in serum estrogen and androgen levels contribute to increases in local bone levels of cytoclastic cytokines, followed by increased osteoclastogenesis and bone loss. Similarly, the presence of decreased gonadal hormones and IGF-1, combined with unusually high peripheral levels of cytokines, inflammatory mediators and coagulation markers all enhance the risk of sarcopenia and frailty. We propose that a translational research approach which emphasizes common pathophysiologic mechanisms in osteoporosis and sarcopenia could accelerate the speed of discovery of effective strategies for both frailty and hip fracture prevention.

From bedside to bench: research agenda for frailty

The American Geriatrics Society sponsored a working conference in January 2004, funded by the National Institute on Aging, to establish the state of the art in frailty research and to set a research agenda for the future. The invited participants included senior basic biologists, epidemiologists, geneticists, and clinical investigators who study aging-related issues. This article summarizes the central theoretical observations on frailty and research needs and opportunities presented and discussed at this conference, and lays out an agenda for future research on frailty.

Sarcopenia, obesity, and inflammation--results from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors study

BACKGROUND

Age-related body-composition changes are associated with health-related outcomes in elders. This relation may be explained by inflammation and hemostatic abnormalities.

OBJECTIVES

Our objectives were to evaluate the relation between body-composition measures [body mass index (BMI), total fat mass, and appendicular lean mass (aLM)] and C-reactive protein (CRP), interleukin 6 (IL-6), and plasminogen activator inhibitor 1 (PAI-1) and to explore the effect of obesity and sarcopenia on CRP, IL-6, and PAI-1 concentrations.

DESIGN

The data are from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN) study baseline visit (n = 286; mean age = 66.0 y). Total fat mass and aLM were assessed with a dual-energy X-ray absorptiometry scan. Linear regressions were performed between body-composition measures and CRP, IL-6, or PAI-1 concentrations. The effect of sarcopenia and obesity (defined as the percentage of fat mass) on CRP, IL-6, and PAI-1 concentrations was evaluated with the use of analyses of covariance.

RESULTS

CRP and IL-6 were positively associated with both BMI [beta = 0.027 (P = 0.03) and beta = 0.048 (P < 0.001), respectively] and total fat mass [beta = 0.049 (P < 0.001) and beta = 0.055 (P < 0.001), respectively] and were inversely associated with fat-adjusted aLM [beta = -0.629 (P = 0.002) and beta = -0.467 (P = 0.02), respectively]. PAI-1 was positively associated with both BMI (beta = 0.038, P = 0.005) and total fat mass (beta = 0.032, P = 0.007). No significant interaction was found between either obesity or sarcopenia and CRP, IL-6, and PAI-1 concentrations. Obesity remained significantly associated with high CRP and IL-6 concentrations after adjustments for sarcopenia.

CONCLUSIONS

CRP and IL-6 are positively associated with total fat mass and negatively associated with aLM. Obesity-associated inflammation may play an important role in the age-related process that leads to sarcopenia. The relation of inflammation with sarcopenia was not independent of any of the considered obesity indexes.

Physical activity and modulation of systemic low-level inflammation

It has been recognized for some time that cardiovascular disease and type 2 diabetes are, to a major extent, inflammatory disorders associated with an environment characterized by a sedentary lifestyle together with abundant intakes of calories. Systemic low-level inflammation is suggested to be a cause as well as consequence of pathological processes with local tumor necrosis factor alpha production as an important biological driver. It is hypothesized that physical inactivity contributes to an enhanced proinflammatory burden independently of obesity, as regular muscle contractions mediate signals with myokines/cytokines as important messengers, which suppress proinflammatory activity at distant sites as well as within skeletal muscle. Muscle-derived interleukin (IL)-6 is considered to possess a central role in anti-inflammatory activities and health beneficial effects in relation to physical exercise. It is discussed how this fits the consistent observation that enhanced plasma levels of IL-6 represent a strong risk marker in chronic disorders associated with systemic low-level inflammation and all-cause mortality.

An approach to the management of unintentional weight loss in elderly people

Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period. A variety of physical, psychological and social conditions, along with age-related changes, can lead to weight loss, but there may be no identifiable cause in up to one-quarter of patients. We review the incidence and prevalence of weight loss in elderly patients, its impact on morbidity and mortality, the common causes of unintentional weight loss and a clinical approach to diagnosis. Screening tools to detect malnutrition are highlighted, and nonpharmacologic and pharmacologic strategies to minimize or reverse weight loss in older adults are discussed.

Inflamm-ageing and lifelong antigenic load as major determinants of ageing rate and longevity

Immunosenescence is the consequence of the continuous attrition caused by chronic antigenic stress. The most important characteristics of immunosenescence (accumulation of memory and effector T cells, reduction of naive T cells, shrinkage of T cell repertoire, reduction of the immunological space) are compatible with this assumption. Immunosenescence can be taken as proof that the beneficial effects of the immune system, devoted to the neutralization of harmful agents early in life, become detrimental late in life, in a period not foreseen by evolution. This perspective could explain the mechanisms of the ageing process as well as the pathogenesis of age-related diseases.

Age-related differences in skeletal muscle protein synthesis: relation to markers of immune activation

Aging is associated with decreased skeletal muscle mass and function. These changes are thought to derive, in part, from a reduction in skeletal muscle protein synthesis. Although some studies have shown reduced postabsorptive muscle protein synthesis with age in humans, recent studies have failed to find an age effect. In addition to this disparity, few studies have attempted to characterize the hormonal factors that may contribute to changes in protein synthesis. Thus we examined the effect of age on skeletal muscle protein metabolism, with a specific emphasis on myosin heavy chain (MHC) protein, and the relationship of protein synthesis rates to plasma hormone levels. We measured body composition, muscle function, muscle protein synthesis, MHC and actin protein content, MHC isoform distribution, and plasma concentrations of cytokines and insulin-like growth factor-I (IGF-I) in 7 young [29 +/- 2 (SE) yr] and 15 old (72 +/- 1 yr; P < 0.01) volunteers. Mixed-muscle (-19%; P = 0.11), MHC (-22%; P = 0.08), and nonmyofibrillar (-17%; P = 0.10) protein synthesis all tended to be lower in old volunteers. Old volunteers were characterized by increased circulating tumor necrosis factor-alpha receptor II (P < 0.05) and reduced IGF-I (P < 0.01). In addition, plasma C-reactive protein, interleukin-6, and tumor necrosis factor-alpha receptor II concentrations were negatively related to mixed-muscle and MHC protein synthesis rates (range of r values: -0.422 to -0.606; P < 0.05 to <0.01). No differences in MHC or actin protein content were found. Old volunteers showed reduced (P < 0.05) MHC IIx content compared with young volunteers but no differences in MHC I or IIa. Our data show strong trends toward reduced postabsorptive muscle protein synthesis with age. Moreover, reduced muscle protein synthesis rates were related to increased circulating concentrations of several markers of immune activation.

Recombinant Human Insulin-Like Growth Factor I (IGF-I): Risks and Benefits of Normalizing Blood IGF-I Concentrations

Recombinant human (rh) insulin-like growth factor I (IGF-I) is being developed as a therapy for short stature caused by IGF deficiency (IGFD) and also for diabetes mellitus. To complement the human efficacy and safety data, a large amount of information is available regarding the pharmacology and toxicology of rhIGF-I in animals. This review summarizes the risks and benefits of normalizing blood IGF-I concentrations in IGFD, especially with regard to carcinogenicity, and compares and contrasts safety data for rhIGF-I, recombinant human growth hormone (rhGH), and insulin. A major difference between rhIGF-I and rhGH is that rhIGF-I (like insulin) has hypoglycaemic activity, whereas rhGH opposes insulin action and is diabetogenic. In most of their actions, GH and IGF-I are similar. IGF-I mediates most of the actions of GH, so the safety of rhGH and that of rhIGF-I also share many common features. In animals, the transgenic expression of hGH has been shown to act directly, by activating the prolactin receptor, to increase the incidence of mammary and prostate tumours. In comparison, the over-expression of IGF-I in animals or the administration of rhIGF-I does not have a carcinogenic effect. In formal toxicology and carcinogenicity studies, rhIGF-I has similar effects to insulin in that it can increase food intake, body size, and the growth rate of existing tumours. In animals and humans, IGFD has many long-term detrimental effects besides short stature: it increases the risk of diabetes, cardiovascular disease, and low bone mineral density. Therefore, a case can be made for replacement therapy with rhIGF-I to normalize blood IGF-I levels and reverse the detrimental effects of IGFD.

Emerging drugs for sarcopenia: age-related muscle wasting

Sarcopenia is the term widely used to describe the progressive loss of muscle mass with advancing age. Even before significant muscle wasting becomes apparent, ageing is associated with a slowing of movement and a gradual decline in muscle strength, factors that increase the risk of injury from sudden falls and the reliance of the frail elderly on assistance in accomplishing even basic tasks of independent living. Sarcopenia is recognised as one of the major public health problems now facing industrialised nations, and its effects are expected to place increasing demands on public healthcare systems worldwide. Although the effects of ageing on skeletal muscle are unlikely to be halted or reversed, the underlying mechanisms responsible for these deleterious changes present numerous targets for drug discovery with potential opportunities to attenuate muscle wasting, improve muscle function, and preserve functional independence. Very few drugs have been developed with sarcopenia specifically in mind. However, because many of the effects of ageing on skeletal muscle resemble those indicated in many neuromuscular disorders, drugs that target neurodegenerative diseases may also have important relevance for treating age-related muscle wasting and weakness. This review describes a selection of the emerging drugs that have been developed during the period 1997 - 2004, relevant to sarcopenia.

Muscle fiber specific apoptosis and TNF-alpha signaling in sarcopenia are attenuated by life-long calorie restriction

Increased tumor necrosis factor-alpha (TNF-alpha) levels have been found with age and are connected to muscle atrophy and cell loss, yet the signaling events that occur in vivo are unknown. Calorie restriction (CR), a robust intervention shown to repeatedly evade the physiological declines associated with aging, has been reported to reduce TNF-alpha and may assist in understanding the mechanisms of muscle sarcopenia. The effects of age and CR on muscle mass, myocyte area, fiber number, myocyte TNF-alpha expression, plasma TNF-alpha levels, and specific elements linked with the TNF-alpha signaling cascade (TNF-R1, IKKgamma, IkappaBalpha, p65, NF-kappaB binding activity, FADD, caspase-8, and DNA fragmentation) were investigated in soleus (predominately Type I fiber), and superficial vastus lateralis (SVL, predominately Type II fiber), of 6-month-old ad libitum fed (6AL), 26-month-old ad libitum fed (26AL), and 26-month-old calorie-restricted (26CR) male Fischer 344 rats (CR = 40% restriction compared with ad libitum). Plasma TNF-alpha was increased with age, and the age-associated rise was attenuated with life-long CR. In soleus muscle, we reported a greater capacity to cultivate inflammatory signaling through the transcription factor NF-kappaB compared with that detected in SVL with age. In contrast, in the SVL TNF-alpha stimulated apoptotic signaling with age to a much higher extent than was observed in the soleus. Moreover, a reduction in muscle mass, cross-sectional area, and fiber number in the SVL coincided with this age-linked elevation in apoptosis. In agreement with CR's ability, TNF-alpha stimulation of both inflammatory and apoptotic pathways were abrogated. Our results suggest that TNF-alpha signals transmitted to specific fiber types determine the decision of selecting life or death signaling pathways and are linked to the extent of fiber loss experienced in the aging muscle. Such a specific potential may constitute a major proponent in the pathogenesis of sarcopenia.

Prognostic importance of low body mass index in relation to cardiovascular mortality in rheumatoid arthritis

OBJECTIVE

Various etiologic mechanisms have been implicated in the observed increase in cardiovascular mortality in rheumatoid arthritis (RA). Body mass index (BMI) is associated with cardiovascular mortality in the general population. This study compared the effect of BMI on cardiovascular mortality in a population-based cohort of subjects with RA with that in a cohort of individuals without RA from the same population.

METHODS

The RA cohort comprised all members of an incidence cohort of Rochester, Minnesota residents ages > or =18 years who were first diagnosed with RA (by the American College of Rheumatology 1987 criteria) from 1955 through 1994. An age- and sex-matched comparison cohort of subjects without RA was assembled. Both cohorts were followed up longitudinally through their complete (inpatient, outpatient) medical records beginning at age 18 years and continuing until death, migration, or January 1, 2001, and the details of weight and height changes during this period were recorded. High BMI was defined as a BMI >30 kg/m(2) and low BMI as <20 kg/m(2). Cox regression models were used to estimate the effect of BMI on cardiovascular mortality after accounting for traditional cardiac risk factors and malignancies.

RESULTS

RA subjects with low BMI at incidence had a significantly higher risk of cardiovascular death (hazard ratio [HR] 3.34, 95% confidence interval [95% CI] 2.23-4.99) compared with non-RA subjects with normal BMI, after adjusting for age, sex, personal cardiac history, smoking status, and presence of diabetes, hypertension, and malignancies. RA subjects with normal BMI at incidence who experienced low BMI during followup also had a higher risk of cardiovascular death (HR 2.09, 95% CI 1.50-2.92) when compared with non-RA subjects who maintained normal BMI throughout followup.

CONCLUSION

Among patients with RA, low BMI is associated with a significantly increased risk of cardiovascular death.

Age impairments in sleep, metabolic and immune functions

Age-related sleep impairments are chronic and common, occurring even in the absence of diagnosable disorders. Additional loss of sleep occurs with clinical sleep disorders, many of which can be ameliorated. This literature, reviewed below, raises the question of the possible biological consequences of age-related, chronic sleep loss, an area that is poorly understood at present. Some of the more age-relevant theories about sleep loss will be explored in a review of current research on sleep deprivation arising from normal aging, experimental induction and pathology. The biological consequences of sleep deprivation in young adults include metabolic, systemic inflammatory and immune changes that are similar to those of aging and age-related disorders. The possibility that chronic sleep impairment contributes to age changes in metabolism, systemic inflammation and immunocompetence is explored.

Somatostatin inhibits IGF-1 mediated induction of VEGF in human retinal pigment epithelial cells

Neovascularization stimulated by IGF-1 mediated induction of vascular endothelial growth factor (VEGF) is one of the leading causes of blindness in humans. It plays a central role in the pathogenesis of proliferative diabetic retinopathy (DR), neovascular glaucoma, exudative age-related macular degeneration (AMD) and retinopathy of prematurity. Neovascularization is a multi-step process that involves complex interactions of a variety of mitogenic factors such as VEGF and IGF-I which are produced locally in the human eye by a variety of cells including retinal pigment epithelial (RPE) cells, retinal capillary pericytes, endothelial cells, Mueller cells and ganglion cells. We hypothesized that somatostatin would inhibit the IGF-1 signal transduction pathway in RPE cells, resulting in decreased VEGF production. We have observed expression of somatostatin receptor protein in retinal pigment epithelial (RPE) cells of the human eye using immunohistochemistry and have confirmed expression of somatostatin receptors in cultured human RPE cells using reverse transcriptase-PCR. IGF-1 induced a dose dependent increase in IGF-1R phosphorylation and in VEGF mRNA levels in cultured human RPE cells. Somatostatin and octreotide, a somatostatin analogue, inhibited IGF-1 receptor (IGF-1R) phosphorylation and decreased VEGF production. Both IGF-1R phosphorylation and accumulation of VEGF mRNA were inhibited by physiological levels of somatostatin and octreotide (1 nM). These results demonstrate somatostatin and octreotide mediated attenuation of both IGF-1R signal transduction and VEGF mRNA accumulation via somatostatin receptor type 2 (sst2). Furthermore, these data suggest a rationale for the use of octreotide as a prophylactic and therapeutic option in disease states that cause ocular neovascularization.