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Lim H, Jani NDB, Pang WT, Lim ECW. Community-based exercises improve health status in pre-frail older adults: A systematic review with meta-analysis. BMC Geriatr 2024; 24:589. [PMID: 38987690 PMCID: PMC11234756 DOI: 10.1186/s12877-024-05150-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 06/14/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Pre-frailty is associated with increased healthcare utilization. Over the past decade, public health interventions such as community-based exercises to target pre-frailty have been increasingly studied. However, the effects of community-based exercises on clinical outcome measures amongst community-dwelling older adults with pre-frailty remain unclear. This review aims to better understand the effects of community-based exercise on physical function, cognition, quality of life and frailty status in community-dwelling pre-frail older adults. A secondary objective was to investigate the optimal exercise parameters on clinical outcomes. METHODS Searches of MEDLINE, CINAHL, Google Scholar and Web of Science databases were conducted. Articles were included if they were randomized controlled trials (RCTs), and excluded if the participants consist of less than 50% pre-frail community-dwelling older adults. Meta-analyses (where possible) with either a fixed- or random- effect(s) model, standardized mean difference (SMD), odds ratio (OR) and tests of heterogeneity were performed. Multivariable meta-regression was performed to identify predictors of statistically significant outcome measures. The risk of bias was assessed using the modified Cochrane Risk-of-Bias tool. RESULTS Twenty-two RCTs with 900 participants in the experimental group and 1015 participants in the control group were included. When compared to minimal intervention, community-based exercises significantly improved lower limb strength (10 RCTs, 384 participants in the experimental group and 482 participants in the control group) with SMD 0.67 (95% CI 0.29 to 1.04), and lower limb function (5 RCTs, 120 participants in the experimental group and 219 participants in the control group) with SMD 0.27 (95% CI 0.03 to 0.51). Those who have received community-based exercises were more likely to reverse from pre-frailty to healthy state (OR = 2.74, 95% CI 1.36 to 5.51) (6 RCTs, 263 participants in the experimental group and 281 participants in the control group). The frequency of exercise sessions was a significant predictor of the effect size for gait speed (P<0.05). CONCLUSIONS Community-based exercise intervention is superior to minimal intervention for improving health status in pre-frail older adults. This has implications on the implementation of community-based exercise intervention by healthcare providers and policymakers. OTHER Nil funding for this review. PROSPERO registration number CRD42022348556.
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Affiliation(s)
- Huijun Lim
- New Hope Community Services, Yishun, Singapore
| | | | | | - Edwin Choon Wyn Lim
- Health and Social Sciences Cluster, Singapore Institute of Technology, Dover, Singapore.
- Active Global Home and Community Care, 51 Goldhill Plaza, #12-11, Novena, 308900, Singapore.
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2
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Riddle E, Munoz N, Clark K, Collins N, Coltman A, Nasrallah L, Nishioka S, Scollard T, Simon JR, Moloney L. Prevention and Treatment of Malnutrition in Older Adults Living in Long-Term Care or the Community: An Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2024; 124:896-916.e24. [PMID: 38583584 DOI: 10.1016/j.jand.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
Malnutrition in older adults can decrease quality of life and increase risk of morbidities and mortality. Accurate and timely identification of malnutrition, as well as subsequent implementation of effective interventions, are essential to decrease poor outcomes associated with malnutrition in older adults. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based nutrition practice guideline for the prevention and treatment of malnutrition in older adults. The objective of this guideline was to provide evidence-based recommendations to identify, prevent, or treat protein-energy malnutrition in older adults (mean age ≥65 years) living in long-term care and community settings. This guideline provides 11 nutrition recommendations to inform shared decision making among dietitians, members of the health care team, family members or caregivers, and older adults living in long-term care or the community to prevent or treat malnutrition. Topics include dietitian effectiveness, nutrition assessment tools, oral nutrition supplements, food fortification, and home-delivered and congregate meals. Guideline implementation should include consideration of the importance of comprehensive individualized nutrition care for older adults. Future research is needed to address gaps that were identified related to the validity, reliability, and feasibility of nutrition assessment tools, as well as the effectiveness of dietitian interventions on outcomes of interest in older adults living in long-term care and the community.
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Affiliation(s)
- Emily Riddle
- State University of New York at Oneonta, Oneonta, New York
| | - Nancy Munoz
- Veterans Affairs Southern Nevada Healthcare System, Las Vegas, Nevada
| | | | | | - Anne Coltman
- Commission on Dietetic Registration, Chicago, Illinois
| | - Lamia Nasrallah
- Outpatient Nutrition Services, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Shinta Nishioka
- Department of Clinical Nutrition and Food Services, Nagasaki Rehabilitation Hospital, Nagasaki, Japan
| | | | - Judy R Simon
- Nutrition and Health Promotion Consultant, Easton, Maryland
| | - Lisa Moloney
- Academy of Nutrition and Dietetics, Chicago, Illinois.
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3
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Zheng Y, Feng J, Yu Y, Ling M, Wang X. Advances in sarcopenia: mechanisms, therapeutic targets, and intervention strategies. Arch Pharm Res 2024; 47:301-324. [PMID: 38592582 DOI: 10.1007/s12272-024-01493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/25/2024] [Indexed: 04/10/2024]
Abstract
Sarcopenia is a multifactorial condition characterized by loss of muscle mass. It poses significant health risks in older adults worldwide. Both pharmacological and non-pharmacological approaches are reported to address this disease. Certain dietary patterns, such as adequate energy intake and essential amino acids, have shown positive outcomes in preserving muscle function. Various medications, including myostatin inhibitors, growth hormones, and activin type II receptor inhibitors, have been evaluated for their effectiveness in managing sarcopenia. However, it is important to consider the variable efficacy and potential side effects associated with these treatments. There are currently no drugs approved by the Food and Drug Administration for sarcopenia. The ongoing research aims to develop more effective strategies in the future. Our review of research on disease mechanisms and drug development will be a valuable contribution to future research endeavors.
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Affiliation(s)
- Youle Zheng
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, 430070, Hubei, China
| | - Jin Feng
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, 430070, Hubei, China
| | - Yixin Yu
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, 430070, Hubei, China
| | - Min Ling
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, 430070, Hubei, China
| | - Xu Wang
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, 430070, Hubei, China.
- MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Huazhong Agricultural University, Wuhan, 430070, Hubei, China.
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4
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Liao CD, Huang SW, Chen HC, Huang MH, Liou TH, Lin CL. Comparative Efficacy of Different Protein Supplements on Muscle Mass, Strength, and Physical Indices of Sarcopenia among Community-Dwelling, Hospitalized or Institutionalized Older Adults Undergoing Resistance Training: A Network Meta-Analysis of Randomized Controlled Trials. Nutrients 2024; 16:941. [PMID: 38612975 PMCID: PMC11013298 DOI: 10.3390/nu16070941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Aging-related sarcopenia exerts harmful impacts on muscle mass, strength, and physical mobility. Protein supplementation has been demonstrated to augment efficacy of resistance training (RT) in elderly. This study compared the relative effects of different protein supplements on muscle mass, strength, and mobility outcomes in middle-aged and older individuals undergoing RT. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) examining the efficacy of protein supplement plus RT in untrained community-dwelling adults, hospitalized, or institutionalized residents who suffered acute or chronic health conditions. Network meta-analysis (NMA) was performed using a frequentist method for all analyses. Treatment effects for main outcomes were expressed as standard mean difference (SMD) with 95% confidence interval (CI). We used the surface-under-the cumulative-ranking (SUCRA) scores to rank probabilities of effect estimation among all identified treatments. Meta-regression analyses were performed to identify any relevant moderator of the treatment efficacy and results were expressed as β with 95% credible interval (CrI). We finally included 78 RCTs (5272 participants) for analyses. Among the six protein sources identified in this NMA, namely whey, milk, casein, meat, soy, and peanut, whey supplement yielded the most effective treatments augmenting efficacy of RT on muscle mass (SMD = 1.29, 95% CI: 0.96, 1.62; SUCRA = 0.86), handgrip strength (SMD = 1.46, 95% CI: 0.92, 2.00; SUCRA = 0.85), and walking speed (SMD = 0.73, 95% CI: 0.39, 1.07; SUCRA = 0.84). Participant's health condition, sex, and supplementation dose were significant factors moderating the treatment efficacy on muscle mass (β = 0.74; 95% CrI: 0.22, 1.25), handgrip strength (β = -1.72; 95% CrI: -2.68, -0.77), and leg strength (β = 0.76; 95% CrI: 0.06, 1.47), respectively. Our findings suggest whey protein yields the optimal supplements to counter sarcopenia in older individuals undergoing RT.
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Affiliation(s)
- Chun-De Liao
- International Ph.D. Program in Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, New Taipei City 110301, Taiwan;
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan; (S.-W.H.); (H.-C.C.); (T.-H.L.)
| | - Shih-Wei Huang
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan; (S.-W.H.); (H.-C.C.); (T.-H.L.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 110301, Taiwan
| | - Hung-Chou Chen
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan; (S.-W.H.); (H.-C.C.); (T.-H.L.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 110301, Taiwan
| | - Mao-Hua Huang
- Department of Biochemistry, University of Washington, Seattle, WA 98015, USA;
| | - Tsan-Hon Liou
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235041, Taiwan; (S.-W.H.); (H.-C.C.); (T.-H.L.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 110301, Taiwan
| | - Che-Li Lin
- Department of Orthopedic Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, New Taipei City 11031, Taiwan
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Zheng Y, Yu Y, Feng J, Ling M, Wang X. Unveiling the Potential of Nelumbo nucifera-Derived Liensinine to Target The Myostatin Protein and to Counteract Muscle Atrophy. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2024; 72:2240-2249. [PMID: 38258624 DOI: 10.1021/acs.jafc.3c09002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Muscle atrophy refers to a decline in muscle mass and function, which has become a global concern due to the aging population. Various clinical trials have investigated the inhibitors of myostatin (MSTN). They have shown promising improvements in muscle function and quality of life. However, there are no drugs specifically targeting MSTN that have been approved for clinical use. In this study, we virtually screened liensinine (LIE), a food (Nelumbo nucifera)-derived compound, with low toxicity, from over 1.1 million compounds. We subsequently identified it as a potential candidate that targets MSTN by a cellular thermal shift assay (CETSA) and drug affinity response target stability (DARTS) assay. Further validation through cellular and in vivo studies demonstrated its promising potential in combating muscle atrophy. The mechanism of action may involve hindering the interaction between MSTN and the activin receptor type IIB (ActRIIB) and downregulating the expression of downstream proteins, including the muscle RING-finger protein-1 (MuRF-1) and muscle atrophy F-box (MAFbx)/Atrogin-1, ultimately promoting muscle regeneration. These results provide a strong foundation for future studies to explore the therapeutic potential of LIE in clinical settings.
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Affiliation(s)
- Youle Zheng
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Yixin Yu
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Jin Feng
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Min Ling
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Xu Wang
- National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues, Huazhong Agricultural University, Wuhan, Hubei 430070, China
- MOA Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products, Huazhong Agricultural University, Wuhan, Hubei 430070, China
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Hidayat K, Tong X, Rizzoli R, Fan JB, Shi YJ, Su HW, Liu B, Qin LQ. The skeletal safety of milk-derived proteins: A meta-analysis of randomized controlled trials. Osteoporos Int 2023; 34:1937-1949. [PMID: 37526672 DOI: 10.1007/s00198-023-06840-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/21/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE There has been a persistent claim that dairy products contain calcium-leaching proteins, although the soundness of such a claim has been challenged. A meta-analysis of randomized controlled trials (RCTs) on the effects of milk-derived protein supplementation on bone health indices in adults was performed to reconcile the controversy surrounding the potential skeletal safety concerns of proteins of dairy origin. METHODS The PubMed and Web of Science databases were searched for relevant RCTs. A random-effects model was used to generate pooled effect sizes and 95% confidence intervals. RESULTS Milk-derived protein supplementation did not significantly affect whole-body BMD (n = 7 RCTs) and BMD at the lumbar spine (n = 10), hip (n = 8), femoral neck (n = 9), trochanter (n = 5), intertrochanter (n = 2), and ultradistal radius (n = 2). The concentrations of bone formation markers (bone-specific alkaline phosphatase [n = 11], osteocalcin [n = 6], procollagen type 1 amino-terminal propeptide [n = 5]), bone resorption markers (N-terminal telopeptide of type 1 collagen [n = 7], C-terminal telopeptide of type 1 collagen [n = 7], deoxypyridinoline [n = 4]), and parathyroid hormone (n = 7) were not significantly affected. However, increased insulin-like growth factor-1 (IGF-1) concentrations (n = 13) were observed. Reduced IGF-1 concentrations were observed when soy protein was used as a comparator, and increased IGF-1 concentrations were observed when carbohydrate was used. CONCLUSION Our findings do not support the claim that proteins of dairy origin are detrimental to bone health.
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Affiliation(s)
- Khemayanto Hidayat
- Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, 215123, China.
| | - Xing Tong
- Laboratory Center, Medical College of Soochow University, Suzhou, 215123, China
| | - René Rizzoli
- Division of Bone Diseases, Department of Internal Medicine, Geneva University Hospitals and Faculty of Medicine, 1211, Geneva, Switzerland
| | - Jing-Bo Fan
- Laboratory Center, Medical College of Soochow University, Suzhou, 215123, China
| | - Yu-Jie Shi
- Branch Company, Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, 010110, China
| | - Hong-Wen Su
- Branch Company, Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, 010110, China
| | - Biao Liu
- Branch Company, Inner Mongolia Yili Industrial Group Co., Ltd., Hohhot, 010110, China.
| | - Li-Qiang Qin
- Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, 215123, China.
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7
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Buigues C, Theou O, Fonfría-Vivas R, Martínez-Arnau FM, Rockwood K, Cauli O. Can Leucine Supplementation Improve Frailty Index Scores? Geriatrics (Basel) 2023; 8:102. [PMID: 37887975 PMCID: PMC10606811 DOI: 10.3390/geriatrics8050102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/27/2023] [Accepted: 10/08/2023] [Indexed: 10/28/2023] Open
Abstract
Sarcopenia and frailty are important conditions that become increasingly prevalent with age. There is partial overlap between the two conditions, especially in terms of the physical aspects of the frailty phenotype: low grip strength, gait speed, and muscle mass. This study examined whether administration of the essential branched-chain amino acid leucine, besides improving sarcopenia, may reduce frailty assessed by frailty index (FI) in older institutionalized people living in nursing homes. We conducted a secondary analysis of a placebo-controlled, randomized, double-blind design study (ClinicalTrials.gov NCT03831399). The study included fifty males and females aged 65 and over who were living in nursing homes and did not have dementia. The participants were randomized to a parallel group intervention of 13 weeks' duration, with a daily intake of leucine (6 g/day) or placebo (lactose, 6 g/day). The outcome of this study was to evaluate whether there was a change in the level of a 95 item FI compared to the baseline and to compare the effect of the leucine group versus the placebo group. A significant inverse correlation was found between FI and performance of the activities of daily life, cognitive function, gait and balance, muscle function parameters, and nutritional status (p < 0.001 in all cases). There were no statistically significant differences in FI levels at baseline (placebo group FI 0.27 ± 0.08 and leucine group FI 0.27 ± 0.10) and at the 13 week follow-up (placebo group FI 0.28 ± 0.10 and leucine group FI 0.28 ± 0.09). There were also no significant differences between the leucine and placebo groups in the mean FI difference between baseline and follow-up (p = 0.316, Cohen's d: 0.04). This pilot study showed that a nutritional supplementation with leucine did not significantly modify the frailty index in older nursing home residents.
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Affiliation(s)
- Cristina Buigues
- Frailty and Cognitive Impairment Research Group (FROG), University of Valencia, 46010 Valencia, Spain
- Department of Nursing, University of Valencia, 46010 Valencia, Spain
| | - Olga Theou
- Department of Medicine, Dalhousie University, 5955 Veterans' Memorial Lane, Halifax, NS B3H 2E1, Canada
- School of Physiotherapy, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Rosa Fonfría-Vivas
- Frailty and Cognitive Impairment Research Group (FROG), University of Valencia, 46010 Valencia, Spain
- Department of Nursing, University of Valencia, 46010 Valencia, Spain
| | - Francisco M Martínez-Arnau
- Frailty and Cognitive Impairment Research Group (FROG), University of Valencia, 46010 Valencia, Spain
- Department of Physiotherapy, University of Valencia, 46010 Valencia, Spain
| | - Kenneth Rockwood
- Department of Medicine, Dalhousie University, 5955 Veterans' Memorial Lane, Halifax, NS B3H 2E1, Canada
| | - Omar Cauli
- Frailty and Cognitive Impairment Research Group (FROG), University of Valencia, 46010 Valencia, Spain
- Department of Nursing, University of Valencia, 46010 Valencia, Spain
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Tezze C, Sandri M, Tessari P. Anabolic Resistance in the Pathogenesis of Sarcopenia in the Elderly: Role of Nutrition and Exercise in Young and Old People. Nutrients 2023; 15:4073. [PMID: 37764858 PMCID: PMC10535169 DOI: 10.3390/nu15184073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/01/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
The development of sarcopenia in the elderly is associated with many potential factors and/or processes that impair the renovation and maintenance of skeletal muscle mass and strength as ageing progresses. Among them, a defect by skeletal muscle to respond to anabolic stimuli is to be considered. Common anabolic stimuli/signals in skeletal muscle are hormones (insulin, growth hormones, IGF-1, androgens, and β-agonists such epinephrine), substrates (amino acids such as protein precursors on top, but also glucose and fat, as source of energy), metabolites (such as β-agonists and HMB), various biochemical/intracellular mediators), physical exercise, neurogenic and immune-modulating factors, etc. Each of them may exhibit a reduced effect upon skeletal muscle in ageing. In this article, we overview the role of anabolic signals on muscle metabolism, as well as currently available evidence of resistance, at the skeletal muscle level, to anabolic factors, from both in vitro and in vivo studies. Some indications on how to augment the effects of anabolic signals on skeletal muscle are provided.
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Affiliation(s)
- Caterina Tezze
- Department of Biomedical Sciences, University of Padova, via Ugo Bassi 58/b, 35121 Padova, Italy;
- Veneto Institute of Molecular Medicine, via Orus 2, 35129 Padova, Italy
| | - Marco Sandri
- Department of Biomedical Sciences, University of Padova, via Ugo Bassi 58/b, 35121 Padova, Italy;
- Veneto Institute of Molecular Medicine, via Orus 2, 35129 Padova, Italy
- Department of Medicine, McGill University, Montreal, QC H4A 3J1, Canada
| | - Paolo Tessari
- Department of Medicine, University of Padova, via Giustiniani 2, 35128 Padova, Italy
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Stoodley IL, Williams LM, Wood LG. Effects of Plant-Based Protein Interventions, with and without an Exercise Component, on Body Composition, Strength and Physical Function in Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2023; 15:4060. [PMID: 37764843 PMCID: PMC10537483 DOI: 10.3390/nu15184060] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Maintaining muscle mass, strength, and function is crucial for our aging population. Exercise and dietary protein intake are recommended strategies; however, animal proteins have been the most studied. Plant-based protein sources have lower digestibility and incomplete amino acid profiles. However new innovative plant-based proteins and products may have overcome these issues. Therefore, this systematic review aimed to synthesize the current research and evaluate the effects of plant-based protein interventions compared to placebo on body composition, strength, and physical function in older adults (≥60 years old). The secondary aim was whether exercise improved the effectiveness of plant-based protein on these outcomes. Randomized controlled trials up to January 2023 were identified through Medline, EMBASE, CINAHL, and Cochrane Library databases. Studies contained a plant-protein intervention, and assessed body composition, strength, and/or physical function. Thirteen articles were included, all using soy protein (0.6-60 g daily), from 12 weeks to 1 year. Narrative summary reported positive effects on muscle mass over time, with no significant differences compared to controls (no intervention, exercise only, animal protein, or exercise + animal protein interventions). There was limited impact on strength and function. Meta-analysis showed that plant-protein interventions were comparable to controls, in all outcomes. In conclusion, plant-protein interventions improved muscle mass over time, and were comparable to other interventions, warranting further investigation as an anabolic stimulus in this vulnerable population.
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Affiliation(s)
- Isobel L. Stoodley
- Immune Health Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia; (I.L.S.); (L.M.W.)
- School of Biomedical Science and Pharmacy, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Lily M. Williams
- Immune Health Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia; (I.L.S.); (L.M.W.)
- School of Biomedical Science and Pharmacy, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Lisa G. Wood
- Immune Health Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia; (I.L.S.); (L.M.W.)
- School of Biomedical Science and Pharmacy, University of Newcastle, Callaghan, NSW 2308, Australia
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10
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Merchant RA, Chan YH, Anbarasan D, Seetharaman S, Au L, Nachammai V, Lai A, Ho V, Wong BLL, Pang E, Bhaskaran K. Impact of exercise and leucine-enriched protein supplementation on physical function, body composition, and inflammation in pre-frail older adults: a quasi-experimental study. Front Med (Lausanne) 2023; 10:1204198. [PMID: 37644985 PMCID: PMC10461448 DOI: 10.3389/fmed.2023.1204198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
Background Exercise and a protein-enriched diet are essential for muscle protein synthesis, cellular growth, mitochondrial function, and immune function. The U.S. Food and Nutrition Board's current guideline on recommended dietary allowance for protein in older adults is 0.8 g/kg per day, which may not be sufficient in vulnerable pre-frail older adults. Aims This study aimed to evaluate the impact of leucine-enriched protein supplementation with or without exercise over 3 months in pre-frail older adults who consumed ≤1 g/kg/day of protein on improving (i) physical function, (ii) body composition measures, and (iii) inflammatory biomarkers such as interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α). Methods A non-randomized cluster quasi-experimental study guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist of 178 pre-frail older adults [112 control, 44 nutrition (Nu), and 22 in the nutrition with exercise (Nu+Ex) group] comparing the effect of Nu+Ex and Nu on physical function, body composition, and inflammation. At 0, 3, and 6 months, questionnaires on demographics, depression, perceived health, and cognition were administered. Physical function assessment (short physical performance battery [SPPB] test, gait speed, handgrip strength, 5× sit-to-stand [STS]) was conducted, and body composition analysis was performed using a bioelectrical impedance analysis machine. IL-6 and TNF-α were measured at 0 and 3 months. Results At 3 months, there were significant improvements in gait speed, 5× STS, SPPB scores, depression, perceived health, fat-free mass, and appendicular skeletal muscle mass indices in the Nu+Ex group. Both Nu+Ex and Nu groups had improvements in body cell mass and reductions in IL-6 and TNF-α. The improvements were not sustained after 6 months. Conclusion Our study results need to be validated in future longitudinal randomized studies with a larger sample size focusing on populations at risk.
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Affiliation(s)
- Reshma Aziz Merchant
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
- Department of Medicine, National University Singapore, Singapore, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Santhosh Seetharaman
- Healthy Ageing Programme, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Lydia Au
- Department of Geriatrics Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Vidhya Nachammai
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Alexa Lai
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Vanda Ho
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Beatrix Ling Ling Wong
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Eunice Pang
- Health Promotion Board, Singapore, Singapore
| | - Kalpana Bhaskaran
- Glycemic Index Research Unit, School of Applied Science, Temasek Polytechnic, Singapore, Singapore
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11
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Nasimi N, Sohrabi Z, Nunes EA, Sadeghi E, Jamshidi S, Gholami Z, Akbarzadeh M, Faghih S, Akhlaghi M, Phillips SM. Whey Protein Supplementation with or without Vitamin D on Sarcopenia-Related Measures: A Systematic Review and Meta-Analysis. Adv Nutr 2023; 14:762-773. [PMID: 37196876 PMCID: PMC10334153 DOI: 10.1016/j.advnut.2023.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023] Open
Abstract
The effects of supplementation with whey protein alone or with vitamin D on sarcopenia-related outcomes in older adults are unclear. We aimed to assess the effect of whey protein supplementation alone or with vitamin D on lean mass (LM), strength, and function in older adults with or without sarcopenia or frailty. We searched PubMed, Web of Science, and SCOPUS databases. Randomized controlled trials (RCT) that investigated the effect of whey protein supplementation with or without vitamin D on sarcopenia outcomes in healthy and sarcopenic or frail older adults were included. Standardized mean differences (SMDs) were calculated for LM, muscle strength, and physical function data. The analysis showed that whey protein supplementation had no effect on LM and muscle strength; nevertheless, a significant improvement was found in physical function (SMD = 0.561; 95% confidence interval [CIs]: 0.256, 0.865, n = 33), particularly gait speed (GS). On the contrary, whey protein supplementation significantly improved LM (SMD = 0.982; 95% CI: 0.228, 1.736; n = 11), appendicular lean mass and physical function (SMD = 1.211; 95% CI: 0.588, 1.834; n = 16), and GS in sarcopenic/frail older adults. By contrast, co-supplementation with vitamin D enhanced LM gains (SMD =0.993; 95% CI: 0.112, 1.874; n = 11), muscle strength (SMD =2.005; 95% CI: 0.975, 3.035; n = 11), and physical function (SMD = 3.038; 95% CI: 2.196, 3.879; n = 18) significantly. Muscle strength and physical function improvements after whey protein supplementation plus vitamin D were observed without resistance exercise (RE) and short study duration subgroups. Moreover, the combination of whey protein and vitamin D with RE did not enhance the effect of RE. Whey protein supplementation improved LM and function in sarcopenic/frail older adults but had no positive effect in healthy older persons. By contrast, our meta-analysis showed that co-supplementation with whey protein and vitamin D is effective, particularly in healthy older adults, which is likely owing, we propose, to the correction of vitamin D insufficiency or deficiency. The trial was registered at https://inplasy.com as INPLASY202240167.
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Affiliation(s)
- Nasrin Nasimi
- Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Sohrabi
- Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Everson A Nunes
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada; Laboratory of Investigation of Chronic Diseases, Department of Physiological Sciences, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Erfan Sadeghi
- Research Consultation Center (RCC), Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sanaz Jamshidi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Gholami
- Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marzieh Akbarzadeh
- Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shiva Faghih
- Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masoumeh Akhlaghi
- Department of Community Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Stuart M Phillips
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada.
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12
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Burke R, Piñero A, Coleman M, Mohan A, Sapuppo M, Augustin F, Aragon AA, Candow DG, Forbes SC, Swinton P, Schoenfeld BJ. The Effects of Creatine Supplementation Combined with Resistance Training on Regional Measures of Muscle Hypertrophy: A Systematic Review with Meta-Analysis. Nutrients 2023; 15:2116. [PMID: 37432300 DOI: 10.3390/nu15092116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 07/12/2023] Open
Abstract
The purpose of this paper was to carry out a systematic review with a meta-analysis of randomized controlled trials that examined the combined effects of resistance training (RT) and creatine supplementation on regional changes in muscle mass, with direct imaging measures of hypertrophy. Moreover, we performed regression analyses to determine the potential influence of covariates. We included trials that had a duration of at least 6 weeks and examined the combined effects of creatine supplementation and RT on site-specific direct measures of hypertrophy (magnetic resonance imaging (MRI), computed tomography (CT), or ultrasound) in healthy adults. A total of 44 outcomes were analyzed across 10 studies that met the inclusion criteria. A univariate analysis of all the standardized outcomes showed a pooled mean estimate of 0.11 (95% Credible Interval (CrI): -0.02 to 0.25), providing evidence for a very small effect favoring creatine supplementation when combined with RT compared to RT and a placebo. Multivariate analyses found similar small benefits for the combination of creatine supplementation and RT on changes in the upper and lower body muscle thickness (0.10-0.16 cm). Analyses of the moderating effects indicated a small superior benefit for creatine supplementation in younger compared to older adults (0.17 (95%CrI: -0.09 to 0.45)). In conclusion, the results suggest that creatine supplementation combined with RT promotes a small increase in the direct measures of skeletal muscle hypertrophy in both the upper and lower body.
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Affiliation(s)
- Ryan Burke
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
| | - Alec Piñero
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
| | - Max Coleman
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
| | - Adam Mohan
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
| | - Max Sapuppo
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
| | - Francesca Augustin
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
| | - Alan A Aragon
- Department of Family and Consumer Sciences, California State University, Northridge, CA 91330, USA
| | - Darren G Candow
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK S4S 0A2, Canada
| | - Scott C Forbes
- Department of Physical Education Studies, Faculty of Education, Brandon University, Brandon, MB R7A 6A9, Canada
| | - Paul Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen AB10 7AQ, UK
| | - Brad J Schoenfeld
- Department of Exercise Science and Recreation, CUNY Lehman College, Bronx, NY 10468, USA
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13
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Longobardi I, Gualano B, Seguro AC, Roschel H. Is It Time for a Requiem for Creatine Supplementation-Induced Kidney Failure? A Narrative Review. Nutrients 2023; 15:nu15061466. [PMID: 36986197 PMCID: PMC10054094 DOI: 10.3390/nu15061466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/22/2023] Open
Abstract
Creatine has become one of the most popular dietary supplements among a wide range of healthy and clinical populations. However, its potential adverse effects on kidney health are still a matter of concern. This is a narrative review of the effects of creatine supplementation on kidney function. Despite a few case reports and animal studies suggesting that creatine may impair kidney function, clinical trials with controlled designs do not support this claim. Creatine supplementation may increase serum creatinine (Crn) concentration for some individuals, but it does not necessarily indicate kidney dysfunction, as creatine is spontaneously converted into Crn. Based on studies assessing kidney function using reliable methods, creatine supplements have been shown to be safe for human consumption. Further studies with people who have pre-existing kidney disease remain necessary.
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Affiliation(s)
- Igor Longobardi
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, School of Medicine, University of Sao Paulo, Sao Paulo 01246-903, SP, Brazil; (I.L.); (B.G.)
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, School of Medicine, University of Sao Paulo, Sao Paulo 01246-903, SP, Brazil; (I.L.); (B.G.)
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 01246-903, SP, Brazil
| | - Antonio Carlos Seguro
- Nephrology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 01246-903, SP, Brazil;
| | - Hamilton Roschel
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, School of Medicine, University of Sao Paulo, Sao Paulo 01246-903, SP, Brazil; (I.L.); (B.G.)
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo 01246-903, SP, Brazil
- Correspondence: ; Tel.: +55-11-3061-8789
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14
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Mineyama R, Tezuka F, Takagi N, Kokabu S, Okubo M. Nutritional Management in a 101-Year-Old Woman with Physical Inactivity and General Weakness: A Case Report. Geriatrics (Basel) 2023; 8:geriatrics8010008. [PMID: 36648913 PMCID: PMC9844409 DOI: 10.3390/geriatrics8010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/07/2023] Open
Abstract
Japan has the world's highest life longevity, and centenarian patients are no longer rare. However, sufficient information related to centenarians is not available. Herein, we report the case of a 101-year-old centenarian woman who recovered from extreme inactivity and general weakness, mainly through nutritional management at home, to understand instances of nutritional management in centenarians. The patient developed lethargy, with a rapid decline in activity levels and food intake. She was diagnosed with senility by a primary doctor. We concluded that she had no problems with feeding and swallowing and predicted that her motivation to eat had decreased. We planned an intervention that lasted three months. To reduce the risk of aspiration, we paid attention to her posture while eating. To stimulate her appetite, we increased the variety and color of food items. To consider both the texture of food and safety, we changed the form of foods from paste (IDDSI Level 4)-like to solid food of regular size as much as possible. We recommended that the patient consume her favorite sweet between meals to enjoy eating. Two and half months after the initial intervention, the patient's inactivity and general weakness improved dramatically, which was recognized by her willingness to eat, laugh loudly, and hum, although she could not speak clearly. The patient finally was able to have dinner with her family.
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Affiliation(s)
- Ryoko Mineyama
- Takagi Dental Clinic, Tsuchiura 300-0814, Japan
- Food and Nutrition Department, Koibuchi College of Agriculture and Nutrition, Mito 319-0323, Japan
| | | | | | - Shoichiro Kokabu
- Division of Molecular Signaling and Biochemistry, Kyushu Dental University, Kitakyushu 803-8580, Japan
| | - Masahiko Okubo
- Medical Corporation Association RISEIKAI, Tokyo 470-1141, Japan
- Correspondence: ; Tel.: +81-3-3707-4161
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15
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Ibrahim A, Mat Ludin AF, Singh DKA, Rajab NF, Shahar S. Changes in cardiovascular-health blood biomarkers in response to exercise intervention among older adults with cognitive frailty: A scoping review. Front Physiol 2023; 14:1077078. [PMID: 36875037 PMCID: PMC9975543 DOI: 10.3389/fphys.2023.1077078] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023] Open
Abstract
Introduction: Cardiovascular health contributes significantly to the incidence of cognitive impairment. Prior to conducting exercise-related intervention, it is crucial to explore cardiovascular health blood parameters that have been commonly used as guidance for the purpose of monitoring. Information on the effectiveness of exercise on cardiovascular-related biomarkers is lacking, especially among older adults with cognitive frailty. Therefore, we aimed to review existing evidence on cardiovascular-related blood parameters and their changes following exercise intervention among older adults with cognitive frailty. Methods: A systematic search was conducted on PubMed, Cochrane, and Scopus databases. Related studies involving only human and full text in either English or Malay language were selected. Types of impairment were limited to cognitive impairment, frailty, and cognitive frailty. Studies were restricted to randomized controlled trial and clinical trial design studies. For charting purposes, all variables were extracted and tabulated. Trends in types of parameters studied were explored. Results: A total of 607 articles were screened, and the final 16 were included in this review. Four cardiovascular-related blood parameter categories were extracted: inflammatory, glucose homeostasis, lipid profile, and hemostatic biomarkers. The common parameters monitored were IGF-1 and HbA1c, glucose, and insulin sensitivity in some studies. Out of the nine studies on inflammatory biomarkers, exercise interventions showed a reduction in pro-inflammatory markers, namely, IL-6, TNF-α, IL-15, leptin, and C-reactive protein and an increase in anti-inflammatory markers, namely, IFN-γ and IL-10. Similarly, in all eight studies, glucose homeostasis-related biomarkers had improved with exercise intervention. The lipid profile was tested in five studies, with four studies showing improvements with exercise intervention via a decrease in total cholesterol, triglycerides, and low-density lipoprotein and an increase in high-density lipoprotein. A decrease in pro-inflammatory biomarkers and an increase in anti-inflammatory biomarkers were demonstrated with multicomponent exercise, including aerobic exercise in six studies and aerobic exercise on its own in the remaining two studies. Meanwhile, four out of six studies that yielded improvements in glucose homeostasis biomarkers involved only aerobic exercise and the remaining two studies involved multicomponent with aerobic exercise. Conclusion: The most consistent blood parameters studied were glucose homeostasis and inflammatory biomarkers. These parameters have been shown to improve with multicomponent exercise programs, particularly with the inclusion of aerobic exercise.
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Affiliation(s)
- Azianah Ibrahim
- Centre for Healthy Ageing and Wellness (HCARE), Faculty of Health Sciences, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | - Arimi Fitri Mat Ludin
- Centre for Healthy Ageing and Wellness (HCARE), Faculty of Health Sciences, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | - Devinder Kaur Ajit Singh
- Centre for Healthy Ageing and Wellness (HCARE), Faculty of Health Sciences, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | - Nor Fadilah Rajab
- Centre for Healthy Ageing and Wellness (HCARE), Faculty of Health Sciences, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | - Suzana Shahar
- Centre for Healthy Ageing and Wellness (HCARE), Faculty of Health Sciences, Universiti Kebangsaan, Kuala Lumpur, Malaysia
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16
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Li Y, Liu Y, Tan R, Liu Y. Effect of flavonoids on skeletal muscle mass, strength and physical performance in middle-aged and older adults with or without Sarcopenia: A meta-analysis of randomized controlled trials. Front Nutr 2022; 9:1013449. [PMID: 36299989 PMCID: PMC9589257 DOI: 10.3389/fnut.2022.1013449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
The role of flavonoids in regulating the synthesis and function of skeletal muscles is increasingly recognized. However, randomized controlled trials have yielded inconsistent results on the influence of flavonoids on human muscular parameters. Therefore, we performed a meta-analysis to evaluate the possible effects of flavonoids on sarcopenia-related parameters in middle-aged and elderly people. Eligible literature and randomized controlled trials reports have been extensively searched from PubMed, Cochrane Library, Web of Science, and EMBASE databases until April 2022. A total of 20 articles involving 796 participants were available for the meta-analysis. There were significant benefits for participants in appendicular muscle mass gain (SMD = 0.29; 95% CI: 0.07, 0.52; P = 0.01) and 6-min walk distance (SMD = 0.37; 95% CI: 0.01, 0.73; P = 0.05). A subgroup analysis indicated that flavonoid significantly improves appendicular muscle mass (SMD = 0.50; 95% CI: 0.21, 0.80; P < 0.01) and Timed-Up and Go test (SMD = −0.47; 95% CI: −0.85, −0.09; P = 0.02) in Sarcopenia population. Our results provide insight into the effects of flavonoids on skeletal muscle mass and gait speed for those without exercise. However, there was no significant improvement in the subjects' muscle strength.
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Affiliation(s)
- Yuzhuo Li
- Department of Nephrology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China,Guangzhou Institute of Disease-Oriented Nutritional Research, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yun Liu
- Department of Nephrology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China,Guangzhou Institute of Disease-Oriented Nutritional Research, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Rongshao Tan
- Guangzhou Institute of Disease-Oriented Nutritional Research, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yan Liu
- Department of Nephrology, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China,Guangzhou Institute of Disease-Oriented Nutritional Research, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China,*Correspondence: Yan Liu
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17
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Candow DG, Chilibeck PD, Forbes SC, Fairman CM, Gualano B, Roschel H. Creatine supplementation for older adults: Focus on sarcopenia, osteoporosis, frailty and Cachexia. Bone 2022; 162:116467. [PMID: 35688360 DOI: 10.1016/j.bone.2022.116467] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022]
Abstract
Sarcopenia refers to the age-related reduction in strength, muscle mass and functionality which increases the risk for falls, injuries and fractures. Sarcopenia is associated with other age-related conditions such as osteoporosis, frailty and cachexia. Identifying treatments to overcome sarcopenia and associated conditions is important from a global health perspective. There is evidence that creatine monohydrate supplementation, primarily when combined with resistance training, has favorable effects on indices of aging muscle and bone. These musculoskeletal benefits provide some rationale for creatine being a potential intervention for treating frailty and cachexia. The purposes of this narrative review are to update the collective body of research pertaining to the effects of creatine supplementation on indices of aging muscle and bone (including bone turnover markers) and present possible justification and rationale for its utilization in the treatment of frailty and cachexia in older adults.
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Affiliation(s)
- Darren G Candow
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada.
| | - Philip D Chilibeck
- College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Scott C Forbes
- Department of Physical Education Studies, Brandon University Brandon, MB, Canada
| | - Ciaran M Fairman
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Bruno Gualano
- Applied Physiology & Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculty of Medicine FMUSP, University of Sao Paulo, Sao Paulo, Brazil
| | - Hamilton Roschel
- Applied Physiology & Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculty of Medicine FMUSP, University of Sao Paulo, Sao Paulo, Brazil
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18
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Guo Y, Fu X, Hu Q, Chen L, Zuo H. The Effect of Leucine Supplementation on Sarcopenia-Related Measures in Older Adults: A Systematic Review and Meta-Analysis of 17 Randomized Controlled Trials. Front Nutr 2022; 9:929891. [PMID: 35845777 PMCID: PMC9284268 DOI: 10.3389/fnut.2022.929891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background The role of leucine in sarcopenia prevention remains unclear. We aimed to summarize the published data from randomized controlled trials (RCTs) to estimate the effect of leucine supplementation on sarcopenia-related measures in older adults. Methods A systematic literature search was performed using the electronic databases PubMed, Embase, and Web of Science with restriction to randomized controlled trials design from January 1, 2009 to March 19, 2022. Sarcopenia-related measures included handgrip strength, total lean mass, gait speed, leg press, 6-min walk test, short-physical performance battery, timed up-and-go test and 30-s chair-stand test. Fixed- and random-effects meta-analysis models were used to generate pooled weighted mean differences (WMDs) and 95% CIs. Heterogeneity was examined in subgroup and sensitivity analyses. Publication bias assessments were performed. Results A total of 17 RCTs enrolling 1418 subjects were identified. Leucine-isolated supplementation showed no effect on total lean mass (WMD = 0.03 kg, 95% CI: –0.51, 0.57, P = 0.917), handgrip strength (WMD = 1.23 kg, 95% CI: –0.58, 3.03, P = 0.183) and leg press (WMD = –1.35 kg, 95% CI: –7.46, 4.77, P = 0.666). However, leucine-combined supplementation including vitamin D showed a significant improvement in handgrip strength (WMD = 2.17 kg, 95% CI: 0.24, 4.10, P = 0.027) and gait speed (WMD = 0.03 m/s, 95% CI: 0.01, 0.05, P = 0.008). Conclusion Leucine-isolated supplementation did not improve muscle mass and strength in elderly. However, leucine-combined supplementation including vitamin D exhibited a significant benefit for muscle strength and performance including handgrip strength and gait speed in older adults. A combination of nutritional supplements would be a viable option for improving sarcopenia.
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Affiliation(s)
- Yufei Guo
- School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Xiaoya Fu
- School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Qingjing Hu
- School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Lihua Chen
- Department of Nutrition and Food Hygiene, School of Public Health, Nantong University, Nantong, China
| | - Hui Zuo
- School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Suzhou Medical College of Soochow University, Suzhou, China
- *Correspondence: Hui Zuo,
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19
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Smith C, Woessner MN, Sim M, Levinger I. Sarcopenia definition: Does it really matter? Implications for resistance training. Ageing Res Rev 2022; 78:101617. [PMID: 35378297 DOI: 10.1016/j.arr.2022.101617] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/21/2022] [Accepted: 03/30/2022] [Indexed: 12/13/2022]
Abstract
The loss of muscle mass, strength and function, known as sarcopenia, is common in older adults, and is associated with falls, fractures, cardiometabolic diseases, and lower quality of life. Sarcopenia can also occur secondarily to chronic diseases. Recently, sarcopenia was recognized as a disease with an International Classification of Disease (ICD) code, yet, at least five definitions for its clinical identification exist. Most definitions include three themes: low muscle mass, strength and physical performance. However, the definitions vary by the number of themes needed to diagnose sarcopenia and, within each theme various parameters and cut-off levels exist. The lack of consensus on what constitutes a diagnosis can create confusion and hesitation in sarcopenia diagnosis. Currently, no pharmacological treatment exists for sarcopenia. Resistance training (RT) is safe and effective to improve muscle mass, strength and physical performance in older adults and clinical populations. Based on current guidelines, whether an individual is defined as "sarcopenic", or not, does not change the way RT is prescribed. Here, we present evidence and the inconsistencies in sarcopenia definitions and recommend that focus should be on optimizing ways to prescribe RT and increase long-term adherence, rather than on slight modifications to sarcopenia definitions.
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Affiliation(s)
- Cassandra Smith
- Institute for Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, St Albans, VIC, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Mary N Woessner
- Institute for Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia
| | - Marc Sim
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia; Medical School, Royal Perth Hospital Unit, The University of Western Australia, Perth, WA, Australia
| | - Itamar Levinger
- Institute for Health and Sport (IHES), Victoria University, Melbourne, VIC, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, St Albans, VIC, Australia; Western Health and the University of Melbourne, Department of Medicine, Footscray, VIC, Australia.
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20
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Preoperative sarcopenia is a negative predictor for enhanced postoperative recovery after pancreaticoduodenectomy. Langenbecks Arch Surg 2022; 407:2355-2362. [PMID: 35593934 DOI: 10.1007/s00423-022-02558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/11/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Sarcopenia is common in pancreatic cancer patients. Considering the growing adoption of standardized protocols for enhanced recovery after surgery (ERAS), we examined the clinical impact of sarcopenia in pancreaticoduodenectomy (PD) patients in a 5-day accelerated ERAS program, termed the Whipple Accelerated Recovery Pathway. METHODS A retrospective review was conducted of patients undergoing PD from 2017 through 2020 on the ERAS pathway. Preoperative computerized tomographic scans taken within 45 days before surgery were analyzed to determine psoas muscle cross-sectional area (PMA) at the third lumbar vertebral body. Sarcopenia was defined as the lowest quartile of PMA respective to gender. Outcome measures were compared between patients with or without sarcopenia. RESULTS In this 333-patient cohort, 252 (75.7%) patients had final pathology revealing pancreatic or periampullary cancer. The median age was 66.7 years (16.4-88.4 years) with a 161:172 male to female ratio. Sarcopenia correlated with delayed tolerance of oral intake (OR 2.2; 95%CI 1.1-4.3, P = 0.03), increased complication rates (OR 4.3; 95%CI 2.2-8.5, P < 0.01), and longer hospital length of stay (LOS) (P < 0.05). Preoperative albumin levels, BMI, and history of pancreatitis were also found to correlate with LOS (P < 0.05). Multivariate regression analysis found low PMA, BMI, and male gender to be independent predictors of increased LOS (P < 0.05). CONCLUSION Sarcopenia correlated with increased LOS and postoperative complications in ERAS patients after PD. Sarcopenia can be used to predict poor candidates for ERAS protocols who may require an alternative recovery protocol, promoting a clinical tier-based approach to ERAS for pancreatic surgery.
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21
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Abstract
PURPOSE OF REVIEW To provide an updated overview of recent efficacy data on the use of muscle-targeted nutritional therapy, which should consider the optimization of protein and essential amino acids intakes, possibly in combination with supplementation with vitamin D (correction of deficiency/insufficiency status) and v-3 fatty acids. RECENT FINDINGS Intervention studies conducted in the last years in different healthcare settings and heterogeneous patient populations support the use of muscle-targeted oral nutritional supplementation to improve muscle mass, function and physical performance in patients with sarcopenia. Higher efficacy is likely to be achieved in combination with individually tailored resistance exercise training programs and when nutritional therapy and the provision of specific nutrients result in an adequate protein-calorie balance. However, not only a reactive but also a pro-active application of this therapy could be proposed as evidence exists on the maintenance of or improvement in the same outcome variables in patients at risk of losing skeletal muscle mass. SUMMARY Based on available efficacy data, both a reactive and pro-active use of muscle-targeted nutritional therapy are promising and should be proposed. However, future research should be directed toward the management of patient populations characterized by substantial muscle wasting, as these have been frequently excluded from previous trials, perhaps to avoid confounding.
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Affiliation(s)
- Emanuele Cereda
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlínico San Matteo, Pavia
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlínico San Matteo, Pavia
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22
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de Azevedo Bach S, Radaelli R, Beck Schemes M, Neske R, Garbelotto C, Roschel H, Silveira Pinto R, Dornelles Schneider C. Can supplemental protein to low-protein containing meals superimpose on resistance-training muscle adaptations in older adults? A randomized clinical trial. Exp Gerontol 2022; 162:111760. [PMID: 35240263 DOI: 10.1016/j.exger.2022.111760] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/08/2022] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the effects of supplementing protein to the low-protein containing meals on selected parameters of muscle mass, strength, and functional capacity in older individuals undergoing resistance training. METHODS Thirty-one male and female older individuals (60 to 80 years) were randomized into either a whey protein/WP (n = 15, 20 g at breakfast + 20 g at dinner) or placebo-maltodextrin/PL (n = 16, 20 g at breakfast + 20 g at dinner) group. Both groups underwent a supervised, progressive resistance training (2×/week) program for 12 weeks. Maximal isometric voluntary contraction (MIVC) of knee extensors, muscle thickness (MT) of knee extensors and elbow flexors, rectus femoris muscle quality (MQ), body composition (as measured by DXA) and functional capacity [as measured by 30-s sit-to-stand (30ss) and timed-up-and-go tests (TUG)] were evaluated at baseline and after the 12-week intervention. RESULTS Knee extensor MIVC (WP ∆ = 11.9 ± 11.4% and PL ∆ = 12.9 ± 9.9%) was significantly increased over time, with no between-group differences (all p < 0.05 for main effect of time). Upper- and lower-limb MT were significantly increased over time, with no effect of supplementation (WP: ∆ = 7.0 ± 7.3%, PL: ∆ = 9.5 ± 10.3%; and WP: ∆ = 4.5 ± 5.8%, PL: ∆ = 14.7 ± 28.9%, respectively; all p = 0.001 for main effect of time, respectively). Total and upper-limb lean mass were significantly increased, irrespective of the dietary intervention (WP: ∆ = 0.2 ± 6.3%, PL: ∆ = 1.8 ± 2.9%; and WP: ∆ = 0.10 ± 0.03%, PL: ∆ = 0.15 ± 0.02%, respectively; all p < 0.05 for main effect of time). Main effects of time (all p < 0.05) were also found for 30SS and TUG (fast and usual speeds) (WP: ∆ = 18.2 ± 34.4%, PL: ∆ = 10.4 ± 16.9%; WP: ∆ = 5.4 ± 6.7%, PL: ∆ = 0.7 ± 6.0% and WP: ∆ = 3.3 ± 6.1%, PL: ∆ = 2.3 ± 5.2%, respectively). CONCLUSION Supplementing additional whey protein to the lowest-protein containing meals (i.e., ~20 g at breakfast and ~20 g at dinner, daily) did not further augment resistance training-induced neuromuscular adaptations (i.e. muscle strength and mass) in healthy older individuals.
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Affiliation(s)
- Simone de Azevedo Bach
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
| | - Régis Radaelli
- Neuromuscular Research Lab, Faculty of Human Kinetics, University of Lisbon, Cruz Quebrada Dafundo, Portugal
| | - Márcio Beck Schemes
- Strength Training Research Group, School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Rodrigo Neske
- Strength Training Research Group, School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Charlles Garbelotto
- Nutrition Course, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Hamilton Roschel
- Applied Physiology and Nutrition Group, School of Physical Education and Sport, Division of Rheumatology, Faculty of Medicine, FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ronei Silveira Pinto
- Strength Training Research Group, School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Cláudia Dornelles Schneider
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
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23
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Strategies to Prevent Sarcopenia in the Aging Process: Role of Protein Intake and Exercise. Nutrients 2021; 14:nu14010052. [PMID: 35010928 PMCID: PMC8746908 DOI: 10.3390/nu14010052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 12/24/2022] Open
Abstract
Sarcopenia is one of the main issues associated with the process of aging. Characterized by muscle mass loss, it is triggered by several conditions, including sedentary habits and negative net protein balance. According to World Health Organization, it is expected a 38% increase in older individuals by 2025. Therefore, it is noteworthy to establish recommendations to prevent sarcopenia and several events and comorbidities associated with this health issue condition. In this review, we discuss the role of these factors, prevention strategies, and recommendations, with a focus on protein intake and exercise.
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24
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Lixandrão ME, Longobardi I, Leitão AE, Morais JVM, Swinton PA, Aihara AY, Goes PCK, Ugrinowitsch C, Candow DG, Gualano B, Roschel H. Daily Leucine Intake Is Positively Associated with Lower Limb Skeletal Muscle Mass and Strength in the Elderly. Nutrients 2021; 13:nu13103536. [PMID: 34684538 PMCID: PMC8539207 DOI: 10.3390/nu13103536] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 01/03/2023] Open
Abstract
Higher daily protein intake, with an emphasis on leucine content, is thought to mitigate age-related anabolic resistance, potentially counteracting age-related morphological and functional declines. The present study investigated potential associations between total daily leucine intake and dependent variables, including quadriceps muscle cross-sectional area (CSA) and maximum dynamic muscle strength (1-RM) in a cohort of healthy free-living older individuals of both sexes (n = 67; 34/33 men/women). Participants performed three 24 h dietary recalls and underwent a magnetic resonance imaging exam followed by 1-RM tests. Our results demonstrate moderate associations between total daily leucine and both quadriceps CSA (r = 0.42; p = 0.004) and 1-RM (r = 0.45; p = 0.001). Furthermore, our exploratory biphasic linear regression analyses, adjusted for sex, age, and protein intake relative to body weight, revealed a plateau for daily leucine intake and muscle mass and muscle strength (~7.6–8.0 g·day−1) in older adults. In conclusion, we demonstrated that total daily leucine intake is associated with muscle mass and strength in healthy older individuals and this association remains after controlling for multiple factors, including overall protein intake. Furthermore, our breakpoint analysis revealed non-linearities and a potential threshold for habitual leucine intake, which may help guide future research on the effects of chronic leucine intake in age-related muscle loss.
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Affiliation(s)
- Manoel E. Lixandrão
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculdade de Medicina FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil; (M.E.L.); (I.L.); (A.E.L.); (J.V.M.M.); (B.G.)
- School of Physical Education and Sport, University of São Paulo, São Paulo 05508-030, SP, Brazil;
| | - Igor Longobardi
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculdade de Medicina FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil; (M.E.L.); (I.L.); (A.E.L.); (J.V.M.M.); (B.G.)
| | - Alice E. Leitão
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculdade de Medicina FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil; (M.E.L.); (I.L.); (A.E.L.); (J.V.M.M.); (B.G.)
| | - João V. M. Morais
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculdade de Medicina FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil; (M.E.L.); (I.L.); (A.E.L.); (J.V.M.M.); (B.G.)
| | - Paul A. Swinton
- School of Health Sciences, Robert Gordon University, Aberdeen AB10 7QE, UK;
| | - André Y. Aihara
- Laboratório Delboni Auriemo, São Paulo 04037-005, SP, Brazil; (A.Y.A.); (P.C.K.G.)
| | - Paola C. K. Goes
- Laboratório Delboni Auriemo, São Paulo 04037-005, SP, Brazil; (A.Y.A.); (P.C.K.G.)
| | - Carlos Ugrinowitsch
- School of Physical Education and Sport, University of São Paulo, São Paulo 05508-030, SP, Brazil;
| | - Darren G. Candow
- Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK S4S 0A2, Canada;
| | - Bruno Gualano
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculdade de Medicina FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil; (M.E.L.); (I.L.); (A.E.L.); (J.V.M.M.); (B.G.)
| | - Hamilton Roschel
- Applied Physiology and Nutrition Research Group, School of Physical Education and Sport, Rheumatology Division, Faculdade de Medicina FMUSP, University of São Paulo, São Paulo 01246-903, SP, Brazil; (M.E.L.); (I.L.); (A.E.L.); (J.V.M.M.); (B.G.)
- Correspondence: ; Tel.: +55-11-3091-8783
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