Sarcopenic Obesity Is Associated With Activities of Daily Living and Home Discharge in Post-Acute Rehabilitation

Factors associated with sarcopenic obesity in Brazilian adults and older people: Systematic review and meta-analysis of observational studies

AIM

Sarcopenic obesity (SO) is characterized by the coexistence of the loss of muscle mass and function with excess adipose tissue. Its prevalence has increased concomitantly with population aging, becoming one of the most significant challenges for public health, threatening the quality of life and the physical and mental health of the elderly population.

METHODS

This study estimated the prevalence and factors associated with SO among adults and the elderly in Brazil's macro-regions, utilizing MEDLINE, Embase, Web of Science, and the Virtual Health Library databases. Primary outcomes included SO prevalence overall and by subgroups, with secondary outcomes identifying associated factors.

RESULTS

A systematic review of 33 studies with 10 266 participants up to July 2023 showed a 17% prevalence of SO (95% confidence interval: 13-21%), using a random effects meta-analysis. The Central-West region had the highest occurrence (27%). Dual-energy X-ray absorptiometry (26%) and bioimpedance (6%) were the top diagnostic methods. Protective factors were chronic kidney disease and healthy lifestyles; risk factors included socioeconomic status, functionality, lifestyle, biochemical parameters, and comorbidities such as osteoarthritis and apnea.

CONCLUSIONS

The prevalence of SO in Brazil is significant, emerging as a critical public health problem. It is essential to direct attention to changes in prevalence rates in the coming years, given the rising obesity trends and the absolute increase in the elderly population. Geriatr Gerontol Int 2024; ••: ••-••.

Impaired oral status is associated with sarcopenic obesity in post-stroke patients

PURPOSE

Oral problems and muscle health are indeed significant concerns in ageing populations. However, there is limited evidence concerning the association between these issues. The study's focus was to investigate the association between oral problems and sarcopenic obesity, wherein sarcopenia and obesity coexist concurrently, in post-stroke patients.

METHODS

This retrospective, observational, cross-sectional study included patients hospitalised for post-stroke rehabilitation. Oral problems were assessed using the Revised Oral Assessment Guide (ROAG). Sarcopenic obesity was diagnosed according to the European Society of Clinical Nutrition and Metabolism/European Association for the Study of Obesity criteria. Multiple linear regression analysis was used to examine the association between the ROAG and sarcopenic obesity after adjusting for confounding factors.

RESULTS

A total of 760 patients were included, with a mean (SD) age of 71 (9) years, of whom 408 (54.7%) were male. The median (interquartile range, 25th and 75th percentiles) ROAG was 11 [9, 13]. Sarcopenic obesity was diagnosed in 16 (3.9%) men, 18 (5.1%) women, and 34 (4.5%) patients overall. Multivariate linear analysis showed that ROAG was significantly and positively associated with sarcopenic obesity (β = .091, P = .023), followed by obesity alone (β = .084, P = .044), and sarcopenia alone (β = .081, P = .037).

CONCLUSION

Oral problems were associated with sarcopenic obesity in post-stroke. Oral assessment and intervention may have a positive impact on ADL and QOL in post-stroke patients with sarcopenic obesity.

The relationship between sarcopenic obesity and changes in quadriceps muscle thickness and echo intensity in patients with stroke

BACKGROUND

Research findings on skeletal muscle degeneration in post-stroke sarcopenic obesity are limited. Thus, this study aimed to investigate the association between post-stroke sarcopenic obesity and quantitative and qualitative changes in skeletal muscles.

METHODS

This was a cross-sectional study conducted on patients with stroke admitted to the convalescent rehabilitation ward. For skeletal muscle assessment, an ultrasound system was used to measure quadriceps muscle thickness and echo intensity (QMT and QEI) on the paretic and non-paretic sides. Sarcopenic obesity was defined as the presence of both sarcopenia and obesity. Multiple regression analysis was performed to determine the relationships between sarcopenic obesity and QMT and QEI.

RESULTS

A total of 130 patients with stroke were included in this study (mean age: 69.4 ± 12.7 years). The prevalence of sarcopenic obesity was 23.1%. The multiple regression analysis showed that sarcopenic obesity was significantly negatively associated with QMT on both the paretic and non-paretic sides (paretic side: β =  -0.28, p < 0.001; non-paretic side: β =  -0.37, p < 0.001) and significantly positively associated with QEI (paretic side β = 0.21, p = 0.034; non-paretic side: β = 0.20, p = 0.029).

CONCLUSIONS

Post-stroke sarcopenic obesity was independently associated with quantitative and qualitative changes in skeletal muscles on both the paretic and non-paretic sides.

Decreased intracellular water is associated with sarcopenic obesity in chronic haemodialysis patients

OBJECTIVE

To explore the association between intracellular water (ICW) and sarcopenic obesity in patients undergoing chronic haemodialysis (HD).

METHODS

A multicentre, cross-sectional study of 3354 adult chronic HD patients was conducted in 20 haemodialysis centres from June 1, 2021, to August 30, 2021. The diagnosis of sarcopenic obesity was made according to the revised Asian Working Group's definition of sarcopenia combined with obesity per the body fat percentage definition. Body composition was evaluated by a body composition monitor using bioimpedance spectroscopy. Multiple logistic regression models, stratified analyses, interactive analyses, and receiver-operating characteristic analyses were conducted.

RESULTS

A total of 752 patients were diagnosed with sarcopenic obesity among 3354 participants. The patients were grouped by sex-specific ICW median levels, and the prevalence of sarcopenic obesity was significantly higher in the low ICW group than in the high ICW group (41.3%vs 3.0%). Decreased ICW was significantly associated with sarcopenic obesity. The association remained statistically significant even after adjusting for dialysis vintage, age, body mass index, biochemical indicators, and various medical histories. The odds ratios of the low ICW group were much higher than those of the high ICW group in both males and females (P for trend < 0.001). The association was stable across subgroups, and the interaction analysis showed that age, body mass index and history of diabetes had interactive roles in the association between ICW and sarcopenic obesity (P for interaction < 0.05). Furthermore, the ICW cut-off values for identifying sarcopenic obesity were 19.1 kg and 14.5 kg for males and females, respectively.

CONCLUSION

Decreased ICW was an independent risk factor for sarcopenic obesity in chronic HD patients. The measurement of ICW by bioimpedance spectroscopy might be a non-invasive and valid means for identifying the risk of future sarcopenic obesity in HD patients.

Associations of sarcopenic obesity vs either sarcopenia or obesity alone with cognitive impairment risk in patients requiring maintenance hemodialysis

BACKGROUND

The association between sarcopenic obesity (SO) and cognitive impairment (CI) risk in patients requiring maintenance hemodialysis (MHD) is not known. In this study, we investigated the prevalence of SO in MHD patients. Furthermore, we would explore and compare the associations between SO, sarcopenia, and obesity with CI risk in this population.

METHODS

A multicenter, cross-sectional study was conducted. Data from 2743 adult MHD patients were recorded. SO was defined as the co-occurrence of sarcopenia and obesity. Cognitive function was assessed with the Mini-Mental State Examination (MMSE). Multiple logistic regression models, stratified analyses, and interactive analyses were conducted.

RESULTS

21.58% of the participants met the criteria for SO. The overall prevalence of CI was 23.3% in our study. Participants in the SO group had the highest CI prevalence (34.6%). The association between SO and CI was weakened but remained statistically significant after adjusting for age, sex, and educational status (odds ratio, 1.47; 95% CI, 1.11-1.96). However, associations between sarcopenia, obesity, and CI disappeared after adjusting for these variables. The additional adjustment did not attenuate the significant association between SO and CI. Subgroup analyses and interactive analyses showed that the associations were similar across subgroups (P > 0.05 for interaction for all).

CONCLUSIONS

SO and CI are highly prevalent in MHD patients. Participants with SO are at significantly higher risk of CI than those with sarcopenia or obesity alone. Furthermore, this association is consistent across different subgroups.

Phase angle is associated with sarcopenic obesity in post-stroke patients

BACKGROUND & AIMS

Evidence is limited concerning the association between bioimpedance analysis-derived phase angle and sarcopenic obesity. This study examined this association in patients who underwent convalescent rehabilitation after stroke.

METHODS

This cross-sectional study included hospitalized patients with post-acute stroke. The phase angle was measured using a multifrequency bioimpedance analysis. Sarcopenic obesity was diagnosed according to the European Society of Clinical Nutrition and Metabolism/European Association for the Study of Obesity criteria. A multiple linear regression analysis was used to examine the association between the phase angle and sarcopenic obesity after adjusting for confounding factors. A receiver operating characteristic curve was used to calculate the optimal phase angle cutoff value for predicting sarcopenic obesity.

RESULTS

A total of 760 patients (median age 71 years; 352 women) were analyzed. The median (interquartile range, 25th and 75th percentiles) phase angle was 4.45° (4.10°, 4.88°). Sarcopenic obesity was diagnosed in 16 (3.9%) men, 18 (5.1%) women, and 34 (4.5%) patients overall. The multiple linear regression analysis showed that sarcopenic obesity (β = -0.185, p = 0.017) and sarcopenia (β = -0.121, p = 0.012) were significantly and negatively associated with the phase angle. Obesity was not significantly associated with the phase angle (β = -0.078, p = 0.094). The optimal cutoff value of the phase angle for diagnosing sarcopenic obesity was 4.29° (sensitivity 0.65, specificity 0.80, area under the curve [AUC] 0.79, 95% CI 0.77-0.87, p < 0.001) in men and 3.84° (sensitivity 0.67, specificity 0.84, AUC 0.81, 95% CI 0.79-0.86, p < 0.001) in women.

CONCLUSION

The phase angle was associated with sarcopenic obesity, and the cutoff values of the phase angle that could predict sarcopenic obesity were 4.29° for men and 3.84° for women. This simple and practical phase angle-based prediction of sarcopenic obesity can be useful in clinical practice.

Obesity Impairs Functional Recovery of Older Stroke Patients with Possible Sarcopenia: A Retrospective Cohort Study

The functional prognosis of older patients with coexisting obesity and possible sarcopenia remains uncertain following acute stroke. This study aimed to determine whether coexisting obesity independently affects activities of daily living (ADL) and balance ability at discharge in older patients with possible sarcopenia admitted to a stroke rehabilitation ward. A total of 111 patients aged 65 years or older with possible sarcopenia were included, of whom 36 (32.4%) had coexisting obesity. Possible sarcopenia was diagnosed based on low handgrip strength without reduced muscle mass, while obesity was determined by body fat percentage (≥25% for men, ≥30% for women). Multivariate linear regression analysis revealed that compared to patients without obesity, patients with obesity had a higher likelihood of poorer ADL (b = -0.169; p = 0.02) and balance ability (b = -0.14; p = 0.04) performance at discharge following a 4-week period of inpatient rehabilitation. These findings suggest that obesity may be a modifiable risk factor in the rehabilitation of older patients with possible sarcopenia and should be considered in the assessment of decreased muscle strength.

Post-discharge consequences of protein-energy malnutrition, sarcopenia, and frailty in older adults admitted to rehabilitation: A systematic review

BACKGROUND & AIMS

Malnutrition, sarcopenia, and frailty are three prevalent wasting conditions among older rehabilitation patients that lead to multiple health-related negative outcomes. This systematic review and meta-analysis aimed to determine the post-discharge consequences of malnutrition, sarcopenia, and frailty in older adults admitted to inpatient rehabilitation.

METHODS

MEDLINE, Embase, Web of Science, and CINAHL databases were searched on 20 April, 2021 for longitudinal studies in older adults (≥65 years) admitted for inpatient rehabilitation. This systematic review included and synthesised studies that 1) measured malnutrition, sarcopenia, and/or frailty using a validated assessment tool or guideline; and 2) reported the association with post-discharge mortality, physical function, quality of life, or discharge location. The Academy of Nutrition & Dietetics Quality Criteria Checklist and GRADE criteria were used to assess risk of bias and evidence certainty. Where possible, data were pooled using Revman.

RESULTS

Twenty-six observational studies (n = 9709 participants in total) with similarly aged populations were included. Eight, seven, and eleven studies assessed malnutrition, sarcopenia, and frailty, respectively. Follow-up periods ranged from immediate to 7 years post-rehabilitation. Malnutrition was associated with discharge to a higher level of care (GRADE: very low), and worse quality of life (GRADE: very low) and physical function (GRADE: very low). Sarcopenia was associated with worse physical function (GRADE: very low) and lower rate of home discharge (OR: 0.14; 95%CI: 0.09-0.20; I²:30%; GRADE: low). Frailty was associated with increased mortality (GRADE: very low), hospital readmission (GRADE: very low), and decreased home discharge (GRADE: very low).

CONCLUSION

Wasting conditions in older adults during rehabilitation admission may be associated with poorer quality of life, lower rates of home discharge, and higher rates of health service use, physical dysfunction, and mortality following discharge. Further research is needed to investigate the comparative and combined impacts, as well as the overlap of malnutrition, sarcopenia, and frailty during and after rehabilitation to guide priority screening and intervention.

Association between deprescribing from polypharmacy and functional recovery and home discharge among older patients with sarcopenia after stroke

OBJECTIVE

Evidence regarding the association between deprescribing from polypharmacy and outcomes in the convalescent rehabilitation setting is rare. The aim of this study was to assess the association between deprescribing from polypharmacy and functional recovery and home discharge in older patients with sarcopenia after stroke.

METHODS

This retrospective cohort study was conducted at a convalescent rehabilitation hospital from January 2015 to December 2021. Among newly admitted patients in the convalescent rehabilitation ward who had experienced a stroke, patients aged ≥65 y with sarcopenia at admission and who were using at least five medications were included. Sarcopenia was diagnosed according to hand-grip strength and skeletal muscle mass index following the criteria of the Asian Working Group for Sarcopenia 2019. The primary outcome measures were functional independence-measured motor activity (FIM-motor) at discharge and home discharge. Multiple regression analysis was used to determine whether deprescribing from polypharmacy at admission was independently associated with rehabilitation outcomes.

RESULTS

Among the 264 patients with polypharmacy, 153 patients (mean age, 81.1 y; 46.4% males) were diagnosed with sarcopenia and included in the analysis. Of them, 56 (36.6%) were deprescribed from polypharmacy. Deprescribing from polypharmacy was independently associated with FIM-motor at discharge (β, 0.137; P = 0.017) and home discharge (odds ratio, 1.393; P = 0.002).

CONCLUSIONS

Because no effective pharmacotherapy for sarcopenia has been established, the novel findings of this study may be useful in the pharmacotherapy for older patients with sarcopenia after stroke. Deprescribing from polypharmacy on admission was positively associated with functional status at discharge and home discharge in older patients with sarcopenia after stroke.

Prevalence of Sarcopenic Obesity and Factors Influencing Body Composition in Persons with Spinal Cord Injury in Japan

This study aims to investigate the prevalence of sarcopenic obesity and factors influencing body composition in persons with spinal cord injury (SCI) in Japan. Adults with SCI aged ≥ 20 years who underwent whole-body dual-energy X-ray absorptiometry between 2016 and 2022 were retrospectively analyzed. Data from 97 patients were examined. The primary outcome was appendicular skeletal muscle mass (ASM). Multiple linear regression analysis was conducted to assess factors influencing the lean and adipose indices in persons with SCI. Sarcopenia, obesity, and sarcopenic obesity were prevalent in 76%, 85%, and 64% of patients, respectively. Multivariate linear regression analysis revealed that sex (β = 0.34, p < 0.001), lesion level (β = 0.25, p = 0.007), severity (β = 0.20, p = 0.043), and ability to walk (β = 0.29, p = 0.006) were independently associated with ASM. Sex (β = −0.63, p < 0.001) was independently associated with percent body fat. In conclusion, sarcopenia, obesity, and sarcopenic obesity were prevalent among patients with SCI in Japan. Female sex, tetraplegia, motor-complete injury, and inability to walk were risk factors for sarcopenia, whereas female sex was a risk factor for obesity in persons with SCI. A routine monitoring of body composition is necessary, especially among those with multiple risk factors, to identify individuals in need of preventive and therapeutic interventions.

Prevalence of sarcopenic obesity based on newly proposed diagnostic criteria and functional outcomes in older adults undergoing rehabilitation

In 2022, the European Society for Clinical Nutrition and Metabolism (ESPEN) and European Association for the Study of Obesity (EASO) working group proposed uniform diagnostic criteria for sarcopenic obesity. However, no study has adapted these criteria to an Asian population or examined sarcopenic obesity prevalence diagnosed using these criteria or its association with functional outcomes. This retrospective cohort study investigated sarcopenic obesity prevalence diagnosed based on the ESPEN and EASO criteria, and its association with functional outcomes in 1080 older Japanese patients (mean age 79.5 years, 43.5 % male) undergoing rehabilitation. Based on the mentioned criteria, sarcopenic obesity is defined as a BMI ≥ 25 kg/m², increased percent body fat (PBF), reduced skeletal muscle mass (SMM), and low handgrip strength. Sarcopenic obesity prevalence was investigated using various ESPEN- and EASO-proposed definitions of increased PBF and reduced SMM. Functional outcomes were evaluated based on whether patients improved in the minimal clinically important difference (MCID) of the Functional Independence Measure (FIM). The prevalence was 4.3-5.3 %. Sarcopenic obesity was not independently related to FIM MCID achievement. Sarcopenic obesity prevalence-based on the ESPEN and EASO criteria-in older Japanese patients undergoing rehabilitation was low and was not associated with poor functional outcomes.

The Applicability of the ESPEN and EASO-Defined Diagnostic Criteria for Sarcopenic Obesity in Japanese Patients after Stroke: Prevalence and Association with Outcomes

Sarcopenic obesity is of growing research and clinical interest; however, validated diagnostic criteria are lacking. We therefore aimed to examine the prevalence of sarcopenic obesity as diagnosed by the criteria recently proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO), and its association with outcomes among patients after stroke. This study was based on a cohort of 760 Japanese patients after stroke admitted to a post-acute rehabilitation hospital. Sarcopenic obesity was diagnosed at admission according to the ESPEN and EASO criteria using reference values specific to Asians. Outcomes included the motor domain of the functional independence measure (FIM-motor) and the food intake level scale (FILS) at discharge. Multivariate linear regression models were used to assess the associations between sarcopenic obesity and outcomes. Among 760 patients (median age, 73 years; 352 women and 408 men), sarcopenic obesity was diagnosed in 34 patients (4.5%; 5.4% of women and 4.1% of men). In multivariate analyses, sarcopenic obesity was independently and negatively associated with FIM-motor (β = −0.048, p = 0.031) and FILS at discharge (β = −0.095, p = 0.046) in women. In contrast, in men, sarcopenic obesity showed an independent negative association with FIM-motor at discharge (β = −0.117, p < 0.001) but no statistically significant association with FILS at discharge (β = −0.004, p = 0.323). In conclusion, the prevalence of sarcopenic obesity diagnosed by the ESPEN and EASO-defined criteria was as low as 4.5% among Japanese patients after stroke. Furthermore, sarcopenic obesity was negatively associated with improvements in activities of daily living and dysphagia.

Association of polypharmacy at hospital discharge with nutritional intake, muscle strength, and activities of daily living among older patients undergoing convalescent rehabilitation after stroke

Matsumoto A, Yoshimura Y, Shimazu S, Nagano F, Bise T, Kido Y, Shiraishi A, Sunahara T. Association of polypharmacy at hospital discharge with nutritional intake, muscle strength, and activities of daily living among older patients undergoing convalescent rehabilitation after stroke. Jpn J Compr Rehabil Sci 2022; 13: 41-48.

Objective

To investigate the association between polypharmacy at discharge and nutritional intake, muscle strength, and activities of daily living (ADL) among older patients undergoing convalescent rehabilitation after stroke.

Methods

This cross-sectional study involved hospitalized patients aged 65 or older who underwent convalescent rehabilitation after stroke. Polypharmacy was defined as the use of six or more medications. Study outcomes included energy intake, protein intake, handgrip strength (HG), and motor subscore of Functional Independence Measure (FIM-motor) at hospital discharge. Multiple linear regression analysis was used to examine the association between polypharmacy at discharge and outcomes.

Results

Of 361 eligible patients (mean [±SD] age, 78.3 ± 7.7 years; 49.3% male), 62.9% had polypharmacy. Multiple regression analysis revealed that polypharmacy at discharge was negatively associated with energy intake (β = -0.122, p = 0.003), protein intake (β = -0.133, p = 0.013), HG (β = -0.070, p = 0.022), and FIM-motor score (β = -0.069, p = 0.031) at discharge.

Conclusion

The impact of polypharmacy should be considered when designing nutritional management strategies for rehabilitation patients to maximize rehabilitation outcomes.

Potentially inappropriate medications are negatively associated with functional recovery in patients with sarcopenia after stroke

BACKGROUND

Evidence is scarce for potentially inappropriate medications (PIMs) in rehabilitation medicine.

AIM

To examine the effect of PIMs on functional recovery in older patients with sarcopenia after stroke.

METHODS

We conducted a retrospective cohort study in a post-acute rehabilitation hospital. All patients diagnosed with sarcopenia aged ≥ 65 years among all post-stroke patients hospitalized from 2015 to 2020 were included. PIMs were defined based on the 2019 Beers criteria. Sarcopenia was diagnosed using handgrip strength (HG) and skeletal muscle mass index (SMI), according to the criteria of the Asian Working Group for Sarcopenia 2019. The outcomes included functional independence measure motor (FIM-motor), HG, and SMI values at discharge. Multiple linear regression analyses were used to determine whether PIMs used at admission were independently associated with outcomes.

RESULTS

Of the eligible patients, 361 were 65 years or older, of whom 196 (mean age 81.0 years, 44.4% male) presented with sarcopenia and were included in the analysis. Of these, 131 (66.8%) were prescribed PIMs at admission. The most frequently prescribed PIMs were proton pump inhibitors, antipsychotics, benzodiazepines, and nonsteroidal anti-inflammatory drugs. The number of PIMs on admission was independently associated with FIM-motor (β = - 0.132, P = 0.001) and HG (β = - 0.091, P = 0.048) at discharge, but not with SMI (β = - 0.055, P = 0.256).

CONCLUSIONS

High admission PIMs prescription numbers are negatively associated with favorable discharge functional status and muscle strength in older patients with sarcopenia after stroke.

Implication of diet and exercise on the management of age‐related sarcopenic obesity in Asians

The incidence of sarcopenic obesity among adults aged ≥65 years is rising worldwide. Sarcopenic obesity is a high‐risk geriatric syndrome defined as a gain in the amount of adipose tissue along with the age‐related loss of muscle mass and strength or physical performance. Sarcopenic obesity is associated with increased risks of falls, physical limitations, cardiovascular diseases, metabolic diseases, and/or mortality. Thus, the identification of preventive and treatment strategies against sarcopenic obesity is important for healthy aging. Diet and exercise are the reasons for the development of sarcopenic obesity and are key targets in its prevention and treatment. Regarding weight reduction alone, it is most effective to maintain a negative energy balance with dietary calorie restriction and aerobic exercise. However, it is important to preserve skeletal muscle mass while reducing fat mass. Resistance exercise and appropriate protein supply are the main ways of preserving skeletal muscle mass, as well as muscle function. Therefore, in order to improve sarcopenic obesity, a complex treatment strategy is needed to limit energy ingestion with proper nutrition and to increase multimodal exercises. In this review, we focus on recently updated interventions for diet and exercise and potential future management strategies for Asian individuals with aging‐related sarcopenic obesity. Geriatr Gerontol Int 2022; 22: 695–704.

Chair-Stand Exercise Improves Sarcopenia in Rehabilitation Patients after Stroke

Currently, there is a lack of evidence to show that exercise therapy improves sarcopenia in older patients in clinical practice. We therefore conducted a retrospective cohort study to clarify the effects of chair-stand exercise on improving sarcopenia among patients diagnosed with sarcopenia undergoing convalescent rehabilitation after stroke. According to the latest Asian criteria, sarcopenia was diagnosed when both skeletal muscle mass index (SMI) and handgrip strength (HGS) were low. Patients were asked to perform a repeated chair-stand exercise as whole-body resistance training, in addition to the rehabilitation program. Outcomes included sarcopenia rates, SMI, HGS, and physical function at hospital discharge. Multivariate analyses were used to examine whether the frequency of daily chair-stand exercise was independently associated with the outcomes after adjustment for potential confounders. After enrollment, 302 patients with sarcopenia (mean age: 78.6 years; 46.4% male) were analyzed. Overall, sarcopenia prevalence decreased by 21.9%, from 100% at admission to 78.1% at discharge. Multivariate analyses showed that the frequency of the exercise was significantly associated with the presence of sarcopenia (odds ratio: 0.986, p = 0.010), SMI (β = 0.181, p < 0.001), and HGS (β = 0.101, p = 0.032) at discharge, respectively. The chair-standing exercise was effective in improving sarcopenia in these patients.

Deprescribing Leads to Improved Energy Intake among Hospitalized Older Sarcopenic Adults with Polypharmacy after Stroke

Evidence is scarce regarding the polypharmacy in patients with sarcopenia. The aim of this study was to investigate the effect of deprescribing for polypharmacy on the improvement of nutritional intake and sarcopenia in older patients with sarcopenia. A retrospective cohort study was conducted with hospitalized older patients with sarcopenia undergoing rehabilitation after stroke. Study outcomes included energy intake, protein intake, handgrip strength (HG) and skeletal muscle mass index (SMI) at hospital discharge. To consider the effects of deprescribing for polypharmacy, we used multivariate analyses to examine whether the change in the number of medications during hospitalization was associated with outcomes. Of 361 patients after enrollment, 91 (mean age 81.0 years, 48.4% male) presented with sarcopenia and polypharmacy and were eligible for analysis. The change in the number of medications was independently associated with energy intake (β = −0.237, p = 0.009) and protein intake (β = −0.242, p = 0.047) at discharge, and was not statistically significantly associated with HG (β = −0.018, p = 0.768) and SMI (β = 0.083, p = 0.265) at discharge, respectively. Deprescribing was associated with improved nutritional intake in older sarcopenic patients with polypharmacy undergoing stroke rehabilitation.

Rehabilitation nutrition for individuals with frailty, disability, sarcopenic dysphagia, or sarcopenic respiratory disability

PURPOSE OF REVIEW

We describe the recent advances in rehabilitation nutrition, which is especially important for disabled or frail older individuals.

RECENT FINDINGS

Recent evidence pertaining to rehabilitation nutrition conducted in rehabilitation wards and acute care hospitals has been accumulating. The combination of rehabilitation nutrition and rehabilitation pharmacotherapy is important for eliciting higher functions. The 2020 update of the clinical practice guidelines for rehabilitation nutrition provides a weak recommendation for enhanced nutritional care for patients with cerebrovascular disease, hip fracture, cancer, or acute illness who are undergoing rehabilitation. Rehabilitation nutritional care process and the International Classification of Functioning, Disability and Health-Dietetics are used to implement high-quality rehabilitation nutrition. Aggressive nutrition therapy incorporates the daily energy expenditure plus daily energy accumulation to increase body weight and muscle mass. Preventing and treating sarcopenic dysphagia should include iatrogenic sarcopenia prevention and aggressive nutrition therapy. The diagnosis criteria for respiratory sarcopenia and sarcopenic respiratory disability have been established.

SUMMARY

The International Association of Rehabilitation Nutrition and Total Nutrition Therapy Rehabilitation program may contribute to international expansion of rehabilitation nutrition. Improving evidence-practice gaps in rehabilitation nutrition and increasing national health insurance coverage of aggressive nutrition therapy and rehabilitation nutrition teams are warranted.

Relative low muscle mass and muscle strength is associated with the prevalence of metabolic syndrome in patients with type 2 diabetes

This cross-sectional study investigated the association of metabolic syndrome (MetS) with sarcopenia defined by absolute low muscle mass (aLMM) and absolute low muscle strength (aLMS), or sarcopenia defined by relative low muscle mass (rLMM) and relative low muscle strength (rLMS). The cut-off values for men and women were as follows: aLMM, appendicular muscle mass in kg/height‍² was <7.0 kg/m‍² and <5.7 kg/m‍²; rLMM, appendicular muscle mass/body weight ×100 was <28.64% and <24.12%; aLMS, handgrip strength was <28 kg and <18 kg; and rLMS, handgrip strength/body weight ×100 was 51.26% and 35.38%. Among 207 men and 164 women, 41.5% men and 57.3% women had MetS, 14.0% men and 6.1% women had sarcopenia as defined by aLMM and aLMS, and 14.0% men and 22.0% women had sarcopenia defined by rLMM and rLMS. Compared with non-sarcopenia, adjusted OR of sarcopenia defined by aLMM and aLMS for the prevalence of MetS was 0.79 (95% CI 0.38–1.67), whereas that of sarcopenia defined by rLMM and rLMS for the prevalence of MetS was 20.6 (95% CI 7.81–54.3). Sarcopenia defined by rLMM and rLMS was associated with the risk of prevalence of MetS, whereas sarcopenia defined by aLMM and aLMS was not.

Goal setting for nutrition and body weight in rehabilitation nutrition: position paper by the Japanese Association of Rehabilitation Nutrition (secondary publication)

The most important nutrition goals in rehabilitation nutrition are improving function and quality of life, and they are useful to set body weight goals to further improve these aspects. In this paper, we clarified our position, as the Japanese Association of Rehabilitation Nutrition, on body weight goal setting. Body weight goals should be SMART (Specific, Measurable, Achievable, Realistic/Relevant, and Timed). The standard amount of energy accumulation/deficit needed to gain/lose 1 kg body weight is 7500 kcal. In other words, if the nutrition goal is set at 1 kg body weight gain per month, daily energy accumulation can be calculated as approximately 250 kcal. It is necessary to reconcile the rehabilitation goal setting, the content, quantity, and quality of physical activity and exercise therapy, and the patient's general condition and intentions to set nutrition goals. Body weight goal setting is more variable than rehabilitation goal setting, and it is important to confirm the degree of achievement through rehabilitation nutrition monitoring.

Sarcopenia is associated with incontinence and recovery of independence in urination and defecation in post-acute rehabilitation patients

OBJECTIVE

The aim of this study was to examine the association between sarcopenia and recovery of independence in urination and defecation in patients undergoing convalescent rehabilitation.

METHODS

This single-center, retrospective cohort study included post-acute rehabilitation patients. Sarcopenia was diagnosed using the muscle mass index and handgrip strength according to the updated criteria of the Asian Working Group for Sarcopenia 2019. Study outcomes and the recovery of independence in urination and defecation were evaluated using the sphincter control items of the Functional Independence Measure (FIM) at discharge: urination (FIM-Bladder) and defecation (FIM-Bowel), respectively. Multivariate regression analyses were used to determine whether sarcopenia at baseline was associated with the study outcomes. Statistical significance was set at P < 0.05.

RESULTS

After enrollment, 917 patients (mean age 74.7 ± 13.5 y; 58% women) were included in the final analyses. Sarcopenia was present in 451 patients (49.2%). The median FIM-Bladder and FIM-Bowel scores at admission were 5 [2-7] and 5 [3-7], respectively. Multivariate analyses showed that the presence of sarcopenia at admission was independently and negatively associated with FIM-Bladder and FIM-Bowel at discharge (all P < 0.001), respectively, after adjusting for potential confounders including baseline outcome variables, FIM, and disease.

CONCLUSIONS

Sarcopenia was negatively associated with the recovery of independence in urination and defecation in a post-acute rehabilitation setting. This relationship was independent of physical and cognitive level and disease. Early detection of sarcopenia and treatment by rehabilitation nutrition should be implemented to predict and maximize improvement in toileting independence in this population.

Sarcopenia, Obesity, and Sarcopenic Obesity: Relationship with Skeletal Muscle Phenotypes and Single Nucleotide Polymorphisms

Obesity may aggravate the effects of sarcopenia on skeletal muscle structure and function in the elderly, but no study has attempted to identify the gene variants associated with sarcopenia in obese women. Therefore, the aims of the present study were to: (1) describe neuromuscular function in sarcopenic and non-sarcopenic women with or without obesity; (2) identify gene variants associated with sarcopenia in older obese women. In 307 Caucasian women (71 ± 6 years, 66.3 ± 11.3 kg), skeletal muscle mass was estimated using bioelectric impedance, and function was tested with a 30 s one-leg standing-balance test. Biceps brachii thickness and vastus lateralis cross-sectional area (VL_ACSA) were measured with B-mode ultrasonography. Handgrip strength, maximum voluntary contraction elbow flexion (MVC_EF), and knee extension torque (MVC_KE) were measured by dynamometry, and MVC_KE/VL_ACSA was calculated. Genotyping was performed for 24 single-nucleotide polymorphisms (SNPs), selected based on their previous associations with muscle-related phenotypes. Based on sarcopenia and obesity thresholds, groups were classified as sarcopenic obese, non-sarcopenic obese, sarcopenic non-obese, or non-sarcopenic non-obese. A two-way analysis of covariance was used to assess the main effects of sarcopenia and obesity on muscle-related phenotypes and binary logistic regression was performed for each SNP to investigate associations with sarcopenia in obesity. There were no significant obesity * sarcopenic status interactions for any of the investigated muscle-related phenotypic parameters. Neither sarcopenia nor obesity had a significant effect on biceps brachii thickness, but sarcopenia was associated with lower VL_ACSA (p = 0.003). Obesity was associated with lower MVC_EF (p = 0.032), MVC_KE (p = 0.047), and MVC_KE/VL_ACSA (p = 0.012) with no significant effect of sarcopenia. Adjusted for age and height, three SNPs (ACTN3 rs1815739, MTHFR rs1801131, and MTHFR rs1537516) were associated with sarcopenia in obese participants. Sarcopenia was associated with a smaller muscle size, while obesity resulted in a lower muscle quality irrespective of sarcopenia. Three gene variants (ACTN3 rs1815739, MTHFR rs1801131, and MTHFR rs1537516) suspected to affect muscle function, homocysteine metabolism, or DNA methylation, respectively, were associated with sarcopenia in obese elderly women. Understanding the skeletal muscle features affected by sarcopenia and obesity, and identification of genes related to sarcopenia in obese women, may facilitate early detection of individuals at particular risk of sarcopenic obesity.

Stored Energy Increases Body Weight and Skeletal Muscle Mass in Older, Underweight Patients after Stroke

We conducted a retrospective observational study in 170 older, underweight patients after stroke to elucidate whether stored energy was associated with gains in body weight (BW) and skeletal muscle mass (SMM). Energy intake was recorded on admission. The energy requirement was estimated as actual BW (kg) × 30 (kcal/day), and the stored energy was defined as the energy intake minus the energy requirement. Body composition was measured by bioelectrical impedance analysis. The study participants gained an average of 1.0 ± 2.6 kg of BW over a mean hospital stay of 100 ± 42 days with a mean stored energy of 96.2 ± 91.4 kcal per day. They also gained an average of 0.2 ± 1.6 kg of SMM and 0.5 ± 2.3 kg of fat mass (FM). This means about 9600 kcal were needed to gain 1 kg of BW. In addition, a 1 kg increase in body weight resulted in a 23.7% increase in SMM and a 45.8% increase in FM. Multivariate regression analyses showed that the stored energy was significantly associated with gains in BW and SMM. Aggressive nutrition therapy is important for improving nutritional status and function in patients with malnutrition and sarcopenia.

Association of Estimated Salt and Miso Intake with the Prevalence of Obesity in People with Type 2 Diabetes: A Cross-Sectional Study

Salt intake is often estimated by the amount of sodium excreted in urine, and miso has been reported to increase it. This cross-sectional study investigated the relationship between obesity and high estimated salt intake with and without habitual miso consumption. Estimates of salt intake (g/day) were calculated using urinary sodium excretion, and a high estimated intake was defined as greater than the median amount of 9.5 g/day. Participants were divided into four groups based on estimated salt intake and miso consumption. Among 300 people, the proportions of obesity were 77.8% (n = 14/18), 40.2% (n = 53/132), 26.0% (n = 33/127), and 34.8% (n = 8/23) in the (+/-), (+/+), (-/+), and (-/-) groups of high estimated salt intake/habitual miso consumption, respectively. Compared with the (+/-) group, the adjusted odds ratios for obesity were 0.07 (95% confidence interval (CI): 0.02-0.26, p < 0.001), 0.16 (95% CI: 0.03-0.76, p = 0.022), and 0.14 (95% CI: 0.04-0.51, p = 0.003) in the (-/+), (-/-), and (+/+) groups, respectively. The presence of obesity was not much higher in people with high estimated salt intake with habitual miso consumption than that in people without. Clinicians should be aware that miso consumption promotes salt excretion, which may lead to an apparently higher estimated salt intake than actual.

Sarcopenic obesity is associated with macroalbuminuria in patients with type 2 diabetes: a cross-sectional study

Sarcopenia is associated with the risk of albuminuria in patients with type 2 diabetes mellitus (T2DM), and obesity is a risk factor for proteinuria. However, the association between sarcopenic obesity and diabetic nephropathy, including albuminuria, in patients with T2DM has not been reported. The study included 206 men and 163 women with T2DM who participated in the KAMOGAWA-DM cohort, which investigating the natural history of diabetes since 2014. Sarcopenia was defined as having both low skeletal muscle mass index (SMI, kg/m²) (<7.0 kg/m² for men and <5.7 kg/m² for women) and low handgrip strength (<28 kg for men and <18 kg for women). Obesity was diagnosed by the percentage of body fat (>30% for men and >35% for women). The patient was said to have sarcopenic obesity if he/she had both sarcopenia and obesity. Urinary albumin excretion of patients with sarcopenic obesity was higher than that of patients without sarcopenic obesity (median [interquartile range]: 342.0 [41.8-467.5] vs. 21.0 [9.0-75.4] mg/g Cr, p = 0.016). Additionally, sarcopenic obesity was associated with the presence of macroalbuminuria, compared with non-sarcopenic obesity (adjusted odds ratio 6.92 [95% confidence interval:1.63-29.4], p = 0.009). Adjusted odds ratios of sarcopenic obesity, sarcopenia only, and obesity only for the presence of macroalbuminuria were 6.52 (1.47-28.8, p = 0.014), 1.29 (0.45-3.71, p = 0.638), and 0.78 (0.38-1.58, p = 0.482), respectively, compared with neither sarcopenia nor obesity. This study indicated that sarcopenic obesity is associated with albuminuria, especially macroalbuminuria, in Japanese patients with T2DM.

Nutrition in the First Week after Stroke Is Associated with Discharge to Home

Malnutrition is associated with poor clinical outcomes in stroke patients. The effect of early nutritional intake after admission on home discharge is unclear. We evaluated the impact of energy intake in the first week of hospitalization of acute stroke patients on home discharge and activities of daily living (ADL). A retrospective cohort study was conducted with 201 stroke patients admitted to an acute care hospital in Japan. The energy and protein intake during the first week were evaluated. Multivariate models were used to estimate variables related to discharge destination and ADL at discharge. The cut-off point of nutritional intake for determining the discharge destination was evaluated using the receiver operating characteristic curve. Out of 163 patients included in the analysis, 89 (54.6%) and 74 (45.4%) were discharged home and elsewhere, respectively. Those discharged home had higher energy and protein intake than those discharged elsewhere. In multiple regression analysis, energy intake was independently associated with ADL at discharge and home discharge (odds ratio 1.146). Those with energy intake >20.7 kcal/kg/day had higher ADL at discharge and more patients discharged home than those with energy intake <20.7 kcal/kg/day. Energy intake during the first week affected home discharge in acute stroke patients.

Risk of Hospital Readmission among Older Patients Discharged from the Rehabilitation Unit in a Rural Community Hospital: A Retrospective Cohort Study

Rehabilitation for hospitalized older people can improve their independence for performing activities of daily living (ADL), but determining its appropriateness can be challenging because of inherent limitations in their ADL and short life expectancy. Thus, we aimed to clarify the benefit of rehabilitation among older Japanese patients. We retrospectively evaluated consecutive older patients (age > 65 years) admitted to the rehabilitation unit of a rural community hospital between 1 April 2016 and 31 March 2020. The primary outcome measure was readmission for acute conditions. Of the 732 patients evaluated, 311 patients (42.5%) were readmitted. Readmission was significantly associated with body mass index (BMI) (p < 0.001), dependent condition (p < 0.001), higher cognitive domain scores in the functional independence measure (FIM) (p = 0.019), and polypharmacy (p = 0.026). The most frequent cause of readmission was pyelonephritis (11.9%), followed by pneumonia (10.9%), compression fracture (10.6%), heat stroke (8.4%), and cerebral stroke (8.0%). In conclusion, older Japanese patients discharged from rehabilitation units have lower readmission rates than those previously reported. Thus, better nutritional control, a multidisciplinary approach to the management of cognitive dysfunction, and a decrease in polypharmacy could be associated with improved outcomes among discharged older patients.

Association of impaired oral health status with chronic kidney disease in post-acute rehabilitation

BACKGROUND

Despite the growing interest in oral health and chronic disease in geriatric medicine, the evidence of an association between the two variables is limited.

OBJECTIVES

This study sought to examine the association between oral health status and chronic kidney disease (CKD) in this setting.

MATERIALS AND METHODS

This retrospective study included consecutive post-acute patients in a rehabilitation hospital. Oral health status was evaluated using the Revised Oral Assessment Guide (ROAG). Renal function or CKD stage was assessed by measurement of the estimated glomerular filtration rate (eGFR). Multivariate logistic regression analysis was used to determine which subcategories of ROAG were independently associated with advanced CKD stages (vs. early CKD stages). Multiple linear regression analysis was used to clarify whether eGFR on admission was independently associated with ROAG score after adjusting for potential confounders.

RESULTS

A total of 1056 (mean age 70 years; 52% women) were included in the analysis. Slight and moderate-to-severe oral health problems were detected in 57.7% and 15.4% of patients, respectively. Patients with oral problems had a more severe stage of CKD (P = .036) and a lower eGFR (P = .028). Among subitems of ROAG, tongue (OR = 1.40, P = .041), saliva (OR = 1.72, P = .039) and oral cavity mucosa (OR = 1.37, P = .013) status was independently associated with the presence of CKD stages 3, 4 and 5. Furthermore, eGFR was independently associated with ROAG score (β = -0.180, P = .034) after adjusting for possible confounders.

CONCLUSIONS

Impaired oral health status is common and closely associated with CKD in post-acute inpatients.

Frequent and personalized nutritional support leads to improved nutritional status, activities of daily living, and dysphagia after stroke

OBJECTIVES

Evidence for appropriate nutritional assessment, energy prediction, and adaptation and their effect on outcomes after stroke is scarce. We sought to determine the frequency of individualized dietary prescriptions issued for individuals undergoing rehabilitation after stroke and to analyze the effect of diet-prescription frequency on outcomes after stroke.

METHODS

This single-center prospective cohort study included poststroke patients newly admitted to convalescent rehabilitation wards. The frequency and content of dietary prescriptions issued as part of nutritional assessments were examined. Study outcomes were nutritional status assessed using changes in skeletal muscle mass, physical function assessed using the Functional Independence Measure motor score, dysphagia status assessed using the Food Intake LEVEL Scale (score < 7), and length of hospital stay. Multivariate analyses were performed to determine whether the frequency of dietary prescriptions issued during hospitalization was independently associated with outcomes of interest, after adjusting for potential confounders.

RESULTS

A total of 454 participants (mean age = 71.8 y; 53.1% men, 46.9% women) were included in the final analysis data set. A median of five (range, 2-11) dietary prescriptions were issued per participant during the median 96 d of hospitalization, with the most common items being diet-texture modification for dysphagia and oral energy/protein enhancement. In multivariate analyses, the frequency of dietary prescriptions was independently associated with the change in skeletal muscle mass (β = 0.165, P = 0.028), Functional Independence Measure motor scores at discharge (β = 0.104, P = 0.045), length of stay (β = -0.056, P = 0.019), and presence of dysphagia at discharge (odds ratio = 0.949, P = 0.032).

CONCLUSIONS

Frequent and individualized nutritional support is associated with improved nutritional status, physical function, and dysphagia after stroke. Intensive nutritional support through multidisciplinary discussion plays a central role in the prevention and management of malnutrition to maximize the improvement of patient outcomes. This study is the first to report this association.

Hemoglobin Improvement is Positively Associated with Functional Outcomes in Stroke Patients with Anemia

OBJECTIVES

The aim of this study was to evaluate the associations between hemoglobin improvement and functional outcomes in anemic patients after stroke.

METHODS

This retrospective cohort study included consecutive hospitalized post-stroke patients with anemia. Data on serum hemoglobin level were extracted from medical records. The "change in hemoglobin levels" was defined as the pre-discharge hemoglobin level minus the baseline hemoglobin level. Study outcomes included the Functional Independence Measure-motor (FIM-motor) efficacy, and length of stay. Multivariate analyses were used to determine whether the change in hemoglobin levels was independently associated with study outcomes, after adjusting for potential confounders.

RESULTS

Of the 637 patients admitted, 194 stroke patients (mean age 75.4 years; 53.6% women) presented anemia at baseline and were included in the analysis. The mean (SD) baseline hemoglobin level was 11.2 (0.9) g/dL and the median (IQR) change was 0.4 (0.1-1.1) g/dL. In multivariate analyses, the change in hemoglobin levels was positively associated with the FIM-motor efficacy (β = 0.114, p = 0.031), and negatively associated with length of stay (β = -0.059, p = 0.039). Moreover, the baseline hemoglobin level was independently associated with the FIM-motor efficacy (β = 0.267, p = 0.001).

CONCLUSIONS

A lower baseline hemoglobin level is negatively associated with functional recovery, and hemoglobin improvement is positively associated with functional recovery and shorter hospital stay in stroke patients with anemia. Anemia should be assessed at baseline as a prognostic indicator and, if treatable, treated appropriately to maximize outcomes in these patients.

Low Hemoglobin Levels are Associated with Sarcopenia, Dysphagia, and Adverse Rehabilitation Outcomes After Stroke

OBJECTIVE

The aim of our study was to evaluate the associations between baseline hemoglobin (Hb) levels and sarcopenia and outcomes in patients undergoing rehabilitation after stroke.

METHODS

This retrospective cohort study included consecutive hospitalized post-stroke patients. Data on serum Hb level were extracted from medical records on tests performed within 24 h of admission. Primary outcome was the presence of sarcopenia at admission, diagnosed based on both low skeletal muscle mass and strength criteria per recently updated Asian Working Group for Sarcopenia 2019 guidelines. Other outcomes included the Functional Independence Measure-motor (FIM-motor) score at discharge and its change from baseline, and the Food Intake Level Scale (FILS) score (measure of dysphagia, FILS score < 7) at discharge. Multivariate analyses were used to determine the association between Hb levels at admission and outcomes of interest, adjusted for potential confounders.

RESULTS

Data from 598 patients (mean age 72.1 years; 52.7% men) were included in the analysis. The mean Hb level at admission was 13.2 g/dL, and 86 (27.3%) men and 102 (36.0%) women had low Hb levels, i.e., 13.0 g/dL and 12.0 g/dL, respectively. In multivariate analyses, the baseline Hb level was independently associated with sarcopenia (odds ratio [OR]: 0.794, 95% confidence interval [CI]: 0.677-0.930, p = 0.004), FIM-motor score (β = 0.096, p = 0.045) at discharge and its change from baseline (β = 0.191, p = 0.018), and dysphagia (OR: 0.762, 95% CI: 0.595-0.961, p = 0.041) at discharge.

CONCLUSION

Baseline low Hb levels were associated with sarcopenia, poorer recovery of physical function, and dysphagia in patients undergoing rehabilitation after stroke.

Incident Impaired Cognitive Function in Sarcopenic Obesity: Data From the National Health and Aging Trends Survey

Objectives

The prevalence of obesity with sarcopenia is increasing in adults aged ≥65 years. This geriatric syndrome places individuals at risk for synergistic complications that leads to long-term functional decline. We ascertained the relationship between sarcopenic obesity and incident long-term impaired global cognitive function in a representative US population.

Design

A longitudinal, secondary data set analysis using the National Health and Aging Trends Survey.

Setting

Community-based older adults in the United States.

Participants

Participants without baseline impaired cognitive function aged ≥65 years with grip strength and body mass index measures.

Methods

Sarcopenia was defined using the Foundation for the National Institutes of Health Sarcopenia Project grip strength cut points (men <35.5 kg; women <20 kg), and obesity was defined using standard body mass index (BMI) categories. Impaired global cognition was identified as impairment in the Alzheimer's Disease-8 score or immediate/delayed recall, orientation, clock-draw test, date/person recall. Proportional hazard models ascertained the risk of impaired cognitive function over 8 years (referent = neither obesity or sarcopenia).

Results

Of the 5822 participants (55.7% women), median age category was 75 to 80, and mean grip strength and BMI were 26.4 kg and 27.5 kg/m², respectively. Baseline prevalence of sarcopenic obesity was 12.9%, with an observed subset of 21.2% participants having impaired cognitive function at follow-up. Compared with those without sarcopenia or obesity, the risk of impaired cognitive function was no different in obesity alone [hazard ratio (HR) 0.98; 95% confidence interval (CI) 0.82-1.16]), but was significantly higher in sarcopenia (HR 1.60; 95% CI 1.42-1.80) and sarcopenic obesity (HR 1.20; 95% CI 1.03-1.40). There was no significant interaction term between sarcopenia and obesity.

Conclusions

Both sarcopenia and sarcopenic obesity are associated with an increased long-term risk of impaired cognitive function in older adults.