Towards a common definition of surgical prehabilitation: a scoping review of randomised trials

BACKGROUND

There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition.

METHODS

The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis.

RESULTS

We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.'

CONCLUSIONS

A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Impact of 14 Days of Bed Rest in Older Adults and an Exercise Countermeasure on Body Composition, Muscle Strength, and Cardiovascular Function: Canadian Space Agency Standard Measures

INTRODUCTION

Head-down bed rest (HDBR) has long been used as an analog to microgravity, and it also enables studying the changes occurring with aging. Exercise is the most effective countermeasure for the deleterious effects of inactivity. The aim of this study was to investigate the efficacy of an exercise countermeasure in healthy older participants on attenuating musculoskeletal deconditioning, cardiovascular fitness level, and muscle strength during 14 days of HDBR as part of the standard measures of the Canadian Space Agency.

METHODS

Twenty-three participants (12 males and 11 females), aged 55-65 years, were admitted for a 26-day inpatient stay at the McGill University Health Centre. After 5 days of baseline assessment tests, they underwent 14 days of continuous HDBR followed by 7 days of recovery with repeated tests. Participants were randomized to passive physiotherapy or an exercise countermeasure during the HDBR period consisting of 3 sessions per day of either high-intensity interval training (HIIT) or low-intensity cycling or strength exercises for the lower and upper body. Peak aerobic power (V̇O2peak) was determined using indirect calorimetry. Body composition was assessed by dual-energy X-ray absorptiometry, and several muscle group strengths were evaluated using an adjustable chair dynamometer. A vertical jump was used to assess whole-body power output, and a tilt test was used to measure cardiovascular and orthostatic challenges. Additionally, changes in various blood parameters were measured as well as the effects of exercise countermeasure on these measurements.

RESULTS

There were no differences at baseline in main characteristics between the control and exercise groups. The exercise group maintained V̇O2peak levels similar to baseline, whereas it decreased in the control group following 14 days of HDBR. Body weight significantly decreased in both groups. Total and leg lean masses decreased in both groups. However, total body fat mass decreased only in the exercise group. Isometric and isokinetic knee extension muscle strength were significantly reduced in both groups. Peak velocity, flight height, and flight time were significantly reduced in both groups with HDBR.

CONCLUSION

In this first Canadian HDBR study in older adults, an exercise countermeasure helped maintain aerobic fitness and lean body mass without affecting the reduction of knee extension strength. However, it was ineffective in protecting against orthostatic intolerance. These results support HIIT as a promising approach to preserve astronaut health and functioning during space missions, and to prevent deconditioning as a result of hospitalization in older adults.

Relationship between Adherence to the 2019 Canada's Food Guide Recommendations on Healthy Food Choices and Nutrient Intakes in Older Adults

BACKGROUND

Following Canada's food guide (CFG) recommendations should ensure adequate nutrient intakes. Older adults have increased needs for certain nutrients and nutrient density; the extent to which adherence to CFG recommendations can help reduce inadequate nutrient intakes is unknown.

OBJECTIVES

We aimed to assess the relationship between adherence to CFG recommendations on healthy food choices and intake of key nutrients in adults 65 y and older from the Canadian Community Health Survey 2015 - Nutrition.

METHODS

Secondary analysis of data from 4093 older adults of the Canadian Community Health Survey 2015 - Nutrition (mean age, 73.6 y, 54% females). Dietary intakes were measured using an interviewer-administered 24-h dietary recall, including 1 repeat in a subsample (42%). The National Cancer Institute multivariate method was used to estimate usual (i.e., long-term) dietary intakes. Adherence to CFG recommendations was measured using the Healthy Eating Food Index (HEFI)-2019 score. Simple linear and logistic regression models estimated the effect of increased HEFI-2019 score on usual nutrient intakes and the prevalence of inadequate nutrient intakes (i.e., below the estimated average requirements), respectively.

RESULTS

Compared with the prevalence of inadequate intakes at median HEFI-2019 score (46.4/80 points), a higher HEFI-2019 (+11 points) was associated with reductions in the prevalence of inadequate intakes of magnesium, vitamin B6 and protein [-19.8% (95% confidence interval (CI): -30.8, -8.9), -12.7% (95% CI: -22.5, -3.0), and -4.7% (95% CI: -9.4, -0.1), respectively]. In contrast, data for higher HEFI-2019 scores were compatible with increased prevalence of inadequate intakes of folate, vitamin D, and calcium [4.0% (95% CI: -8.4, 16.3), 2.6% (95% CI: 1.1, 4.0), and 2.3% (95% CI: -3.0, 7.5), respectively].

CONCLUSIONS

Based on dietary intakes of Canadian older adults in 2015, increasing the degree of adherence to CFG recommendations on healthy food choices may reduce nutrient intake inadequacy for most key nutrients except folate, vitamin D, and calcium.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review

BACKGROUND

Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists.

METHODS

Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions.

SOURCES OF EVIDENCE

search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane.

CHARTING METHODS

identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD).

RESULTS

We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1).

CONCLUSION

Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

Multimodal Biomarkers That Predict the Presence of Gleason Pattern 4: Potential Impact for Active Surveillance

PURPOSE

Latent grade group ≥2 prostate cancer can impact the performance of active surveillance protocols. To date, molecular biomarkers for active surveillance have relied solely on RNA or protein. We trained and independently validated multimodal (mRNA abundance, DNA methylation, and/or DNA copy number) biomarkers that more accurately separate grade group 1 from grade group ≥2 cancers.

MATERIALS AND METHODS

Low- and intermediate-risk prostate cancer patients were assigned to training (n=333) and validation (n=202) cohorts. We profiled the abundance of 342 mRNAs, 100 DNA copy number alteration loci, and 14 hypermethylation sites at 2 locations per tumor. Using the training cohort with cross-validation, we evaluated methods for training classifiers of pathological grade group ≥2 in centrally reviewed radical prostatectomies. We trained 2 distinct classifiers, PRONTO-e and PRONTO-m, and validated them in an independent radical prostatectomy cohort.

RESULTS

PRONTO-e comprises 353 mRNA and copy number alteration features. PRONTO-m includes 94 clinical, mRNAs, copy number alterations, and methylation features at 14 and 12 loci, respectively. In independent validation, PRONTO-e and PRONTO-m predicted grade group ≥2 with respective true-positive rates of 0.81 and 0.76, and false-positive rates of 0.43 and 0.26. Both classifiers were resistant to sampling error and identified more upgrading cases than a well-validated presurgical risk calculator, CAPRA (Cancer of the Prostate Risk Assessment; P < .001).

CONCLUSIONS

Two grade group classifiers with superior accuracy were developed by incorporating RNA and DNA features and validated in an independent cohort. Upon further validation in biopsy samples, classifiers with these performance characteristics could refine selection of men for active surveillance, extending their treatment-free survival and intervals between surveillance.

Infrared thermotransmittance-based temperature field measurements in semitransparent media

Contactless temperature field measurements in or at the surfaces of semitransparent media are a scientific challenge as classical thermography techniques based on proper material emission cannot be used. In this work, an alternative method using infrared thermotransmittance for contactless temperature imaging is proposed. To overcome the weakness of the measured signal, a lock-in acquisition chain is developed and an imaging demodulation technique is used to retrieve the phase and amplitude of the thermotransmitted signal. These measurements, combined with an analytical model, enable the estimation of the thermal diffusivity and conductivity of an infrared semitransparent insulator (wafer of Borofloat 33 glass) and the monochromatic thermotransmittance coefficient at 3.3 µm. The obtained temperature fields are in good agreement with the model, and a detection limit of ±2 °C is estimated with this method. The results of this work open new opportunities in the development of advanced thermal metrology for semitransparent media.

Lifestyle Behaviour Changes and Associated Risk Factors During the COVID-19 Pandemic: results of the Canadian COVIDiet Online Cohort Study

BACKGROUND

The COVID-19 pandemic and related lockdowns have impacted lifestyle behaviours including eating habits and physical activity; yet few studies identified emerging patterns of such changes and associated risk factors.

OBJECTIVE

To identify patterns of weight and lifestyle behaviour change, and potential risk factors, resulting from the pandemic in Canadian adults.

METHODS

Analyses were conducted on 1,609 adults (18-89 y; 90.1% women; 81.8% White) of the Canadian COVIDiet study baseline data (May-Dec 2020). Self-reported current and pre-pandemic weight, physical activity, smoking status, perceived eating habits, alcohol intake and sleep quality were collected by online questionnaires. Based on these 6 indicator variables, latent class analysis (LCA) was used to identify lifestyle behaviour change patterns. Associations with potential risk factors including age, gender, ethnicity, education, income, chronic diseases, body image perception, and changes in stress level, living situation and work arrangement were examined with logistic regressions.

RESULTS

Participants' mean BMI was 26.1 ± 6.3 kg/m2; 60.9% had >= bachelor's degree. Since the pandemic, 35% had decreased income and 49% changed work arrangement. Most participants reported unchanged weight, sleep quality, physical activity level, smoking and alcohol consumption, yet 44% reported a perceived decrease in eating habits quality. From LCA, 2 classes of lifestyle behaviour change emerged; "healthy" and "less healthy" (probability: 0.605 and 0.395; BIC=15574.3, entropy=4.8). "Healthy" class participants more frequently reported unchanged weight, sleep quality, smoking and alcohol intake, unchanged/improved eating habits and increased physical activity. The "less healthy" class reported significant weight gain, deteriorated eating habits and sleep quality, unchanged/increased alcohol intake and smoking, and decreased physical activity. Among risk factors, body image dissatisfaction OR=8.8, 95%CI (5.3-14.7), depression OR=1.8, 95%CI (1.3, 2.5), increased stress level OR=3.4, 95%CI (2.0, 5.8) and of gender minority identity OR=5.5, 95% CI (1.3-22.3) were associated with adopting "less healthy" behaviours in adjusted models.

CONCLUSIONS

The COVID-19 pandemic appeared to have influenced lifestyle behaviours unfavorably in some, but favorably in others. Body image perception, change in stress level and gender identity were factors associated with behaviour change patterns; whether these will sustain overtime remains to be studied. Findings provide insights to develop strategies in supporting adults with poorer mental well-being in the post-pandemic context and promoting healthful behaviours during future disease outbreaks.

CLINICALTRIAL

This study was registered on ClinicalTrials.gov (NCT04407533).

Relative Validation of an Artificial Intelligence–Enhanced, Image-Assisted Mobile App for Dietary Assessment in Adults: Randomized Crossover Study

Background

Thorough dietary assessment is essential to obtain accurate food and nutrient intake data yet challenging because of the limitations of current methods. Image-based methods may decrease energy underreporting and increase the validity of self-reported dietary intake. Keenoa is an image-assisted food diary that integrates artificial intelligence food recognition. We hypothesized that Keenoa is as valid for dietary assessment as the automated self-administered 24-hour recall (ASA24)–Canada and better appreciated by users.

Objective

We aimed to evaluate the relative validity of Keenoa against a 24-hour validated web-based food recall platform (ASA24) in both healthy individuals and those living with diabetes. Secondary objectives were to compare the proportion of under- and overreporters between tools and to assess the user’s appreciation of the tools.

Methods

We used a randomized crossover design, and participants completed 4 days of Keenoa food tracking and 4 days of ASA24 food recalls. The System Usability Scale was used to assess perceived ease of use. Differences in reported intakes were analyzed using 2-tailed paired t tests or Wilcoxon signed-rank test and deattenuated correlations by Spearman coefficient. Agreement and bias were determined using the Bland-Altman test. Weighted Cohen κ was used for cross-classification analysis. Energy underreporting was defined as a ratio of reported energy intake to estimated resting energy expenditure <0.9.

Results

A total of 136 participants were included (mean 46.1, SD 14.6 years; 49/136, 36% men; 31/136, 22.8% with diabetes). The average reported energy intakes (kcal/d) were 2171 (SD 553) in men with Keenoa and 2118 (SD 566) in men with ASA24 (P=.38) and, in women, 1804 (SD 404) with Keenoa and 1784 (SD 389) with ASA24 (P=.61). The overall mean difference (kcal/d) was −32 (95% CI −97 to 33), with limits of agreement of −789 to 725, indicating acceptable agreement between tools without bias. Mean reported macronutrient, calcium, potassium, and folate intakes did not significantly differ between tools. Reported fiber and iron intakes were higher, and sodium intake lower, with Keenoa than ASA24. Intakes in all macronutrients (r=0.48-0.73) and micronutrients analyzed (r=0.40-0.74) were correlated (all P<.05) between tools. Weighted Cohen κ scores ranged from 0.30 to 0.52 (all P<.001). The underreporting rate was 8.8% (12/136) with both tools. Mean System Usability Scale scores were higher for Keenoa than ASA24 (77/100, 77% vs 53/100, 53%; P<.001); 74.8% (101/135) of participants preferred Keenoa.

Conclusions

The Keenoa app showed moderate to strong relative validity against ASA24 for energy, macronutrient, and most micronutrient intakes analyzed in healthy adults and those with diabetes. Keenoa is a new, alternative tool that may facilitate the work of dietitians and nutrition researchers. The perceived ease of use may improve food-tracking adherence over longer periods.

Remission of type 2 diabetes and improved diastolic function by combining structured exercise with meal replacement and food reintroduction among young adults: the RESET for REMISSION randomised controlled trial protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) onset before 40 years of age has a magnified lifetime risk of cardiovascular disease. Diastolic dysfunction is its earliest cardiac manifestation. Low energy diets incorporating meal replacement products can induce diabetes remission, but do not lead to improved diastolic function, unlike supervised exercise interventions. We are examining the impact of a combined low energy diet and supervised exercise intervention on T2DM remission, with peak early diastolic strain rate, a sensitive MRI-based measure, as a key secondary outcome.

METHODS AND ANALYSIS

This prospective, randomised, two-arm, open-label, blinded-endpoint efficacy trial is being conducted in Montreal, Edmonton and Leicester. We are enrolling 100 persons 18-45 years of age within 6 years' T2DM diagnosis, not on insulin therapy, and with obesity. During the intensive phase (12 weeks), active intervention participants adopt an 800-900 kcal/day low energy diet combining meal replacement products with some food, and receive supervised exercise training (aerobic and resistance), three times weekly. The maintenance phase (12 weeks) focuses on sustaining any weight loss and exercise practices achieved during the intensive phase; products and exercise supervision are tapered but reinstituted, as applicable, with weight regain and/or exercise reduction. The control arm receives standard care. The primary outcome is T2DM remission, (haemoglobin A1c of less than 6.5% at 24 weeks, without use of glucose-lowering medications during maintenance). Analysis of remission will be by intention to treat with stratified Fisher's exact test statistics.

ETHICS AND DISSEMINATION

The trial is approved in Leicester (East Midlands - Nottingham Research Ethics Committee (21/EM/0026)), Montreal (McGill University Health Centre Research Ethics Board (RESET for remission/2021-7148)) and Edmonton (University of Alberta Health Research Ethics Board (Pro00101088). Findings will be shared widely (publications, presentations, press releases, social media platforms) and will inform an effectiveness trial.

TRIAL REGISTRATION NUMBER

ISRCTN15487120.

Association of Low Muscle Mass With Cognitive Function During a 3-Year Follow-up Among Adults Aged 65 to 86 Years in the Canadian Longitudinal Study on Aging

IMPORTANCE

Cross-sectional studies have shown that combined low muscle mass and strength are associated with cognitive impairment. Whether low muscle mass, reflective of physiologic reserve, is independently associated with faster cognitive decline remains unknown.

OBJECTIVE

To investigate the associations between low muscle mass and cognitive decline in 3 distinct domains among adults aged at least 65 years.

DESIGN, SETTING, AND PARTICIPANTS

The Canadian Longitudinal Study on Aging is a prospective population-based cohort study of community-dwelling adults. Enrollment occurred from 2011 to 2015 with a 3-year follow-up. Analyses for this study were conducted on those aged at least 65 years from April 24 to August 12, 2020.

EXPOSURE

Appendicular lean soft tissue mass (ALM) was assessed by dual energy x-ray absorptiometry. Low ALM was identified using the sex-specific Canadian cut points.

MAIN OUTCOMES AND MEASURES

Memory was assessed using the Rey auditory verbal learning test. Executive function was assessed using the mental alternation test, Stroop high interference (words/dot) test, the animal fluency test, and the controlled oral word association test. Psychomotor speed was assessed using computer-administered choice reaction time. Composite scores by domain were created.

RESULTS

Of 8279 participants, 4003 (48%) were female, 8005 (97%) were White, and the mean (SD) age was 72.9 (5.6) years. A total of 1605 participants (19.4%) had low ALM at baseline. Participants with low ALM were older, had lower body mass index and physical activity level. The presence of low ALM at baseline was associated with faster 3-year cognitive decline in executive functions and psychomotor speed from multiple linear regressions. After adjusting for covariates including age, level of education, percentage body fat, and handgrip strength, low ALM remained independently associated with executive function decline (standardized β: -0.032; P = .03) only. Low ALM was not associated with memory.

CONCLUSIONS AND RELEVANCE

This cohort study found longitudinal associations between low ALM and cognition in aging. Identification of older adults with low muscle mass, a targetable modifiable factor, may help estimate those at risk for accelerated executive function decline. Further longer-term investigation of associations is warranted.

Validity and Reliability of the Smart Food Diary Keenoa Against Recovery Biomarkers: A Study Protocol

Objectives

Dietary assessment provides essential data for nutrition research, but current methods have limitations impeding the accuracy of reported intakes. Keenoa is a new mobile food diary that integrates artificial intelligence food recognition. Participants take pictures of their meals, specify foods and beverages consumed and estimate portion sizes with the help of visual pictograms. Data are analyzed from the Canadian Nutrient File v2015 and other national databases. Objectives are 1) To assess Keenoa's validity and reliability for energy, protein, potassium and sodium intakes against recovery biomarkers; 2) to determine the optimal number of tracking days for maximal validity; 3) to assess the appreciation and usability from participants.

Methods

Adult participants (18–70 y, n = 120) will be recruited for this 3-month study. They will track their food intake using a weighted written food diary (WFD) and Keenoa, in a randomized order, at month 1 (4 consecutive days), 2 (7 days) and 3 (4 days). At month 2, urinary nitrogen, sodium and potassium excretion will be measured from 24-h urine collections on day 3 of each tracking tool. A subsample of n = 30 will undergo measurement of total energy expenditure using the gold-standard doubly labeled water method. Intakes in other key nutrients will be compared to those reported by WFD, as a relative comparator considered the most accurate among conventional methods. Proportions of under/over-reporters will be analyzed by gender and BMI category. Perceived usability of the Keenoa application will be assessed using the validated System Usability Scale (SUS). The validity of Keenoa will be tested by comparing reported intakes of multiple days against measured recovery biomarkers with paired t-tests and Wilcoxon Signed rank test, as applicable, and Bland Altman's test for bias. Reliability will be tested by comparing repeated measures over time with intraclass correlations. P-values < 0.05 will be considered significant.

Results

N/A

Conclusions

If proven accurate, reliable, and appreciated by users, this innovative tool could be used by researchers in a cost-effective manner. It could contribute to expanding nutrition knowledge and support research on the role of nutrition in health.

Funding Sources

Canadian Foundation for Dietetics Research.

Adopting a Less Healthy Lifestyle Pattern During the COVID-19 Pandemic Is Modulated by Body Image Dissatisfaction and Increased Stress in Adults of the Canadian COVIDiet Study

Objectives

The COVID-19 pandemic and related lockdowns may impact lifestyle behaviors including eating habits and physical activity; few studies identified emerging patterns of such changes and associated risk factors. Objectives were to identify patterns of weight and lifestyle behavior change resulting from the pandemic in Canadian adults; and potential risk factors.

Methods

Analyses were conducted on 1,609 adults (18–89 y; 90.1% women; 81.8% White) of the Canadian COVIDiet study baseline data (May-Dec 2020). Self-reported current and pre-pandemic weight, physical activity, smoking status, perceived eating habits, alcohol intake and sleep quality were collected by online questionnaires. Based on these 6 indicator variables, categorized into 3–5 levels of change, latent class analysis (LCA) was used to identify lifestyle behavior change patterns. Associations with potential risk factors including age, gender, ethnicity, education, income, chronic diseases, body image perception, and changes in stress level, living situation and work arrangement were examined with logistic regressions.

Results

Participants’ mean BMI was 26.8 ± 6.7; 61% had > = bachelor's degree. Since the pandemic, 21% could not always afford balanced meals, 35% had decreased income and 49% changed work arrangement. From LCA, 2 classes of lifestyle behavior change emerged; “healthy” and “less healthy” (probability: 0.58 and 0.42; BIC = 19,354.8, entropy = 5.5). “Healthy” class participants more frequently reported unchanged weight, sleep quality, smoking and alcohol intake, unchanged/improved eating habits and increased physical activity. The “less healthy” class reported significant weight gain, deteriorated eating habits and sleep quality, unchanged/increased alcohol intake and smoking, and decreased physical activity. Among risk factors, body image dissatisfaction [OR = 12.2, 95%CI (9.4–15.8)] and increased stress level [(OR = 5.0, 95%CI (3.8, 6.4)] were associated with adopting “less healthy” behaviors in adjusted models.

Conclusions

The COVID-19 pandemic appeared to have influenced lifestyle behaviors unfavorably in some but favorably in others. Body image perception and change in stress level may have modulated these changes; whether these will sustain overtime remains to be studied.

Funding Sources

McGill University.

Current considerations for clinical management and care of non-alcoholic fatty liver disease: Insights from the 1st International Workshop of the Canadian NASH Network (CanNASH)

Non-alcoholic fatty liver disease (NAFLD) affects approximately 8 million Canadians. NAFLD refers to a disease spectrum ranging from bland steatosis to non-alcoholic steatohepatitis (NASH). Nearly 25% of patients with NAFLD develop NASH, which can progress to liver cirrhosis and related end-stage complications. Type 2 diabetes and obesity represent the main risk factors for the disease. The Canadian NASH Network is a national collaborative organization of health care professionals and researchers with a primary interest in enhancing understanding, care, education, and research around NAFLD, with a vision of best practices for this disease state. At the 1st International Workshop of the CanNASH network in April 2021, a joint event with the single topic conference of the Canadian Association for the Study of the Liver (CASL), clinicians, epidemiologists, basic scientists, and community members came together to share their work under the theme of NASH. This symposium also marked the initiation of collaborations between Canadian and other key opinion leaders in the field representative of international liver associations. The main objective is to develop a policy framework that outlines specific targets, suggested activities, and evidence-based best practices to guide provincial, territorial, and federal organizations in developing multidisciplinary models of care and strategies to address this epidemic.

Comparison of Different Approaches to Operationalize Fried’s Phenotypic Frailty in the NuAge Cohort

Many operationalization approaches were proposed to identify frailty in older adults. The common use of Fried’s original criteria or other cut-offs based on cohort distribution may not apply in every cohort leading to potential bias in the identification of frail individuals. We thus aimed to apply different Fried’s phenotypic frailty operationalization approaches in the Quebec NuAge cohort of generally healthy community-dwelling older adults (n=1,753; aged 67-84 years), and longitudinally compare prevalence, incidence and predictive strength on outcomes, such as functional autonomy, falls, hospitalization and mortality. Significant variability in prevalence, classification agreement and predictive strengths were observed between approaches, notably using different types of distribution cut-offs, variables, or ways to handle missing data. This strategy helped us to prioritize a specific Fried’s phenotypic frailty operationalization in NuAge, which could then be used in secondary research projects aiming to study determinants of Fried’s phenotypic frailty and its role in health outcomes.

Ultra-broadband contactless imaging power meter

Knowledge of the spatial and temporal distribution of heat flux is of great interest for the quantification of heat sources. In this work, we describe the development of a new ultra-broadband contactless imaging power meter based on electromagnetic to infrared technology. This new sensor and the mathematical processing of images enable the reconstruction of both spatial and amplitude distributions through a wide spectral range of sources. The full modeling of the thermoconverter based on 3D formalism of thermal quadrupoles is presented first before deriving a reduced model more suitable for quick and robust inverse processing. The inverse method makes it possible to simultaneously identify the heat losses and the spatial and temporal source distribution for the first time, to the best of our knowledge. Finally, measurements of multispectral sources are presented and discussed, with an emphasis on the spatial and temporal resolution, accuracy and capabilities of the power meter.

Feasibility of a novel mixed-nutrient supplement in a multimodal prehabilitation intervention for lung cancer patients awaiting surgery: A randomized controlled pilot trial

OBJECTIVE

To investigate, in lung cancer patients awaiting elective surgery, the feasibility of delivering a novel four-week multimodal prehabilitation intervention and its effects on preoperative functional capacity and health-related quality of life (HRQoL), compared to standard hospital care.

METHODS

Adult patients awaiting elective thoracotomy for lung cancer stages I, II or IIIa, were approached to participate in an open-label, randomized controlled trial of two parallel arms: multimodal prehabilitation combining a mixed-nutrient supplement with structured supervised and home-based exercise training, and relaxation-strategies (Prehab) or standard hospital care (Control). Feasibility was assessed based on recruitment and adherence rates to the intervention and study outcome assessment. Functional capacity, measured by the 6-min walk test (6MWT), and HRQoL were measured at baseline and after four weeks (preoperative).

RESULTS

Within 5 months, 34 patients were enrolled and randomized (2:1) to Prehab (n = 24; median age = 67 years) or Control (n = 10; median age = 69 years); recruitment rate of 58.6%. The study was interrupted by the COVID-19 pandemic. Adherence to the prescribed intensity of the supervised exercise program was 84.1% (SD 23.1). Self-reported adherence to the home-based exercise program was 88.2% (SD 21) and to the nutritional supplement, 93.2% (SD 14.2). Adherence to patients' preoperative assessment was 82% and 88% in Prehab and Control, respectively. The mean adjusted difference in 4-week preoperative 6MWT between groups was 37.7 m (95% CI, -6.1 to 81.4), p = 0.089. There were no differences in HRQoL between groups.

CONCLUSION

Within a preoperative timeframe, it was feasible to deliver this novel multimodal prehabilitation intervention in lung cancer patients awaiting surgery.

A 16-week randomized controlled trial of a fish oil and whey protein-derived supplement to improve physical performance in older adults losing autonomy-A pilot study

Background

Low functional capacity may lead to the loss of independence and institutionalization of older adults. A nutritional intervention within a rehabilitation program may attenuate loss of muscle function in this understudied population.

Objective

This pilot study assessed the feasibility for a larger RCT of a nutritional supplementation in older adults referred to an outpatient assessment and rehabilitation program.

Methods

Participants were randomized to receive a supplement (EXP: 2g fish oil with 1500 IU vitamin D3 1x/d + 20-30g whey protein powder with 3g leucine 2x/d) or isocaloric placebo (CTR: corn oil + maltodextrin powder) for 16 weeks. Handgrip and knee extension strength (using dynamometry), physical performance tests and plasma phospholipid n-3 fatty acids (using GCMS) were evaluated at weeks 0, 8 and 16; and lean soft tissue mass (using DXA), at weeks 0 and 16.

Results

Over 2 years, 244 patients were screened, 46 were eligible (18.9%), 20 were randomized, 10 completed the study (6 CTR, 4 EXP). Median age was 87 y (77–94 y; 75% women) and gait speed was 0.69 m/s; 55% had low strength, and all performed under 420m on the 6-minute walk test, at baseline. Overall self-reported compliance to powder and oil was high (96% and 85%) but declined at 16 weeks for fish oil (55%). The EXP median protein intake surpassed the target 1.2–1.5 g/kg/d, without altering usual diet. Proportions of plasma phospholipid EPA and DHA increased significantly 3- and 1.5-fold respectively, at week 8 in EXP, with no change in CTR. Participants were able to complete most assessments with sustained guidance.

Conclusion

Because of low eligibility, the pilot study was interrupted and deemed non-feasible; adherence to rigorous study assessments and to supplements was adequate except for long-term fish oil. The non-amended protocol may be applied to populations with greater functional capacity.

Trial registration

ClinicalTrials.gov NCT04454359.

Effects of multimodal prehabilitation on muscle size, myosteatosis, and dietary intake of surgical patients with lung cancer - a randomized feasibility study

Many patients with lung cancer undergo surgery, which can increase the risk for muscle loss, leading to worsened outcomes. A multimodal prehabilitation intervention integrating dietary and muscle assessment may help clinicians better understand changes in these outcomes. This pilot assessed feasibility of multimodal prehabilitation in early-stage surgical lung cancer patients and explored relationships between body composition, muscle characteristics and dietary intake, as well as muscle changes due to prehabilitation. Patients were randomized to one of two groups: multimodal prehabilitation including nutritional supplements (fish oil with vitamin D3 + whey protein with leucine), exercise and relaxation, or standard of care. Physical function, dietary intake and muscle were evaluated at 0 and 4 weeks pre-operatively. Of 87 patients assessed for eligibility, 34 (39%) were randomized and 3 (9%) were lost to follow-up. Median age was 69 years and baseline protein intake was 1.0 g/kg/d. Adherence to exercise (86%) and supplements was high (93%); 3 patients (16%) reported side effects. Supplements significantly increased protein, omega-3 fatty acid, leucine and vitamin D intake. There were no significant changes in muscle characteristics. Multimodal prehabilitation with dietary and muscle analyses proved to be feasible. An adequately powered randomized controlled trial is warranted. ClinicalTrials.gov registration no: NCT04610606. Novelty: • Multimodal prehabilitation incorporating dietary assessment and muscle analysis is feasible for early-stage surgical lung cancer patients. • An adequately powered randomized controlled trial is warranted to further explore functional and post-operative outcomes.

Milk, yogurt and cheese intake is positively associated with cognitive executive functions in older adults of the Canadian Longitudinal Study on Aging

BACKGROUND

Dairy products provide essential nutrients such as calcium, vitamins B12 and D, and include bioactive peptides and fermented products, which may be beneficial for cognition, especially in older adults. Yet, few studies of large contemporary cohorts have investigated this relationship using sensitive domain-specific cognitive tests.

METHODS

In community-dwelling older adults of the Canadian Longitudinal Study on Aging (2011-2015), we examined cross-sectional associations between total and specific dairy product intake and performance in three cognitive domains (executive functions, memory, psychomotor speed). Cheese, milk, yogurt, regular-fat, low-fat and fermented dairy product intake frequencies were estimated using a food frequency questionnaire; participants were classified into quartiles. MANCOVA models were applied to estimate differences.

RESULTS

In 7,945 participants (65-86 y, 49% women, 97% Caucasian), the mean dairy product intake was 1.9 (1.1) times/d. Total dairy product, cheese and low-fat dairy product intake were positively associated with the executive function domain and yogurt intake with the memory domain (all p<0.05), independently of important covariates including age, gender, education and diet quality. Intakes of total dairy product, cheese and low-fat dairy were associated with verbal fluency specifically (all p<0.05). Participants with a dairy product intake > 2.5 times/d had a higher score compared to those consuming less. No associations were found with psychomotor speed.

CONCLUSIONS

This large cohort study suggests a specific role for dairy components in executive function phonemic verbal fluency and memory. Dairy product intake, a modifiable factor, may be targeted in cognitive health-promoting interventions.

Malnourished lung cancer patients have poor baseline functional capacity but show greatest improvements with multimodal prehabilitation

OBJECTIVE

The objective is to characterize the presence of malnutrition, examine the association between malnutrition and baseline functional capacity (FC), and the extent to which patients benefit from preoperative multimodal prehabilitation in patients undergoing lung resection for cancer.

METHODS

Data from 162 participants enrolled in multimodal prehabilitation or control before lung cancer surgery were analyzed. Malnutrition was measured using the Patient-Generated Subjective Global Assessment (PG-SGA) according to triage levels: low-nutrition-risk (PG-SGA 0-3), moderate-nutrition-risk (4-8) and high-nutrition-risk (≥9). Baseline differences in FC, measured by the 6-minute walk test (6MWT), were compared. Factorial analysis of covariance (ANCOVA) was conducted to examine the effect of nutrition status and intervention on mean change in 6MWT preoperatively.

RESULTS

51.2% patients were considered low-nutrition-risk, 37.7% moderate-nutrition-risk, and 11.1% high-nutrition-risk. Low-nutrition-risk patients had significantly higher 6MWT at baseline (mean of 484 m [standard deviation (SD) = 88]) compared with moderate-nutrition-risk (432 m [SD = 107], P = .005) and high-nutrition-risk groups (416 m [SD = 90], P = .022). The adjusted mean change in 6MWT between prehabilitation vs control was 18.1 (95% confidence interval, 3.8 to 32.3) vs 5.6 m (-14.1 to 25.4) in low-nutrition-risk (P = .309), 28.5 (11 to 46) vs -4 m (-31.3 to 23.4) in moderate-nutrition-risk (P = .053), and 58.9 (16.7 to 101.2) vs -39.7 m (-80.2 to 0.826) in high-nutrition-risk group (P = .001).

CONCLUSIONS

Lung cancer patients at high-nutrition-risk awaiting surgery had significantly lower baseline FC compared with low-nutrition-risk patients but experienced significant improvements in preoperative FC upon receiving multimodal prehabilitation.

Determinants of hospital and one-year mortality among older patients admitted to intensive care units: results from the multicentric SENIOREA cohort

BACKGROUND

Improving outcomes of older patients admitted into intensive care units (ICU) is a raising concern. This study aimed at determining which geriatric and ICU parameters were associated with in-hospital and long-term mortality in this population.

METHODS

We conducted a prospective multicentric observational cohort study, including patients aged 75 years and older requiring mechanical ventilation, admitted between September 2012 and December 2013 into ICU of 13 French hospitals. Comprehensive geriatric assessment at ICU admission and ICU usual parameters were registered in a standardized manner. Survival was recorded and comprehensive geriatric assessment was updated after 1 year during a dedicated home visit.

RESULTS

501 patients were analyzed. 108 patients (21.6%) died during the hospital stay. One-year survival rate was 53.8% (IC 95% [49.2%; 58.2%]). Factors associated with increased in-hospital mortality were higher acute illness severity score, resuscitated cardiac arrest as primary ICU diagnosis, perception of anxiety and low quality of life by the proxy, and living in a chronic care facility before ICU admission. Among patients alive at hospital discharge, factors associated with increased 1-year mortality in multivariate analysis were longer duration of mechanical ventilation, all primary ICU diagnoses other than septic shock, a Katz-activities of daily living (ADL) score below 5 and living in a chronic care facility before ICU admission. Among the 163 survivors at 1 year who received a second comprehensive geriatric assessment, the ADL score (functional abilities) showed a significant but moderate decline over time, whereas the Mini-Zarit score (family burden) improved. No significant change in patients' place of life was observed after 1 year, and quality of life was reported as happy-to-very-happy in 88% of survivors.

CONCLUSIONS

The mortality rate remains high among older ICU patients requiring mechanical ventilation. Factors associated with short- and long-term mortality combined geriatric and ICU criteria, which should be jointly evaluated in routine care. Clinical trial registration NCT01679171.

Prospective associations of protein intake parameters with muscle strength and physical performance in community-dwelling older men and women from the Quebec NuAge cohort

BACKGROUND

Dietary protein has been related to muscle function in aging. Beyond total intake, parameters such as protein distribution across meals might also be important.

OBJECTIVES

We aimed to examine prospective associations of different protein intake parameters with muscle strength and physical performance in community-dwelling older men and women.

METHODS

In total, 524 men and 574 women aged 67-84 y at baseline (T1) were followed annually for 3 y (T2, T3, T4). Outcomes included handgrip strength (kPa), knee extensor strength (kg), and physical performance (Timed Up and Go, s) at T4, and their 3-y changes (T4 minus T1). Protein intake parameters were assessed using nine 24-h recalls collected over 3 y (T1, T2, T3) and included daily total intake (g/d), number of protein-providing meals and snacks, and protein distribution across meals (expressed as CV). Associations were examined by multivariable linear regression models including all protein intake parameters simultaneously. Also, the optimal protein dose (g) per meal for the maximum effect size of total daily intake was determined.

RESULTS

Higher daily protein intake was associated with better knee extensor strength and physical performance at T4 in both sexes and less physical performance decline in women. Optimal protein doses per meal were 30-35 g in men and 35-50 g in women for these outcomes. In men, more uneven protein distribution was associated with better physical performance at T4 and less handgrip strength decline. In women, a higher number of protein-providing snacks was associated with better handgrip strength and knee extensor strength at T4 and less handgrip strength decline. In neither sex was number of protein-providing meals associated with outcomes.

CONCLUSIONS

Higher daily protein intake, up to 30-50 g protein/meal, may contribute to better knee extensor strength and physical performance in generally well-functioning older men and women. More aspects of protein intake may contribute to muscle strength and physical performance than solely the daily quantity, notably the protein dose per meal.

Mitochondrial Content, but Not Function, Is Altered With a Multimodal Resistance Training Protocol and Adequate Protein Intake in Leucine-Supplemented Pre/Frail Women

Background: Frailty is a clinical condition associated with loss of muscle mass and strength (sarcopenia). Mitochondria are centrally implicated in frailty and sarcopenia. Leucine (Leu) can alter mitochondrial content in myocytes, while resistance training (RT) is the strongest stimulus to counteract sarcopenia and may enhance mitochondrial biogenesis. Objective: We determined the effects of Leu supplementation and RT on mitochondrial content and function in pre/frail elderly women in a randomized double-blinded placebo-controlled study. Methods: Nineteen pre/frail elderly women (77.5 ± 1.3 y, BMI: 25.1 ± 0.9 kg/m²), based on the Frailty Phenotype, underwent 3-months of RT 3×/week with protein-optimized diet and were randomized to 7.5 g/d of Leu supplementation or placebo alanine (Ala). Pre/post-intervention mitochondrial respiration, reactive oxygen species (ROS) production, calcium retention capacity (CRC), time to permeability transition pore (mPTP) opening, mitochondrial voltage-dependent anion channel (VDAC) protein content, leg press 1-repetition maximum (1RM), and 6-min walk test (6MWT) were measured. Results: No time, supplementation, or interaction effects were observed for respiration, ROS, time to mPTP opening, and CRC. VDAC levels significantly increased in the Leu group post-intervention (p = 0.012). Both groups significantly increased leg press 1RM and 6MWT, with no effect of supplementation. Discussion: Leu supplementation with 3 months of RT increased mitochondrial content. Future studies should investigate if there is an increase in mitochondrial turnover or a shift in quality control (mitophagy) in leucine supplemented pre/frail elderly women who undergo 12 weeks of RT. Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT01922167.

Acute hyperaminoacidemia does not suppress insulin-mediated glucose turnover in healthy young men

Elevated circulating amino acids (AA) concentrations are purported to cause insulin resistance (IR) in humans. To quantify hyperaminoacidemia effects on insulin-mediated glucose turnover in healthy men, we performed 2-stage pancreatic clamps using octreotide with glucagon and growth hormone replacement. In the basal stage, insulin was infused to maintain euglycemia at postabsorptive levels. During the clamp stage, insulin was raised to postprandial levels, glycemia clamped at 5.5 mmol/L by glucose infusion, and branched-chain AA (BCAA) maintained at either postabsorptive (Hyper1; n = 8) or postprandial (Hyper2; n = 7) by AA infusion. Glucose turnover was measured by d-3-[³H]glucose dilution. Octreotide suppressed C-peptide; glucagon, growth hormone, and glycemia were maintained at postabsorptive levels throughout. Insulin did not differ at postabsorptive (72 ± 5 vs. 60 ± 5 pmol/L; Hyper1 vs. Hyper2) and increased to similar concentrations at basal (108 ± 11 vs. 106 ± 14) and clamp stages (551 ± 23 vs. 540 ± 25). Postabsorptive BCAA were maintained during Hyper1 and increased >2-fold (830 ± 26 µmol/L) during Hyper2. Endogenous glucose production was similarly suppressed (0.95 ± 0.16 vs. 1.37 ± 0.23 mg/kg lean body mass/min; Hyper1 vs. Hyper2) and basal glucose disposal (3.44 ± 0.12 vs. 3.67 ± 0.14) increased to similar levels (10.89 ± 0.56 vs. 11.11 ± 1.00) during the clamp. Thus, acute physiological elevation of AA for 3 h did not cause IR in healthy men. Novelty: A 2-step pancreatic clamp was used to quantify the effect of AA on insulin sensitivity in humans. Acute physiological elevation of circulating AA to postprandial levels does not cause IR in healthy men.

A 16-week Randomized Controlled Trial of a Fish Oil and Whey Protein-Derived Supplement to Improve Physical Performance in Older Adults Losing Autonomy – A Pilot Study

Objectives

Loss of autonomy is often the trigger for institutionalization of older adults. A nutritional intervention within a rehabilitation program may attenuate loss of muscle mass and function to enable continued autonomy in this understudied group of seniors. Objectives: 1) To assess the feasibility of a combined nutrient supplementation intervention with regards to recruitment, compliance, and completion of assessments in older adults losing autonomy; 2) to characterize this specific population.

Methods

Seniors taking part in a rehabilitation program were randomized to an intervention with a supplement (EXP: 2 g fish oil (EPA+ DHA) with 1500 IU vitamin D3 1x/d+ 20–30 g whey protein powder with 3 g leucine 2x/d) or placebo (CTR; corn oil and maltodextrin powder) for 16 weeks. Lean soft tissue mass (LM) and physical function were assessed. LM (DXA) was measured at weeks 0 and 16, handgrip and knee extension strength (dynamometry), physical performance tests and plasma phospholipid n-3 fatty acids (GCMS) were evaluated at weeks 0, 8 and 16.

Results

Over 2 y, 244 patients were screened, 46 were eligible (18.9%; 95% CI: 15.0, 22.8), 20 were randomized, 10 completed the study (n = 4 in EXP; n = 6 in CTR). Median age was 87 y (77–94 y; 75% women), 35% had low LM, 35% were frail, 85% were using a walking aid daily and physical performance was low, at baseline. Overall self-reported compliance to powder was 96% (95% CI: 83, 108) and to oil, 85% (95% CI: 63, 107). The EXP median protein intake alone surpassed the target 1.2–1.5 g/kg/d for older adults, without altering usual diet. Proportions of EPA and DHA increased significantly 3- and 1.5-fold respectively at week 8 in EXP, with no change in CTR. Participants were able to complete most assessments with sustained guidance.

Conclusions

Because of low eligibility limiting the pool of potential patients, the pilot study was interrupted as deemed non-feasible; however, compliance to supplements and the rigorous study assessments was high. Solutions to address recruitment, such as more liberal eligibility criteria, need to be considered in the design of a large-scale RCT before it can be carried out in this challenging population.

Funding Sources

Helen McCall Hutchison Award and Réseau québécois de la recherche sur le vieillissement of FRQS.

Physical function-derived cut-points for the diagnosis of sarcopenia and dynapenia from the Canadian longitudinal study on aging

BACKGROUND

Aging is associated with sarcopenia (low muscle mass) and dynapenia (low muscle strength) leading to disability and mortality. Widely used previous cut-points for sarcopenia were established from dated, small, or pooled cohorts. We aimed to identify cut-points of low strength as a determinant of impaired physical performance and cut-points of low appendicular lean mass (ALM) as a predictor of low strength in a single, large, and contemporary cohort of community-dwelling older adults and compare these criteria with others.

METHODS

Cross-sectional analyses were conducted on baseline data from 4725 and 4363 community-dwelling men and women (65-86 years, 96.8% Caucasian) of the Canadian longitudinal study on aging comprehensive cohort. Physical performance was evaluated from gait speed, timed up-and-go, chair rise, and balance tests; a weighted-sum score was computed using factor analysis. Strength was measured by handgrip dynamometry; ALM, by dual-energy X-ray absorptiometry and ALM index (ALMI; kg/m² ), was calculated. Classification and regression tree analyses determined optimal sex-specific cut-points of ALMI predicting low strength and of strength predicting impaired physical performance (score < 1.5 SD below the sex-specific mean).

RESULTS

Modest associations were found between ALMI and strength and between strength and physical performance score in both sexes. ALMI was not an independent predictor of physical performance score. Cut-points of <33.1 and <20.4 kg were found to define dynapenia in men and in women, respectively, corresponding to 21.5% and 24.0% prevalence rates. Sarcopenia cut-points were <7.76 kg/m² in men and <5.72 kg/m² in women; prevalence rates of 21.7% and 13.7%. Overall, 8.3% of men and 5.5% of women had sarco-dynapenia. Sarcopenic were older and had lower fat mass and body mass index (BMI) than non-sarcopenic participants. While the agreement between current criteria and the updated European Working Group for Sarcopenia in Older Persons recommendations was fair, we found only slight agreement with the Foundation for the National Institute of Health sarcopenia project. Older persons identified with sarcopenia as per the Foundation for the National Institute of Health criteria (using ALM/BMI as the index) have higher BMI and fat mass compared with non-sarcopenic and have normal ALMI as per our criteria.

CONCLUSIONS

The proposed function-derived cut-points established from this single, large, and contemporary Canadian cohort should be used for the identification of sarcopenia and dynapenia in Caucasian older adults. We advise on using criteria based on ALMI in the diagnosis of sarcopenia. The modest agreement between sarcopenia and dynapenia denotes potential distinct health implications justifying to study both components separately.

Fidelity of muscle fibre reinnervation modulates ageing muscle impact in elderly women

KEY POINTS

Susceptibility to age-related muscle atrophy relates to the degree of muscle denervation and the capacity of successful reinnervation. However, the specific role of denervation as a determinant of the severity of muscle aging between populations with low versus high physical function has not been addressed. We show that prefrail/frail elderly women exhibited marked features of muscle denervation, whereas world class octogenarian female master athletes showed attenuated indices of denervation and greater reinnervation capacity. These findings suggest that the difference in age-related muscle impact between low- and high-functioning elderly women is the robustness of the response to denervation of myofibers.

ABSTRACT

Ageing muscle degeneration is a key contributor to physical frailty; however, the factors responsible for exacerbated vs. muted ageing muscle impact are largely unknown. Based upon evidence that susceptibility to neurogenic impact is an important determinant of the severity of ageing muscle degeneration, we aimed to determine the presence and extent of denervation in pre-frail/frail elderly (FE, 77.9 ± 6.2 years) women compared to young physically inactive (YI, 24.0 ± 3.5 years) females, and contrast these findings to high-functioning world class octogenarian female masters athletes (MA, 80.9 ± 6.6 years). Muscle biopsies from vastus lateralis muscle were obtained from all three groups to assess denervation-related morphological and transcriptional markers. The FE group displayed marked grouping of slow fibres, accumulation of very small myofibres, a severe reduction in type IIa/I size ratio, highly variable inter-subject accumulation of neural cell adhesion molecule (NCAM)-positive myofibres, and an accumulation of pyknotic nuclei, indicative of recurring cycles of denervation/reinnervation and persistent denervation. The MA group exhibited a smaller decline in type IIa/I size ratio and fewer pyknotic nuclei, accompanied by a higher degree of type I fibre grouping and larger fibre group size, suggesting a greater reinnervation of denervated fibres. Consistent with this interpretation, MA had higher mRNA levels of the reinnervation-promoting cytokine fibroblast growth factor binding protein 1 (FGFBP1) than FE. Our results indicate that the muscle of FE women has significant neurogenic atrophy, whereas MA muscle exhibit superior reinnervation capacity, suggesting that the difference in age-related muscle impact between low- and high-functioning elderly women is the robustness of the response to denervation of myofibres.

Effect of a 12-week mixed power training on physical function in dynapenic-obese older men: does severity of dynapenia matter?

INTRODUCTION

Mobility disability affects nearly 15% of people aged 65 or over worldwide. Excess weight or obesity (OB), along with an accentuated loss of muscle strength (dynapenia), is recognized to be one of the most common risk factors for mobility impairment among the elderly.

OBJECTIVE

To investigate the effect of a 12-week mixed power training (MPT high-velocity resistance training mixed with functional exercises) on physical function in obese older men exhibiting different severities of dynapenia.

METHODS

Community-dwelling older men (69 ± 6 years) were assigned to the study if they were considered obese (OB, fat mass ≥ 25% body weight, BW) and to one of the two groups according to severity of dynapenia [(handgrip strength-HS)/BW]: type 1(OB-DY1) or type 2(OB-DY2), < 1 or 2SD from a young reference group. Participants followed a 12-week MPT, three times/week, 75 min/session. Main outcomes included the performance on the 4-m and 6-min walking tests, Timed Up and Go, stair and balance tests.

RESULTS AND DISCUSSION

At baseline, OB-DY1 performed better than OB-DY2 in all functional tests (p < 0.05). Following the intervention, medium-to-large training effect size (ES) were observed for fat (ES = 0.21) and lean (ES = 0.32, p < 0.001) masses, functional performance (ES 0.11-0.54, p < 0.05), HS (ES = 0.10, p < 0.05) and lower limb muscle strength (ES = 0.67, p < 0.001) and power (ES = 0.60, p < 0.05). Training-by-group interaction showed that OB-DY1 lost more FM (ES = 0.11, p = 0.03) and OB-DY2 improved more HS (ES = 0.19, p = 0.006) than their counterparts.

CONCLUSIONS

Seniors with obesity and severe dynapenia have poorer physical function than those in the early stage of dynapenia. Both seem to benefit from a high-velocity resistance training mixed with functional exercises, although by slightly different pathways.

Leucine Supplementation Does Not Alter Insulin Sensitivity in Prefrail and Frail Older Women following a Resistance Training Protocol

BACKGROUND

Frailty is a clinical condition associated with loss of muscle mass and strength (sarcopenia). Although sarcopenia has multifactorial causes, it might be partly attributed to a blunted response to anabolic stimuli. Leucine acutely increases muscle protein synthesis, and resistance training (RT) is the strongest stimuli to counteract sarcopenia and was recently shown to improve insulin sensitivity (IS) in frail older women. Discrepancies exist regarding whether chronic supplementation of leucine in conjunction with RT can improve muscle mass and IS.

OBJECTIVE

The aim of this double-blinded placebo-controlled study was to determine the effects of leucine supplementation and RT on IS in prefrail and frail older women.

METHODS

Using the Fried criteria, 19 nondiabetic prefrail (1-2 criteria) and frail (≥3 criteria) older women (77.5 ± 1.3 y; body mass index (kg/m2): 25.1 ± 0.9) underwent a 3-mo intervention of RT 3 times/wk with protein-optimized diet of 1.2 g·kg-1·d-1 and 7.5 g·d-1 of l-leucine supplementation compared with placebo l-alanine. Pre-/postintervention primary outcomes were fasting plasma glucose, serum insulin, and 4-h responses to a standard meal of complete liquid formula. Secondary outcomes of resting energy expenditure using indirect calorimetry and body composition using dual-energy X-ray absorptiometry were obtained. Paired t tests analyzed pooled data, and 2-factor repeated-measures ANOVA determined supplementation, training, and interaction effects.

RESULTS

No significant time, group, or interaction effects were observed for postprandial areas under the curve of serum insulin or plasma glucose or for resting energy expenditure in l-leucine compared with l-alanine. Total lean body mass increased and percentage body fat decreased significantly for both groups postintervention (0.76 ± 0.13 and -0.92 ± 0.33 kg, respectively; time effect: P < 0.01).

CONCLUSIONS

IS was not affected by RT and leucine supplementation in nondiabetic prefrail and frail older women. Therefore, leucine supplementation does not appear to influence IS under these conditions. This trial was registered at clinicaltrials.gov as NCT01922167.

An Update on Protein, Leucine, Omega-3 Fatty Acids, and Vitamin D in the Prevention and Treatment of Sarcopenia and Functional Decline

Aging is associated with sarcopenia and functional decline, leading to frailty and disability. As a modifiable risk factor, nutrition may represent a target for preventing or postponing the onset of these geriatric conditions. Among nutrients, high-quality protein, leucine, vitamin D, and omega-3 polyunsaturated fatty acids (n-3 PUFA) are of particular interest for their demonstrated effects on skeletal muscle health. This narrative review aims to examine the recent observational and interventional evidence on the associations and the role of these nutrients in the muscle mass, strength, mobility, and physical function of free-living older adults, who are either healthy or at risk of frailty. Recent evidence supports a higher protein intake recommendation of 1.0⁻1.2 g/kg/day in healthy older adults; an evenly distributed mealtime protein intake or minimal protein per meal may be beneficial. In addition, vitamin D supplementation of 800⁻1000 IU, particularly when vitamin D status is low, and doses of ~3 g/day of n-3 PUFA may be favorable for physical function, muscle mass, and strength. Reviewed studies are highly heterogenous, yet the quantity, quality, and timing of intakes should be considered when designing intervention studies. Combined protein, leucine, vitamin D, and n-3 PUFA supplements may convey added benefits and may represent an intervention strategy in the prevention of sarcopenia and functional decline.

COPD is independently associated with 6-month survival in patients who have life support withheld in intensive care

BACKGROUND

In-hospital outcomes following decisions of withholding or withdrawing in Intensive Care Unit (ICU) patients have been previously assessed, little is known about outcomes after ICU and hospital discharge. Our objective was to report the 6-month outcomes of discharged patients who had treatment limitations in a general ICU and to identify prognostic factors of survival.

METHODS

We retrospectively collected the data of patients discharged from the ICU for whom life support was withheld from 2009 to 2011. We assessed the survival status of all patients at 6 months post-discharge and their duration of survival. Survivors and non-survivors were compared using univariate and multivariate analyses by Cox's proportional hazard model.

RESULTS

One hundred fourteen patients were included. The survival rate at 6 months was 58.8%. Survival was associated with acute respiratory failure (48% vs 19%, P = .006), a history of COPD (40% vs 21%, P = .03) and a lower SAPS II score (44 vs 49, P = .006). We identified a history of COPD as a prognostic factor for survival in the multivariate analysis (HR = 2.1; IC 95% 1.02-4.36, P = .04).

CONCLUSION

A total of 58.8% of patients for whom life-sustaining therapies were withheld in the ICU survived for at least 6 months after discharge. Patients with COPD appeared to have a significantly higher survival rate. The decision to withhold life support in patients should not lead to a cessation of post-ICU care and to non-readmission of COPD patients.

Even mealtime distribution of protein intake is associated with greater muscle strength, but not with 3-y physical function decline, in free-living older adults: the Quebec longitudinal study on Nutrition as a Determinant of Successful Aging (NuAge study)

Background: Functional status declines with aging, thus impeding autonomy. Recently, a more even mealtime distribution of dietary protein was positively associated with muscle mass, but the relation of this distribution to physical performance remains unknown.Objective: We examined the relation between mealtime protein-intake distribution and physical performance and its 3-y decline in community-dwelling older adults.Design: Three-year follow-up data from 827 men and 914 women (67-84 y) in the longitudinal study on nutrition and aging [Quebec longitudinal study on Nutrition as a Determinant of Successful Aging (NuAge study); Quebec, Canada] were analyzed. Physical performance, which was measured yearly, was grouped into the following 2 functional composite scores: muscle strength (handgrip, arm, and leg) and mobility (timed-up-and-go, chair stand, and walking speed). Dietary data were collected in 2 sets of three 24-h food recalls at baseline and year 2. The individual mealtime protein distribution was calculated as the CV (i.e., SD divided by the mean) of grams of protein per meal. A mixed model analysis was used to examine trajectories of muscle strength and mobility across time by sex as conditioned by the protein distribution and adjusted for potential covariates.Results: Physical performance deteriorated over 3 y with muscle strength declining more than the mobility score in men (-1.51 ± 1.68 compared with -0.66 ± 2.81) and women (-1.35 ± 1.77 compared with -0.78 ± 2.63) (means ± SD, P < 0.001). More-evenly distributed protein intake, independent of the total quantity, was associated with a higher muscle-strength score in both sexes throughout follow-up. It was also associated with a greater mobility score, but only in men and only before adjustment for covariates. Strength and mobility rates of decline were not affected by protein-intake distribution in either sex.Conclusions: In addition to the previously observed association with lean mass, an even distribution of daily protein intake across meals is independently associated with greater muscle strength, but not with the mobility score, in older adults. A longer-term investigation of the role of protein intake and its distribution on physical performance is warranted, as are intervention studies, to support future recommendations.