Publications by authors named "Alessandro Laviano"

167 Publications

ESPEN practical guideline: Clinical Nutrition in cancer.

Clin Nutr 2021 Mar 15;40(5):2898-2913. Epub 2021 Mar 15.

Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.

Background: This practical guideline is based on the current scientific ESPEN guidelines on nutrition in cancer patients.

Methods: ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with cancer.

Results: A total of 43 recommendations are presented with short commentaries for the nutritional and metabolic management of patients with neoplastic diseases. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in cancer patients.

Conclusion: This practical guideline gives guidance to health care providers involved in the management of cancer patients to offer optimal nutritional care.
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http://dx.doi.org/10.1016/j.clnu.2021.02.005DOI Listing
March 2021

Letter to the Editor: Post-operative nutritional care of patients with gastrointestinal cancer: are long-term clinical outcomes achievable?

Clin Nutr 2021 Apr 7;40(5):2504-2505. Epub 2021 Apr 7.

Department of Agricultural, Food and Nutritional Science, University of Alberta, Canada.

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http://dx.doi.org/10.1016/j.clnu.2021.03.038DOI Listing
April 2021

Association of SARC-F and dissociation of SARC-F + calf circumference with comorbidities in older hospitalized cancer patients.

Exp Gerontol 2021 Jun 16;148:111315. Epub 2021 Mar 16.

Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil. Electronic address:

The Strength, Assistance for walking, Rise from a chair, Climb stairs and Falls (SARC-F) score is a tool recommended for screening the risk of sarcopenia in older patients. However, the association between SARC-F or SARC-F + calf circumference (SARC-F + CC) and the Charlson Comorbidity Index (CCI) in hospitalized older cancer patients is not fully understood. Thus, our aim is to evaluate the association between the SARC-F or SARC-F + CC and the presence of comorbidities and risk of death in older hospitalized cancer patients. A cross-sectional study involving 90 (42 M/48F) hospitalized cancer patients over 60 years old with ongoing chemotherapy or surgical treatment is carried out. The SARC-F is performed to assess the muscle function loss (MFL if SARC-F ≥ 4), sarcopenia (SARC-F ≥ 6) and sarcopenia using the calf circumference (SARC-F + CC ≥11). CC is assessed using an inelastic tape. The CCI is used to assess the presence of comorbidities. Logistic regression is used to evaluate the association between the SARC-F and Charlson Comorbidity Index. Mean of age is 67.8 years and half (49%) of the patients present MFL (SARC-F ≥ 4), 31% present sarcopenia using the SARC-F ≥ 6 and 60% using the SARC-F + calf circumference ≥ 11. Although no association in the crude model, there is association after adjusting by age, sex, alcohol use, smoking habit, physical activity, use of oral nutritional supplementation, body mass index, performance status, tumor, and treatment type between SARC-F ≥ 4 or ≥ 6 and CCI (SARC-F ≥ 4 × CCI: OR: 2.31 [95%CI: 1.02-5.23], p = 0.04) and (SARC-F ≥ 6 × CCI: OR: 3.24 [95%CI: 1.21-8.65], p = 0.01), respectively. However, this association is lost when using the SARC-F + calf circumference (SARC-F + CC ≥11 × CCI: OR: 1.12 [95%CI: 0.63-1.90], p = 0.68). In conclusion, screening for the risk of sarcopenia in older cancer patients is highly recommended as sarcopenia is tightly associated with the clinical outcome. The use of the SARC-F score using a cut-off ≥4 or ≥ 6 is more relevant for clinical practice to detect comorbidities and risk of death than the use of SARC-F with the calf circumference.
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http://dx.doi.org/10.1016/j.exger.2021.111315DOI Listing
June 2021

Corrigendum to "High protein diet improves the overall survival in older adults with advanced gastrointestinal cancer" [Clin Nutr] 40/3 (2021) 1376-1380.

Clin Nutr 2021 Apr 6;40(4):1441. Epub 2021 Mar 6.

Clinical and Sports Nutrition Research Laboratory (Labince), Faculty of Nutrition, Federal University of Goias, Goiânia, GO, Brazil.

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http://dx.doi.org/10.1016/j.clnu.2021.02.042DOI Listing
April 2021

Cancer-associated anorexia: Validity and performance overtime of different appetite tools among patients at their first cancer diagnosis.

Clin Nutr 2021 Feb 23. Epub 2021 Feb 23.

Department of Translational and Precision Medicine, Sapienza University of Rome, V.le dell'Università 37, Rome, Italy. Electronic address:

Background & Aims: Anorexia is a frequent symptom in cancer and we aimed to assess its prevalence among patients at their first cancer diagnosis by different appetite tools and the relationship between each tool with self-reports of food intake. We also tested whether cancer anorexia influences outcomes independently of reduced food intake or body weight loss (BWL) overtime and whether BWL was associated with complications during anticancer-therapy.

Methods: Functional Assessment of Anorexia/Cachexia Therapy (FAACT) score, self-assessment of appetite, Anorexia Questionnaire (AQ) and Visual Analog Scale (VAS) were administered. Percent of food intake was used as a criterion measure of anorexia. We registered BWL and anticancer-therapy complications over 3-month-follow-up.

Results: 438 cancer patients from 7 cancer-centers worldwide were included. The prevalence of anorexia was 39.9% by FAACT score, 40.2% by VAS, 40.6% by the self-assessment of appetite and 65.4% by AQ. Low food intake (≤50%) was reported in 28% of patients. All appetite tools correlated with food intake percent (P < 0.0001). We documented a correlation between self-assessment of appetite, FAACT score, VAS and BWL overtime (P < 0.04). The self-assessment of appetite (P = 0.0152) and the FAACT score (P = 0.043) were associated with BWL independently of anticancer therapies. Among patients with BWL, the risk to develop complications was greater with respect to those who maintained a stable or gained body weight (P = 0.03).

Conclusions: In our sample of cancer patients, FAACT score and self-assessment of appetite performed well when low food intake was used as a criterion measure, and revealed an association of anorexia with BWL, which was, in turn, related to the development of anticancer-therapy complications.
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http://dx.doi.org/10.1016/j.clnu.2021.02.016DOI Listing
February 2021

Percutaneous endoscopic gastrojejunostomy in pediatric intestinal pseudo-obstruction.

Nutrition 2021 Jan 29;86:111174. Epub 2021 Jan 29.

Department of Translational Medicine, University of Ferrara, Ferrara, Italy.

Pediatric intestinal pseudoobstruction (PIPO) is the "tip of the iceberg" of the most severe gut motility disorders. In patients with PIPO, the impairment of gastrointestinal propulsive patterns is such as to result in progressive obstructive symptoms without evidence of mechanical causes. PIPO is an important cause of intestinal failure and affects growth and pubertal development. Bowel loop and abdominal distension represent one of the main features of intestinal pseudo-obstruction syndromes, hence intestinal decompression is a mainstay in the management of PIPO. So far, pharmacologic, endoscopic, and surgical treatments failed to achieve long-term relief of bowel distension and related symptoms, including pain. Recent data, however, indicated that percutaneous endoscopic gastrojejunostomy (PEG-J) might be a minimally invasive approach for intestinal decompression, thereby improving abdominal symptoms and nutritional status in adult patients with chronic intestinal pseudo-obstruction. Based on these promising results, we treated for the first time a 12-y-old patient affected by PIPO refractory to any therapeutic options to obtain intestinal decompression by PEG-J. We showed that PEG-J yielded sustained small bowel decompression in the reported PIPO patient with considerable improvement of both abdominal symptoms and nutritional status. The positive outcome of the present case provides a basis to test the actual efficacy PEG-J versus other therapeutic approaches to intestinal decompression in patients with PIPO.
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http://dx.doi.org/10.1016/j.nut.2021.111174DOI Listing
January 2021

Low phase angle is associated with the risk for sarcopenia in unselected patients with cancer: Effects of hydration.

Nutrition 2021 04 6;84:111122. Epub 2021 Jan 6.

Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil. Electronic address:

Objective: Individuals with cancer are affected by a loss of cell membrane integrity due to electrolyte imbalance between the intra- and extracellular fluids. Cell membrane integrity and hydration status can be assessed according to the phase angle (PhA) and the risk for sarcopenia, by using the Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F) questionnaire. To our knowledge, this approach has not been validated in patients with cancer. The aims of this study were to verify the prevalence of the risk for sarcopenia, and to analyze the association between PhA and the risk for sarcopenia with and without adjustment for extracellular water content.

Methods: This was a cross-sectional study conducted with 124 male and female cancer patients (77.4% men). PhA and hydration status were assessed using bioelectrical impedance analysis (BIA), and the risk for sarcopenia (cutoff ≥4) was assessed using the SARC-F questionnaire.

Results: Of the 124 patients, 28 (22.5%) were at risk for sarcopenia (SARC-F ≥4). There was no association between PhA and the risk for sarcopenia in the crude model, nor in the model adjusted for age, sex, smoking, alcohol consumption, and physical activity, nor after adjusting for use of supplements, body mass index, treatment type, performance status, and type and stage of cancer. However, we found an association between lower PhA values and a higher risk for sarcopenia after adjusting for hydration abnormalities (odds ratio, 1.74; 95% confidence interval, 1.03-2.93; P < 0.035).

Conclusion: We found that 22.5% of patients with cancer presented with a risk for sarcopenia. Additionally, an association between lower PhA values and enhanced risk for sarcopenia highlighted the importance of adequate hydration and evaluation of fluid status via BIA as a new recommendation to prevent sarcopenia.
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http://dx.doi.org/10.1016/j.nut.2020.111122DOI Listing
April 2021

Nutrition in the spotlight in cachexia, sarcopenia and muscle: avoiding the wildfire.

J Cachexia Sarcopenia Muscle 2021 Feb 31;12(1):3-8. Epub 2020 Dec 31.

Department of Cardiology and Pneumology, University Medicine Goettingen, Goettingen, Germany.

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http://dx.doi.org/10.1002/jcsm.12673DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890147PMC
February 2021

Translating Evidence-Based Guidelines into Practice-Are We Getting It Right? A Multi-Centre Prospective International Audit of Nutrition Care in Patients with Foregut Tumors (INFORM).

Nutrients 2020 Dec 11;12(12). Epub 2020 Dec 11.

Royal Alexandra Hospital, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB T5H 3V9, Canada.

Malnutrition is highly prevalent in patients with foregut tumors comprising head and neck (HNC) and esophageal (EC) cancers, negatively impacting outcomes. International evidence-based guidelines (EBGs) for nutrition care exist; however, translation of research evidence into practice commonly presents considerable challenges and consequently lags. This study aimed to describe and evaluate current international nutrition care practices compared with the best-available evidence for patients with foregut tumors who are at high risk of malnutrition. A multi-centre prospective cohort study enrolled 170 patients commencing treatment of curative intent for HNC ( = 119) or EC ( = 51) in 11 cancer care settings in North America, Europe and Australia between 2016 and 2018. Adherence criteria were derived from relevant EBG recommendations with pooled results for participating centres reported according to the Nutrition Care Model at either system or patient levels. Adherence to EBG recommendations was: good (≥80%) for performing baseline nutrition screening and assessment, perioperative nutrition assessment and nutrition prescription for energy and protein targets; moderate (≥60 to 80%) for utilizing validated screening and assessment tools and pre-radiotherapy dietitian consultation; and poor (60%) for initiating post-operative nutrition support within 24 h and also dietetic consultation weekly during radiotherapy and fortnightly for 6 weeks post-radiotherapy. In conclusion, gaps in evidence-based cancer nutrition care remain; however, this may be improved by filling known evidence gaps through high-quality research with a concurrent evolution of EBGs to also encompass practical implementation guidance. These should aim to support multidisciplinary cancer clinicians to close evidence-practice gaps throughout the patient care trajectory with clearly defined roles and responsibilities that also address patient-reported concerns.
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http://dx.doi.org/10.3390/nu12123808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763837PMC
December 2020

The centenary of the Harris-Benedict equations: How to assess energy requirements best? Recommendations from the ESPEN expert group.

Clin Nutr 2021 Mar 20;40(3):690-701. Epub 2020 Nov 20.

Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Israel. Electronic address:

Background & Aims: The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is currently known about the estimation and measurement of energy expenditure.

Methods: Current evidence was discussed during the symposium, including the scientific basis and clinical knowledge, and is summarized here to assist with the estimation and measurement of energy requirements that later translate into energy prescription.

Results: In most clinical settings, the majority of predictive equations have low to moderate performance, with the best generally reaching an accuracy of no more than 70%, and often lead to large errors in estimating the true needs of patients. Generally speaking, the addition of body composition measurements did not add to the accuracy of predictive equations. Indirect calorimetry is the most reliable method to measure energy expenditure and guide energy prescription, but carries inherent limitations, greatly restricting its use in real life clinical practice.

Conclusions: While the limitations of predictive equations are clear, their use is still the mainstay in clinical practice. It is imperative to recognize specific patient populations for whom a specific equation should be preferred. When available, the use of indirect calorimetry is advised in a variety of clinical settings, aiming to avoid under-as well as overfeeding.
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http://dx.doi.org/10.1016/j.clnu.2020.11.012DOI Listing
March 2021

Myokines in treatment-naïve patients with cancer-associated cachexia.

Clin Nutr 2021 Apr 2;40(4):2443-2455. Epub 2020 Nov 2.

Cancer Metabolism Research Group, Universidade de Sao Paulo Instituto de Ciencias Biomedicas, Departamento de Biologia Celular e do Desenvolvimento and Faculdade de Medicina da Universidade de Sao Paulo, Departamento de Cirurgia, LIM 26-HC, São Paulo, Brazil.

Cancer-associated cachexia is a complex metabolic syndrome characterized by weight loss and systemic inflammation. Muscle loss and fatty infiltration into muscle are associated with poor prognosis in cancer patients. Skeletal muscle secretes myokines, factors with autocrine, paracrine and/or endocrine action, which may be modified by or play a role in cachexia. This study examined myokine content in the plasma, skeletal muscle and tumor homogenates from treatment-naïve patients with gastric or colorectal stages I-IV cancer with cachexia (CC, N = 62), or not (weight stable cancer, WSC, N = 32). Myostatin, interleukin (IL) 15, follistatin-like protein 1 (FSTL-1), fatty acid binding protein 3 (FABP3), irisin and brain-derived neurotrophic factor (BDNF) protein content in samples was measured with Multiplex technology; body composition and muscle lipid infiltration were evaluated in computed tomography, and quantification of triacylglycerol (TAG) in the skeletal muscle. Cachectic patients presented lower muscle FSTL-1 expression (p = 0.047), higher FABP3 plasma content (p = 0.0301) and higher tumor tissue expression of FABP3 (p = 0.0182), IL-15 (p = 0.007) and irisin (p = 0.0110), compared to WSC. Neither muscle TAG content, nor muscle attenuation were different between weight stable and cachectic patients. Lumbar adipose tissue (AT) index, visceral AT index and subcutaneous AT index were lower in CC (p = 0.0149, p = 0.0455 and p = 0.0087, respectively), who also presented lower muscularity in the cohort (69.2% of patients; p = 0.0301), compared to WSC. The results indicate the myokine profile in skeletal muscle, plasma and tumor is impacted by cachexia. These findings show that myokines eventually affecting muscle wasting may not solely derive from the muscle itself (as the tumor also may contribute to the systemic scenario), and put forward new perspectives on cachexia treatment targeting myokines and associated receptors and pathways.
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http://dx.doi.org/10.1016/j.clnu.2020.10.050DOI Listing
April 2021

High neutrophil to lymphocyte ratio as a prognostic marker in COVID-19 patients.

Clin Nutr ESPEN 2020 12 14;40:101-102. Epub 2020 Aug 14.

Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.

Systemic inflammation has been reported as a new predictor for COVID-19 outcomes. Thus, we highlight in this viewpoint the importance of the neutrophil to lymphocyte ratio in COVID-19 pandemic-infected patients.
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http://dx.doi.org/10.1016/j.clnesp.2020.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427597PMC
December 2020

Nutrition Information in Oncology - Extending the Electronic Patient-Record Data Set.

J Med Syst 2020 Sep 28;44(11):191. Epub 2020 Sep 28.

Faculty of Medicine, Center for Research in Health Technologies and Information Systems (CINTESIS), University of Porto, Porto, Portugal.

Electronic health records (EHRs) present extensive patient information and may be used as a tool to improve health care. However, the oncology context presents a complex content that increases the difficulties of EHR application. This study aimed at developing openEHR-archetypes representing clinical concepts in cancer nutrition-care, as well as to develop an openEHR-template including the aforementioned archetypes. The study involved the following stages: 1) a thorough literature review, followed by an expert's (nutrition guideline authors) survey, aiming to identify the main statements of published clinical guidelines on nutrition in cancer patients that were not included on the Clinical Knowledge Manager (CKM) repository; 2) modelling of the archetypes using the Ocean Archetype Software and submission to the CKM repository; 3) creating an example template with Template Designer; and 4) automatic conversion of the openEHR-template into a readily usable EHR using VCIntegrator. The clinical concepts (among 17 clinical concepts not yet available in the CKM repository) chosen for further development were: body composition, diet plan, dietary nutrients, dietary supplements, dietary intake assessment, and Malnutrition Screening Tool (MST). So far, four archetypes were accepted for review in the CKM repository and a template was created and converted into an EHR. This study designed new openEHR-archetypes for nutrition management in cancer patients. These archetypes can be included in EHR. Future studies are needed to assess their applicability in other areas and their practical impact on data quality, system interoperability and, ultimately, on clinical practice and research.
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http://dx.doi.org/10.1007/s10916-020-01649-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520877PMC
September 2020

High protein diet improves the overall survival in older adults with advanced gastrointestinal cancer.

Clin Nutr 2021 Mar 1;40(3):1376-1380. Epub 2020 Sep 1.

Clinical and Sports Nutrition Research Laboratory (Labince), Faculty of Nutrition, Federal University of Goias, Goiânia, GO, Brazil.

Background: High protein diet (HDP) promotes improvement of lean body mass in elderly without cancer; but the impact of high protein intake on muscle strength and mortality in cancer patients remains to be elucidated. This study evaluates the association between HPD on handgrip strength (HGS) and survival in older adults outpatients with advanced gastrointestinal cancer.

Methods: Ninety-one patients with advanced gastrointestinal cancer (>65% tumor stage III-IV) undergoing radiotherapy, chemotherapy or surgery were enrolled. Upon first oncological visit, tumor stage was assessed by a physician. Then, a nutritionist or a dietitian measured the body mass index (BMI), HGS by means of a dynamometer, and dietary food intake by using 24h food recall. Patients were stratified in HPD (i.e, ≥1.5 g/kg/d) or low protein diet (LPD: <1.5 g/kg/d). Kaplan-Meier curve was used to assess the survival since the cancer diagnosis.

Results: HPD was reported by approximately 30% of patients. Protein intake was significantly higher in HPD vs LPD patients (2.2 ± 0.8 vs. 0.8 ± 0.4 g/kg/d, respectively; p < 0.0001). No significant association was found between HPD and HGS, even after adjustment for physical activity, alcohol intake, smoking, sex, age, tumor stage, oncologic treatment and BMI (OR: 0.97 [95%CI: 0.88-1.08], p = 0.64), or for energy intake kcal/kg/day, leucine g/d and lipids g/d (OR: 0.93 [95%CI: 0.85-1.03, p = 0.19]. In addition, HPD group showed higher overall survival than LPD group (HPD: 14.7 vs. LPD: 7.3 months, p = 0.04).

Conclusion: HPD is not associated with better muscle function as measured by HGS, but with overall survival in older adults outpatients with advanced gastrointestinal cancer. HPD may represent a strategy to mitigate the cancer-induced mortality and should be further explored.
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http://dx.doi.org/10.1016/j.clnu.2020.08.028DOI Listing
March 2021

Expert Opinion on Benefits of Long-Chain Omega-3 Fatty Acids (DHA and EPA) in Aging and Clinical Nutrition.

Nutrients 2020 Aug 24;12(9). Epub 2020 Aug 24.

Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton SO16 6YD, UK.

Life expectancy is increasing and so is the prevalence of age-related non-communicable diseases (NCDs). Consequently, older people and patients present with multi-morbidities and more complex needs, putting significant pressure on healthcare systems. Effective nutrition interventions could be an important tool to address patient needs, improve clinical outcomes and reduce healthcare costs. Inflammation plays a central role in NCDs, so targeting it is relevant to disease prevention and treatment. The long-chain omega-3 polyunsaturated fatty acids (omega-3 LCPUFAs) docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are known to reduce inflammation and promote its resolution, suggesting a beneficial role in various therapeutic areas. An expert group reviewed the data on omega-3 LCPUFAs in specific patient populations and medical conditions. Evidence for benefits in cognitive health, age- and disease-related decline in muscle mass, cancer treatment, surgical patients and critical illness was identified. Use of DHA and EPA in some conditions is already included in some relevant guidelines. However, it is important to note that data on the effects of omega-3 LCPUFAs are still inconsistent in many areas (e.g., cognitive decline) due to a range of factors that vary amongst the trials performed to date; these factors include dose, timing and duration; baseline omega-3 LCPUFA status; and intake of other nutrients. Well-designed intervention studies are required to optimize the effects of DHA and EPA in specific patient populations and to develop more personalized strategies for their use.
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http://dx.doi.org/10.3390/nu12092555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551800PMC
August 2020

Dietary recommendations during the COVID-19 pandemic.

Nutr Rev 2021 03;79(4):382-393

Clinical and Sports Nutrition Research Laboratory (Labince), School of Nutrition, Federal University of Goiás, Goiânia, Goiás, Brazil.

Optimal nutrition can improve well-being and might mitigate the risk and morbidity associated with coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This review summarizes nutritional guidelines to support dietary counseling provided by dietitians and health-related professionals. The majority of documents encouraged the consumption of fruits, vegetables, and whole grain foods. Thirty-one percent of the guidelines highlighted the importance of minerals and vitamins such as zinc and vitamins C, A, and D to maintain a well-functioning immune system. Dietary supplementation has not been linked to COVID-19 prevention. However, supplementation with vitamins C and D, as well as with zinc and selenium, was highlighted as potentially beneficial for individuals with, or at risk of, respiratory viral infections or for those in whom nutrient deficiency is detected. There was no convincing evidence that food or food packaging is associated with the transmission of COVID-19, but good hygiene practices for handling and preparing foods were recommended. No changes to breastfeeding recommendations have been made, even in women diagnosed with COVID-19.
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http://dx.doi.org/10.1093/nutrit/nuaa067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454801PMC
March 2021

Targeted Medical Nutrition in Pre-Cachectic Patients with Non-Small-Cell Lung Cancer: A Subgroup Analysis.

Nutr Cancer 2021 10;73(5):899-900. Epub 2020 Jun 10.

Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.

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http://dx.doi.org/10.1080/01635581.2020.1773873DOI Listing
June 2020

High neutrophil to lymphocytes ratio is associated with sarcopenia risk in hospitalized cancer patients.

Clin Nutr 2021 Jan 11;40(1):202-206. Epub 2020 May 11.

Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition, Federal University of Goiás, Goiânia, Brazil. Electronic address:

Background & Aims: Systemic inflammation has been reported as a new predictor for cancer outcomes. This study aimed i) to identify the neutrophil to lymphocytes ratio (NLR) cut-off point that best predicts sarcopenia and ii) to verify the association between NLR and sarcopenia risk in hospitalized cancer patients.

Methods: A cross-sectional study enrolled a total of 123 hospitalized cancer patients receiving chemotherapy and/or undergoing surgery. Systemic inflammation was assessed as revealed by circulating levels of C-reactive protein, neutrophils, platelet, and by calculating platelet-lymphocytes ratio (PLR) and NLR. Sarcopenia risk was assessed using the Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F; score≥4 identifies sarcopenia risk). ROC curve were used to identify the best NLR cut-off value which predicts sarcopenia risk. Differences between groups were tested using the T Student, Mann-Whitney, or Chi-Square tests. Logistic regression analyses were done to assess the association between NLR and sarcopenia risk.

Results: ROC curve revealed that the best cut-off point to predict sarcopenia risk was NLR ≥6.5 (sensitivity of 45% and specificity of 81%). Those with NLR ≥6.5 presented higher C-reactive protein, neutrophils, platelet-lymphocytes ratio (PLR), and SARC-F than NLR <6.5 group. A negative correlation was found between NLR and gait speed (r = -0.48, p = 0.0001), handgrip strength (r = -0.29, p = 0.002), arm circumference (r = -0.29, p = 0.002) and calf circumference (r = -0.28, p = 0.003). Those with increased NLR values were associated with high sarcopenia risk in crude model, as well as if adjusted by smoking, alcohol intake, and sex (OR:1.19 [95%CI:1.03-1.37], p = 0.013) or by BMI (OR:1.20 [95%CI:1.05-1.38], p = 0.006).

Conclusion: In hospitalized cancer patients, systemic inflammation measured by NLR was associated with increased sarcopenia risk.
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http://dx.doi.org/10.1016/j.clnu.2020.05.005DOI Listing
January 2021

A simple remote nutritional screening tool and practical guidance for nutritional care in primary practice during the COVID-19 pandemic.

Clin Nutr 2020 07 15;39(7):1983-1987. Epub 2020 May 15.

Department of Medical, Surgical and Health Sciences, University of Trieste, Italy.

Challenging periods like the COVID-19 pandemic require fast and efficient adaptations of the healthcare system. It is vital that every patient has access to nutritional care as a part of primary healthcare services, even if social distancing measures are adopted. Therefore, we propose a simple remote nutritional screening tool and practical guidance for nutritional care in primary practice, and their implementation into telemedicine processes and digital platforms suitable for healthcare providers. The acronym for the tool is R-MAPP, as for Remote - Malnutrition APP, while the tool will be available also as an app. This protocol consists of two simple validated clinical tools for identifying nutritional risk and loss of muscle mass and function -Malnutrition Universal Screening Tool ('MUST') and SARC-F (5-item questionnaire: Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls) - and additional practical guidance on nutritional interventions for family physicians.
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http://dx.doi.org/10.1016/j.clnu.2020.05.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7227572PMC
July 2020

Early nutritional supplementation in non-critically ill patients hospitalized for the 2019 novel coronavirus disease (COVID-19): Rationale and feasibility of a shared pragmatic protocol.

Nutrition 2020 06 3;74:110835. Epub 2020 Apr 3.

Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Objectives: Beginning in December 2019, the 2019 novel coronavirus disease (COVID-19) has caused a pneumonia epidemic that began in Wuhan, China, and is rapidly spreading throughout the whole world. Italy is the hardest hit country after China. Considering the deleterious consequences of malnutrition, which certainly can affect patients with COVID-19, the aim of this article is to present a pragmatic protocol for early nutritional supplementation of non-critically ill patients hospitalized for COVID-19 disease. It is based on the observation that most patients present at admission with severe inflammation and anorexia leading to a drastic reduction of food intake, and that a substantial percentage develops respiratory failure requiring non-invasive ventilation or even continuous positive airway pressure.

Methods: High-calorie dense diets in a variety of different consistencies with highly digestible foods and snacks are available for all patients. Oral supplementation of whey proteins as well as intravenous infusion of multivitamin, multimineral trace elements solutions are implemented at admission. In the presence of 25-hydroxyvitamin D deficit, cholecalciferol is promptly supplied. If nutritional risk is detected, two to three bottles of protein-calorie oral nutritional supplements (ONS) are provided. If <2 bottles/d of ONS are consumed for 2 consecutive days and/or respiratory conditions are worsening, supplemental/total parenteral nutrition is prescribed.

Conclusion: We are aware that our straight approach may be debatable. However, to cope with the current emergency crisis, its aim is to promptly and pragmatically implement nutritional care in patients with COVID-19, which might be overlooked despite being potentially beneficial to clinical outcomes and effective in preventing the consequences of malnutrition in this patient population.
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http://dx.doi.org/10.1016/j.nut.2020.110835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7194616PMC
June 2020

Nutrition support in the time of SARS-CoV-2 (COVID-19).

Nutrition 2020 06 2;74:110834. Epub 2020 Apr 2.

Internal Medicine Department, University of Trieste Hospital, Trieste, Italy; Chairwoman, SINPE, Italian Society of Artificial Nutrition and Metabolism, Italy.

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http://dx.doi.org/10.1016/j.nut.2020.110834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7132492PMC
June 2020

Plasma Lipid Profile and Systemic Inflammation in Patients With Cancer Cachexia.

Front Nutr 2020 31;7. Epub 2020 Jan 31.

Cancer Metabolism Research Group, Institute of Biomedical Sciences University of São Paulo, São Paulo, Brazil.

Cancer cachexia affects about 80% of advanced cancer patients, it is linked to poor prognosis and to date, there is no efficient treatment or cure. The syndrome leads to progressive involuntary loss of muscle and fat mass induced by systemic inflammatory processes. The role of the white adipose tissue (WAT) in the onset and manifestation of cancer cachexia gained importance during the last decade. WAT wasting is not only characterized by increased lipolysis and release of free fatty acids (FFA), but in addition, owing to its high capacity to produce a variety of inflammatory factors. The aim of this study was to characterize plasma lipid profile of cachectic patients and to correlate the FA composition with circulating inflammatory markers; finally, we sought to establish whether the fatty acids released by adipocytes trigger and/or contribute to local and systemic inflammation in cachexia. The study selected 65 patients further divided into 3 groups: control (N); weight stable cancer (WSC); and cachectic cancer (CC). The plasma FA profile was significantly different among the groups and was positively correlated with pro-inflammatory cytokines expression in the CC patients. Therefore, we propose that saturated to unsaturated FFA ratio may serve as a means of detecting cachexia.
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http://dx.doi.org/10.3389/fnut.2020.00004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7005065PMC
January 2020

A high-protein diet, not isolated BCAA, is associated with skeletal muscle mass index in patients with gastrointestinal cancer.

Nutrition 2020 04 7;72:110698. Epub 2019 Dec 7.

Laboratory of Research in Clinical Nutrition and Sports (Labince), Faculty of Nutrition. Electronic address:

Objectives: Patients with cancer are susceptible to experiencing the loss of skeletal muscle mass. Thus, the purpose of this study was to evaluate whether a high-protein diet (HPD) or isolated branched-chain amino acid (BCAA) intake is associated with an increased skeletal muscle mass index (SMI) in patients with cancer of the gastrointestinal tract.

Methods: This cross-sectional, observational study included 106 patients with gastrointestinal tract tumors. Food consumption was estimated using 24-h food recall. Patients were divided into two groups: a low-protein diet (LPD) group (≤1.2 g · kg · d) and a high-protein diet (HPD) group (>1.2 g · kg · d). Appendicular muscle mass (ASM) was calculated using Lee's formula, and its values were divided by the square of the height of the patient to obtain SMI values. Differences were considered significant when the probability they occurred by chance was <5% (P < 0.05).

Results: Of 106 patients assessed, 69 (65%) consumed a diet consistent with specifications of the LPD group and 37 (35%) consumed a diet consistent with HPD intake. Logistic regression after adjusting for sex and caloric and carbohydrate consumption showed an association between SMI and HPD (odds ratio, 4.19; 95% confidence interval, 1.06-16.56; P < 0.001) but not with BCAA. Daily total protein intake, but not isolated BCAA or leucine, was able to predict an increase in SMI in 43% of patients considered (P = 0.006). Thus, HPD was associated with SMI, and total protein intake was a better predictor of SMI than BCAAs.

Conclusion: HPD is a cost-effective way to enhance SMI, rather than focusing on the ingestion of isolated BCAAs.
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http://dx.doi.org/10.1016/j.nut.2019.110698DOI Listing
April 2020

Nutrition interventions to treat low muscle mass in cancer.

J Cachexia Sarcopenia Muscle 2020 04 8;11(2):366-380. Epub 2020 Jan 8.

Department of Translational and Precision Medicine, La Sapienza University, Rome, Italy.

Many patients with cancer experience poor nutritional status, which detrimentally impacts clinical outcomes. Poor nutritional status in cancer is primarily manifested by severe muscle mass (MM) depletion, which may occur at any stage (from curative to palliative) and often co-exists with obesity. The objective of this article was to discuss gaps and opportunities related to the role of nutrition in preventing and reversing low MM in cancer. It also provides a narrative review of relevant nutritional interventions for patients capable of oral intake. The impact of nutrition interventions to prevent/treat low MM in cancer is not well understood, potentially due to the limited number of studies and of clinically viable, accurate body composition assessment tools. Additionally, the type of study designs, inclusion criteria, length of intervention, and choice of nutritional strategies have not been optimal, likely underestimating the anabolic potential of nutrition interventions. Nutrition studies are also often of short duration, and interventions that adapt to the metabolic and behavioural changes during the clinical journey are needed. We discuss energy requirements (25-30 kcal/kg/day) and interventions of protein (1.0-1.5 g/kg/day), branched-chain amino acids (leucine: 2-4 g/day), β-hydroxy β-methylbutyrate (3 g/day), glutamine (0.3 g/kg/day), carnitine (4-6 g/day), creatine (5 g/day), fish oil/eicosapentanoic acid (2.0-2.2 g/day EPA and 1.5 g/day DHA), vitamin/minerals (e.g. vitamin D: 600-800 international units per day), and multimodal approaches (nutrition, exercise, and pharmaceutical) to countermeasure low MM in cancer. Although the evidence is variable by modality type, interventions were generally not specifically studied in the context of cancer. Understanding patients' nutritional requirements could lead to targeted prescriptions to prevent or attenuate low MM in cancer, with the overall aim of minimizing muscle loss during anti-cancer therapy and maximizing muscle anabolism during recovery. It is anticipated that this will, in turn, improve overall health and prognostication including tolerance to treatment and survival. However, oncology-specific interventions with more robust study designs are needed to facilitate these goals.
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http://dx.doi.org/10.1002/jcsm.12525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113510PMC
April 2020

Critical appraisal of definitions and diagnostic criteria for sarcopenic obesity based on a systematic review.

Clin Nutr 2020 Aug 27;39(8):2368-2388. Epub 2019 Nov 27.

University of Trieste, Italy.

Background: Sarcopenic obesity is a clinical and functional condition characterized by the coexistence of excess fat mass and sarcopenia. Currently, different definitions of sarcopenic obesity exist and its diagnostic criteria and cut-offs are not universally established. Therefore, the prevalence and sensitivity of this condition for any disease risk prediction is affected significantly.

Aim: This work was conducted under the auspices of the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO). An international expert panel performed a systematic review as an initial step to analyze and summarize the available scientific literature on the definitions and the diagnostic criteria for sarcopenic obesity proposed and/or applied in human studies to date.

Methods: The present systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in April 2018 in three databases (PubMed, Scopus, Web of Science). Human studies conducted in both sexes, irrespective of ethnicity, and published from 2007 to 2018 were included; cohorts of individuals with obesity and acute or chronic conditions and treatments reported to negatively influence skeletal muscle mass and function independently of obesity were excluded from final analyses. The quality of the studies was evaluated using the Newcastle-Ottawa Scale (NOS) adapted for cross sectional studies.

Results: The electronic search retrieved 2335 papers of which 75 met the eligibility criteria. A marked heterogeneity in definitions and approaches to diagnose sarcopenic obesity was observed. This was mainly due to differences in the definitions of obesity and sarcopenia, in the methodologies used to assess body composition and physical function, and in the reference values for the variables that have been used (different cut-offs, interquartile analysis, diverse statistical stratification methods). This variability may be attributable, at least in part, to the availability of the methodologies in the different settings, to the variability in specialties and backgrounds of the researcher, and to the different settings (general population, clinical settings, etc.) where studies were performed.

Conclusion: The results of the current work support the need for consensus proposals on: 1) definition of sarcopenic obesity; 2) diagnostic criteria both at the level of potential gold-standards and acceptable surrogates with wide clinical applicability, and with related cut-off values; 3) methodologies to be used in actions 1 and 2. First steps should be aimed at reaching consensus on plausible proposals that would need subsequent validation based on homogeneous studies and databases, possibly based on analyses of existing cohorts, to help define the prevalence of the condition, its clinical and functional relevance as well as most effective prevention and treatment strategies.
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http://dx.doi.org/10.1016/j.clnu.2019.11.024DOI Listing
August 2020

Are depression and anxiety disorders associated with adductor pollicis muscle thickness, sleep duration, and protein intake in cancer patients?

Exp Gerontol 2020 02 30;130:110803. Epub 2019 Nov 30.

Clinical and Sports Nutrition Research Laboratory (Labince), Faculty of Nutrition, Federal University of Goias, Goiânia, Brazil. Electronic address:

Introduction: Psychological disturbances may be associated with compromised body composition and food intake. However, this has not been elucidated totally. Thus, this study aimed to evaluate the prevalence of anxiety and depression, and whether there is an association between these disorders and adductor pollicis muscle thickness (APMT), protein intake and sleep duration, in gastrointestinal cancer patients.

Methods: A cross-sectional study evaluated 117 patients of both genders diagnosed with gastrointestinal cancer. Protein intake was assessed by the USDA food database; sleep duration by self-administered questionnaire; and APMT using the skinfold. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety (HADS-A) and depression (HADS-D).

Results: A total of 117 (65% male) patients were assessed, of which 40 (34%) had anxiety and 39 (33%) depression. There was a negative correlation between APMT and anxiety (r = -0.20, p = .020) and depression (r = -0.19, p = .03), and between anxiety and sleep duration (r = -0.30, p = .001). Although there was an inverse association between anxiety and APMT (OR: 0.88, 95%CI: 0.79-0.99, p = .032) and sleep duration (OR: 0.71, 95%CI: 0.58-0.87, p = .001), when adjusted for gender and age, the association remained only between anxiety and sleep duration (OR: 0.71, 95%CI: 0.58-0.87, p = .001).

Conclusion: One-third of gastrointestinal cancer patients were classified as expressing anxiety and depression. Additionally, only sleep duration is associated with anxiety.
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http://dx.doi.org/10.1016/j.exger.2019.110803DOI Listing
February 2020

Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective.

J Clin Med 2019 Nov 22;8(12). Epub 2019 Nov 22.

Department of Internal Medicine III, Medical University Vienna, 1090 Vienna, Austria.

Disease-related malnutrition (DRM) is prevalent in hospitals and is associated with increased care needs, prolonged hospital stay, delayed rehabilitation and death. Nutrition care process related activities such as screening, assessment and treatment has been advocated by scientific societies and patient organizations but implementation is variable. We analysed the cross-sectional nutritionDay database for prevalence of nutrition risk factors, care processes and outcome for medical, surgical, long-term care and other patients ( 153,470). In 59,126 medical patients included between 2006 and 2015 the prevalence of recent weight loss (45%), history of decreased eating (48%) and low actual eating (53%) was more prevalent than low BMI (8%). Each of these risk factors was associated with a large increase in 30 days hospital mortality. A similar pattern is found in all four patient groups. Nutrition care processes increase slightly with the presence of risk factors but are never done in more than 50% of the patients. Only a third of patients not eating in hospital receive oral nutritional supplements or artificial nutrition. We suggest that political action should be taken to raise awareness and formal education on all aspects related to DRM for all stakeholders, to create and support responsibilities within hospitals, and to create adequate reimbursement schemes. Collection of routine and benchmarking data is crucial to tackle DRM.
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http://dx.doi.org/10.3390/jcm8122048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947230PMC
November 2019

A Diet Rich in Fish Oil and Leucine Ameliorates Hypercalcemia in Tumour-Induced Cachectic Mice.

Int J Mol Sci 2019 Oct 9;20(20). Epub 2019 Oct 9.

Division of Human Nutrition and Health, Wageningen University, 6700 EV Wageningen, The Netherlands.

Background: Dietary supplementation with leucine and fish oil rich in omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) has previously been shown to reduce cachexia-related outcomes in C26 tumour-bearing mice. To further explore associated processes and mechanisms we investigated changes in plasma Ca levels, the involvement of parathyroid hormone related protein (PTHrP), and its possible interactions with cyclooxygenase 2 (COX-2).

Methods: CD2F1 mice were subcutaneously inoculated with C26 adenocarcinoma cells or sham treated and divided in: (1) controls, (2) tumour-bearing controls, and (3) tumour-bearing receiving experimental diets. After 20 days, body and organ masses and total plasma Ca levels were determined. Furthermore, effects of DHA, EPA and leucine on production of PTHrP were studied in cultured C26 cells.

Results: The combination of leucine and fish oil reduced tumour-associated hypercalcemia. Plasma Ca levels negatively correlated with carcass mass and multiple organ masses. DHA was able to reduce PTHrP production by C26 cells in vitro. Results indicate that this effect occurred independently of COX-2 inhibition.

Conclusion: Our results suggest that cancer-related hypercalcemia may be ameliorated by a nutritional intervention rich in leucine and fish oil. The effect of fish oil possibly relates to a DHA-induced reduction of PTHrP excretion by the tumour.
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http://dx.doi.org/10.3390/ijms20204978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6829241PMC
October 2019

Short-Term Creatine Supplementation May Alleviate the Malnutrition-Inflammation Score and Lean Body Mass Loss in Hemodialysis Patients: A Pilot Randomized Placebo-Controlled Trial.

JPEN J Parenter Enteral Nutr 2020 07 18;44(5):815-822. Epub 2019 Sep 18.

Clinical and Sports Nutrition Research Laboratory (Labince), Faculty of Nutrition, Federal University of Goias, Goiânia, GO, Brazil.

Background: Creatine supplementation has been proposed to alleviate muscle loss in various populations, but has not been investigated in hemodialysis (HD) patients. Thus, our objective was to evaluate whether creatine supplementation could attenuate the loss of lean body mass (LBM) and malnutrition-inflammation score (MIS) in HD patients.

Methods: A randomized, placebo-controlled, double blind, parallel-design study included HD patients, of both sexes, aged 18-59 years. The patients were allocated to a Placebo Group (PG; n = 15; received maltodextrin, 1st week: 40 g/day and 2nd-4th weeks: 10 g/day) and a Creatine Group (CG; n = 15; received creatine plus maltodextrin, 1st week: 20 g/day of creatine plus 20 g/day of maltodextrin and 2nd-4th weeks: 5 g/day of creatine plus 5 g/day of maltodextrin). Pre and post the intervention, patients were evaluated for food intake, MIS, body composition and biochemical parameters.

Results: CG group attenuated the MIS (Pre: 5.57 ± 0.72 vs. Post: 3.85 ± 0.47 score, P = 0.003) compared with PG (Pre: 5.71 ± 0.97 vs. Post: 5.36 ± 0.95 score, P = 0.317) (supplement × time P = 0.017, effect size: 0.964). The change of LBM was greater in CG than in PG (CG: Δ0.95 vs PG: Δ0.13 kg). At post-intervention, 28.6% of PG patients presented LBM loss and 71.4% remain stable. In contrast, 14.4% of CG patients had LBM loss, 42.8% remain stable and 42.8% gained. Food intake and quality of life did not change. CG increased the BMI and gait speed in post-compared to pre-moment, but no difference among the groups.

Conclusion: In HD patients, four weeks of creatine supplementation may alleviate the MIS as well as attenuate the LBM loss compared to placebo.
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http://dx.doi.org/10.1002/jpen.1707DOI Listing
July 2020

Sarcopenia: A Time for Action. An SCWD Position Paper.

J Cachexia Sarcopenia Muscle 2019 10 15;10(5):956-961. Epub 2019 Sep 15.

BIH Center for Regenerative Therapies (BCRT), Charité Uinversitätsmedizin Berlin, Berlin, Germany.

The term sarcopenia was introduced in 1988. The original definition was a "muscle loss" of the appendicular muscle mass in the older people as measured by dual energy x-ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC-F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease-related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age-related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age-related and disease-related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life-long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia.
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http://dx.doi.org/10.1002/jcsm.12483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6818450PMC
October 2019