Food Based Recommendations for Sarcopenia

This report provides evidence-based food recommendations for managing sarcopenia, a condition characterized by muscle wastage in the elderly. It discusses the importance of protein intake and exercise in preventing and treating sarcopenia, and provides specific recommendations for protein sources and exercise types. The report also highlights the need for further research on alternative protein sources and considerations for texture and palatability in elderly individuals.

0FOOD BASED RECOMMENDATIONS FOR SARCOPENIA
FOOD BASED RECOMMENDATION FOR SARCOPENIA
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Executive Summary
Sarcopenia has been regarded as a characteristic symptom of old age and involves a detrimental
loss of muscle mass and the resultant loss of immunity and strength and stamina required to
perform daily life activities. In addition to the physiological processed of ageing, poor nutritional
status and adherence to sedentary lifestyle also contribute to sarcopenic muscle wastage in the
elderly. The following report included an extensive literature search to obtain appropriate
evidence based food based recommendations for sarcopenia management in the form of
enhancec protein intake and resistance training. While relevant information on exercise and
type as well as frequency of protein consumption was obtained, majority of evidence pertaining
to supplementation along with a lack of evidence on the effects of alternative protein sources
were observed – which were irrelevant to the chosen food based research topic.

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Table of Contents
Introduction..........................................................................................................................3
Discussion............................................................................................................................4
Summary of Evidence......................................................................................................4
Critical Interpretation of Evidence..................................................................................5
Recommendations............................................................................................................8
Blog..................................................................................................................................9
Sarcopenia: Ensuring a healthy transition to old-age through Nutrition and Exercise9
Conclusion.........................................................................................................................10
References..........................................................................................................................11
Appendix 1: Table of Evidence (As designed by the Author)...........................................13

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Introduction
Sarcopenia is associated with a detrimental loss in essential mass and functioning of
muscles, and is a characteristic old age physiological symptom. Sarcopenia continues to be a
prevalent age-associated global geriatric health problem, affecting over 10% of men and 30% of
women aged 60 years and above worldwide (1). Sarcopenia is associated with debilitating health
outcomes such as loss of ability to perform activities of daily living (ADL), increased
susceptibility of fracture acquisition as a resultant of falls, along with poor immune status,
increased oxidative stress and risk of chronic diseases. Poor nutritional intake due to age-
associated loss of appetite, dysguesia and dysphagia often pose as additional contributing factors
to occurrences of sarcopenia in the elderly (2).
Following research aims to critically evaluate existing scientific literature on the effect of
exercise and protein intake in the prevention, treatment and management of sarcopenia, with
detrimental consequences in the above mentioned muscle, bone strength and immune status
associated with lack of treatment, as the rationale for the study. Conductance of this research will
pave the way for future performance of evidence based clinical practice associated with
administration of essential nutritional and lifestyle changes in the target population of elderly
patients suffering from sarcopenia, in order to ensure positive geriatric health outcomes and
personal living standards (3).

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Discussion
Summary of Evidence
An electronic literature search was conducted using the keywords, ‘nutrition’, ‘protein’,
‘exercise’ and ‘sarcopenia’, along with Boolean operators, through databases such as BioMed,
COCHRANE, PubMed, Medline and Science Direct. Peer reviewed scholarly researches, with
relevance to the keywords, and published within the last 4 years were included. Studies with
irrelevance to the keywords, along with discussing on alternative nutritional treatments apart
from protein intake such as supplements, Vitamin D, or studies on sarcopenic obesity and only
exercise as treatments were excluded. Three articles were selected and have been tabulated as
summary of evidence in Appendix 1 (4).

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Critical Interpretation of Evidence
A review article was performed by (5), to assess the synergistic functioning of exercise as
well as protein intake for the management of sarcopenia. The authors aimed to summarize the
existing literature pertaining to the research question, through evaluation of randomized
controlled trials as well as opinion articles. While the authors noted formulations and breakdown
of proteins as major contributing factors towards muscle mass, a lack of sufficient evidence
considering associations between sarcopenia susceptibility and anabolic processes or reduced
rates of protein synthesis was also reported. However, studies reporting a requirement of
increased protein intake in the form of 1.0-1.2 gm/kg/day in healthy aged patients, 1.2-1.5
gm/kg/day for elders with chronic and acute disorders and 2.0gm/kg/day for elders with
malnutrition or severe disorders were examined by the authors. Further, exercises of the high
load resistance and low, intensity endurance type enhances muscle mass synergistically with
protein intake via enlargement of muscles capillaries and size increments in fast-twitch muscle
fibers. While reviewing of several randomized controlled trials by the authors is major strength
due to them being regarded as high levels of evidence, the authors also reviewed opinion articles
which acts a limitation due to them belonging to one of the lowest levels of evidence. Further,
despite recognizing the presence of incomplete evidence in associations between muscle mass
and protein synthesis rates, the authors performed insufficient critical appraisal of the studies
they have reviewed, which may be considered as a key limitation (4). Hence, the above results of
protein intake as well as adherence to specific type of exercises may be interpreted for future
recommendations of sarcopenic management, further research may be still ne required due to
low evidence based researches reviewed by the authors, since they are deemed to carry
insufficient weight of evidence.

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Another review conducted by (6), aimed to research the effects of ‘fast digestive proteins’
on the management of age associated sarcopenia. The authors noted that the rate of protein
metabolism as associated with factors in addition to their food sources, such as textures, food
matrix and techniques of food processing utilized. Through changes in the an elderly individual’s
post prandial amino acid status, fast digestive proteins exert greater anabolic effect. To evaluate
the action of fast and slow digestive proteins, the authors evaluated the protein composition of
milk, due to its easy availability, accessibility and varied scope for processing. The authors
researched whey to be a fast digestive protein due to the immediacy with which blood profiles of
essential amino acids increase in elderly patients who consumed whey based milk products.
Caseins were researched by the authors as slow digestive proteins due to them undergoing
clotting in the stomach upon ingestion, which led to their delayed metabolism and delayed rate of
amino acid release in the blood. Meat proteins were also researched to be of the fast digestible
type, with however, keeping in mind on avoidance of high cooking temperatures which may
hamper bioavailability due to denaturation. The authors also noted the direct association between
presence of adherence to resistance training in the elderly and the further enhanced rates of fast
protein metabolism, through increased synthesis of myofibrillar proteins. Hence, the above
research conducted by (6) serves as a beneficial repertoire of findings which can be interpreted in
the form of the type of protein rich foods to be incorporated in the sarcopenic elderly, in addition
to the specifications of protein intake and exercise type obtained from (5). The conductance of
reviews high level evidence based researches such as meta analysis, systematic reviews and
randomized controlled trials can be considered as a major strength of this study (4). However,
the large number of researches reviewed coupled with an absence of critical appraisal of findings
may pose to be as a major limitation due to possibilities of high rates of heterogeneity and

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research invalidity. Further, the review conducted by (6) laid greater emphasis on supplements
rather than whole protein sources, which may be a major limitation paving the way for the
requirement of further research conductance.
The review conducted by (7) aimed to evaluate the role of exercise along with milk and
milk products in the mitigation of sarcopenia in the elderly through assessment of existing
literature. The authors noted that the performance of resistance training or weight bearing
exercises are essential for the maintenance of strength and prevention of muscular fiber loss. In
this study, the authors recognize the necessity of leucine consumption – an essential amino acid
whose rates of absorption significantly undergo a decline in elderly individuals. The authors
recognized that amino acid leucine exerts beneficial effects on the muscle mass in individuals
through activation of the protein anabolic signaling pathway of rapamycin. Considering milk and
milk products to be a major source of leucine, the authors recognized the need for consumption
of three portions of milk products per day by the elderly, in the form of 20 ml of semi skimmed
milk and 200 grams of yogurt fortified with Vitamin D3 – another nutrient deemed to result in
enhanced protein and calcium absorption required for muscle mass and bone strength
enhancement. Specification of the consumption of the type and amount of protein rich food
sources along with the required amino acid are key strengths of this paper, which may be
interpreted in future clinical practice in the form of dietary recommendations while caring for the
sarcopenic elderly. Further, the review conducted by (7) included key insights from high strength
evidence based researches such as systematic reviews and randomized controlled trials hence,
resulting in a major strength through provision of results which possess high research validity
(4). However, similar to the previous studies, the review conducted by (7) recognized an absence
of sufficient information concerning food based recommendations for management of

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sarcopenia, with greater amount of evidence leaning towards supplements – which may be a
major limitation in the form of insufficient evidence based research pertaining to the research
question.
A major shortcoming observed in all the three papers as well as in the literature search is
the lack sufficient consideration given to the texture, palatability and organoleptic qualities of the
recommendation protein rich food items – considering the difficulties in ingestion and
swallowing overcome by elderly individuals. There was also a lack of sufficient information on
the effects of additional protein sources such as soy proteins, since increased research on meat
and milk sources mentioned above would be deemed as ineffective for vegan aged patients (8).
Recommendations
As per the clinical insights reported by (5), it is recommended that aged patients suffering
from sarcopenia, increase their protein intake to 1.0-1.2 gm/kg/day in elderly individuals devoid
of detrimental health symptoms, 1.2-1.5 gm/kg/day for elders with chronic and acute diseases
and 2.0gm/kg/day for elders with life threatening conditions or malnutrition. Taking insights
from the study conducted by (6), the protein sources are recommended to be composed of fast
digestive sources such as meat and whey protein such as slow cooked lean meat sources, eggs
and incorporating whey water obtained from curdling into drinks or curries. Further as
researched by (7), it is recommended that elderly patients with sarcopenia acquire their protein
from three portions of leucine-rich sources such as 200 grams of Vitamin D fortified yogurt and
250 ml of semi-skimmed milk. Finally, as recommended by (5), adherence to a combination of
mild to high resistance training may enhance the muscle repair and fiber buildup characteristics
of proteins, among aged patients suffering from sarcopenia. However, in order to ensure

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feasibility of such recommendations the increased food intake will be modified and incorporated
as per the food consumption frequencies and textural qualities tolerable by elderly patients.
Blog
Sarcopenia: Ensuring a healthy transition to old-age through Nutrition and Exercise
What is Sarcopenia and who is at Risk?
Sarcopenia, known as ‘muscle wastage’ is a common effect of ageing in adults aged 60
years or beyond. Older adults are the most at risk of suffering from muscle wastage, since ageing
leads to a loss of almost 1% of muscle mass every year. muscle wastage due to old age can also
occur if individuals lead a sedentary life, perform minimal or no exercise and consume foods
which may be deficient in adequate amounts of protein and Vitamin D (9). Sarcopenia is one of
the most common effects of ageing, and affects 10% of aged males and 60% of aged females,
worldwide (10).
Why should we be concerned about losing Muscle Mass?
Ageing is normal for everyone and so a loss in muscle mass need not be taken into consideration,
right? Wrong! If untreated, elderly people with severe sarcopenia are likely to face symptoms of
weakness and fatigue and may find it very difficult to perform basic self-care activities of
cooking or bathing, sometimes even finding it hard to get up from bed. Poor levels of muscle
mass may increase chances of injuries from fractures after a fall (11). Proteins also strengthen
immunity and help fight off harmful diseases. If untreated, sarcopenia in an aged person may
make him or her very likely to fall sick more often than healthy individuals (12).

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Is Sarcopenia preventable and manageable?
Thankfully, the negative effects of sarcopenia can be managed. Aged people must firstly visit
their nearest health center to know their existing levels of muscle mass in order to know if they
are sarcopenic or not (13). Elderly with low muscle mass are recommended to consume at least
three sources of good quality protein every day, such as eggs, semi-skimmed milk, chicken and
yogurt which has been fortified with Vitamin D3 (6)(7). Mild resistance training has also been
shown to reverse the effects of sarcopenia (5). So it is advisable for the elderly to engage in
some form of appropriate exercise, after consulting a fitness expert or physical trainer (14).
Conclusion
In conclusion, a number of researches have been conducted to evaluate the effectiveness
of increased protein intake and exercise adherence in the reversal of the detrimental symptoms of
sarcopenia. The selected studies necessitated the intake of fast digestible, primarily milk based
protein sources, with a total of three portions per day, along with conductance of resistance
training principles for the management of age-associated sarcopenia. It was noted that a majority
of studies emphasized more on supplementation rather than food based recommendation, along
with a lack of research on food textures and palatability along with the protein content of soy or
alternative protein foods. Hence, further research is recommended prior to administration of such
food based recommendations on sacropenic elderly patients.

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References
1. Morley JE. Frailty and sarcopenia in elderly. Wiener klinische Wochenschrift. 2016 Dec
1;128(7):439-45.
2. Rondanelli M, Faliva M, Monteferrario F, Peroni G, Repaci E, Allieri F, Perna S. Novel
insights on nutrient management of sarcopenia in elderly. BioMed research international.
2015;2015.
3. Artaza-Artabe I, Sáez-López P, Sánchez-Hernández N, Fernández-Gutierrez N,
Malafarina V. The relationship between nutrition and frailty: Effects of protein intake,
nutritional supplementation, vitamin D and exercise on muscle metabolism in the elderly.
A systematic review. Maturitas. 2016 Nov 1;93:89-99.
4. McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer
review of electronic search strategies: 2015 guideline statement. Journal of clinical
epidemiology. 2016 Jul 1;75:40-6.
5. Martone AM, Marzetti E, Calvani R, Picca A, Tosato M, Santoro L, Di Giorgio A, Nesci
A, Sisto A, Santoliquido A, Landi F. Exercise and protein intake: a synergistic approach
against sarcopenia. BioMed research international. 2017;2017.
6. Boirie Y, Guillet C. Fast digestive proteins and sarcopenia of aging. Current opinion in
clinical nutrition and metabolic care. 2018 Jan 1;21(1):37-41.
7. Cooper LA, Brown SL, Hocking E, Mullen AC. The role of exercise, milk, dairy foods
and constituent proteins on the prevention and management of sarcopenia. International
journal of dairy technology. 2016 Feb;69(1):13-21.

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8. Yanai H. Nutrition for sarcopenia. Journal of clinical medicine research. 2015
Dec;7(12):926.
9. Donini LM, Poggiogalle E, Pinto A, Giusti AM, del Balzo V. Malnutrition in the Elderly.
InDiet and Nutrition in Dementia and Cognitive Decline 2015 (pp. 211-222).
10. Ethgen O, Beaudart C, Buckinx F, Bruyère O, Reginster JY. The future prevalence of
sarcopenia in Europe: a claim for public health action. Calcified tissue international. 2017
Mar 1;100(3):229-34.
11. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC‐F: a symptom
score to predict persons with sarcopenia at risk for poor functional outcomes. Journal of
cachexia, sarcopenia and muscle. 2016 Mar;7(1):28-36.
12. Wilson D, Jackson T, Sapey E, Lord JM. Frailty and sarcopenia: the potential role of an
aged immune system. Ageing research reviews. 2017 Jul 1;36:1-0.
13. Beaudart C, Reginster JY, Slomian J, Buckinx F, Dardenne N, Quabron A, Slangen C,
Gillain S, Petermans J, Bruyere O. Estimation of sarcopenia prevalence using various
assessment tools. Experimental gerontology. 2015 Jan 1;61:31-7.
14. Mickle K, Caputi P, Potter J, Steele J. Resistance training can reverse sarcopenia in older
foot muscles. Journal of Science and Medicine in Sport. 2015 Dec 1;19:e25.

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Appendix 1: Table of Evidence (As designed by the Author)
Authors Research
Design
Research
Objective
Relevant Findings Strengths Limitations Level of
Evidence
(5) Martone AM,
Marzetti E,
Calvani R, Picca
A, Tosato M,
Santoro L, Di
Giorgio A, Nesci
A, Sisto A,
Santoliquido A,
Landi F.
Review To review
effectiveness of
exercise and
nutrition at
preventing
negative
outcomes
associated
with
sarcopenia and
physical
frailty.
 A requirement of
increased protein
intake in the form of
1.0-1.2 gm/kg/day in
healthy aged
patients, 1.2-1.5
gm/kg/day for elders
with chronic and
acute disorders and
2.0gm/kg/day for
elders with
malnutrition or
severe disorders.
 Exercises of the high
load resistance and
low, intensity
endurance type
enhances muscle
mass synergistically
with protein intake
via enlargement of
muscles capillaries
and size increments
in fast-twitch muscle
fibers.
Reviewing of several
randomized controlled
trials by the authors is
major strength due to
them being regarded
as high levels of
evidence.
.
 The authors
also
reviewed
opinion
articles
which acts a
limitation
due to them
belonging to
one of the
lowest
levels of
evidence.
 Despite
recognizing
the presence
of
incomplete
evidence in
associations
between
muscle mass
and protein
synthesis
rates, the
authors
performed
5

14FOOD BASED RECOMMENDATIONS FOR SARCOPENIA
insufficient
critical
appraisal of
the studies
they have
reviewed
(6) Boirie Y,
Guillet C.
Review To review the
effects of fast
digestive
proteins on
sarcopenia of
aging.
The authors researched whey to
be a fast digestive protein due
to the immediacy with which
blood profiles of essential
amino acids increase in elderly
patients who consumed whey
based milk products. Caseins
were researched by the authors
as slow digestive proteins due
to them undergoing clotting in
the stomach upon ingestion,
which led to their delayed
metabolism and delayed rate of
amino acid release in the blood.
Meat proteins were also
researched to be of the fast
digestible type.
Conductance of review
using high level
evidence based
researches such as
meta analysis,
systematic reviews and
randomized controlled
trials.
 However,
the large
number of
researches
reviewed
coupled
with an
absence of
critical
appraisal of
findings
may pose to
be as a
major
limitation
due to
possibilities
of high rates
of
heterogeneit
y and
research
invalidity.
 Laid greater
emphasis on
supplements
rather than
1

15FOOD BASED RECOMMENDATIONS FOR SARCOPENIA
whole
protein
sources.
(7) Cooper LA,
Brown SL,
Hocking E,
Mullen AC.
Review To review
interventions of
exercise, amino
acids
including
leucine, dairy
protein and
foods for
prevention of
sarcopenia.
 Resistance training
or weight bearing
exercises are
essential for the
maintenance of
strength and
prevention of
muscular fiber loss.
 Need for
consumption of
Leucine based
protein sources -
three portions of
milk products per
day by the elderly, in
the form of 20 ml of
semi skimmed milk
and 200 grams of
yogurt fortified with
Vitamin D3.
Included key insights
from high strength
evidence based
researches such as
systematic reviews and
randomized controlled
trials.
An absence of
sufficient information
concerning food
based
recommendations for
management of
sarcopenia, with
greater amount of
evidence leaning
towards supplements.
1