Importancia del ejercicio para mantener el músculo by vhuesca

Importancia del Ejercicio para Mantener el MĂşsculo

24 Junio 2017 Aldo J. MontaĂąo-Loza, MD, MSc, PhD Associate Professor of Medicine Program Director of Hepatology, University of Alberta Autoimmune Liver Disease Clinic Division of Gastroenterology and Liver Unit President of the Canadian Liver Transplant Network

Importancia del Ejercicio para Mantener el Músculo • Sarcopenia/Muscle wasting • Commonest complication of cirrhosis • Contributes significantly to morbidity and mortality • Its prevalence in cirrhosis is estimated 40–70%

• Annual incidence: • Bleeding esophageal varices 10-15%, • Refractory ascites 5–10% • HCC 3–5%

Importancia del Ejercicio para Mantener el MĂşsculo

Sinclair M, et al. Aliment Pharmacol Ther 2016;43:765

Importancia del Ejercicio para Mantener el MĂşsculo

Sinclair M, et al. Aliment Pharmacol Ther 2016;43:765

Importancia del Ejercicio para Mantener el MĂşsculo 100 90 80 70

Never to Rarely Sometimes

n=100

Most of the time / Always

70%

62%

57%

60 50 40 30 20

17%

23%

21%

22% 21%

0 Assessing Exercise Habits

Educating About Exercise

Specific Exercise Prescription

Importancia del Ejercicio para Mantener el Músculo • Regular physical activity in patients with cirrhosis is considered to be important strategy for preventing or improving sarcopenia and its complications • Lifestyle guidelines recommend: • Walking of 5000 or more steps per day • Corresponds to performing approximately 15 min of brisk steps at 4 metabolic equivalent of task (MET)

Montano-Loza AJ. Minerva Gastroenterol Dietol. 2013;59:173

Importancia del Ejercicio para Mantener el Músculo • Percentages of waking hours spent in sedentary (80.8%), light (16.6%), and moderate-to-vigorous activity (2.5%)

• Compared with a range 7,000-13,000 steps/day in healthy adults, their mean steps/day were 2,834 ± 2,119 Physical activity in cirrhotic patients waitlisted for transplantation is highly sedentary

Dunn M, et al. Liver Transpl 2016; In press

Importancia del Ejercicio para Mantener el Músculo

• •

Comparison of 2 cirrhotic pts with identical BMI: 32 kg/m2 Pt at left had sarcopenia: •

Lumbar skeletal index of 50 cm2/m2 vs. 70 cm2/m2 • Red color indicates skeletal muscles: rectus abdominus, oblique and lateral abdominal muscles, psoas, paraspinal muscles

BMI: 23.5 kg/m2 Mean muscle attenuation = 18.5 HU

BMI: 23.1 kg/m2 Mean muscle attenuation = 43.5 HU

Montano-Loza AJ, et al. Hepatology. 2013;58:(S1):865A

Sarcopenia: Clinical Implications

Survival (%)

100

90%

83%

71%

53%

Log Rank, P=0.005

No Sarcopenia (Median Survival 34Âą11 mo) Sarcopenia (Median Survival 19Âą6 mo)

0 0

22 24

38 17

35 17

31 12

27 12

Follow-up (mo)

Pt followed (no.) 67 45

Montano-Loza AJ, et al. Clin Gastroenterol Hepatol 2012;10:166

61 39

59 35

57 32

54 26

49 25

45 21

41 18

26 12

CT Images Used for the Muscularity Assessment in Cirrhosis Comparison of two cirrhotic patients with severe obesity

A) Male patient sarcopenic-obesity (BMI 47 kg/m2, L3 SMI 51cm2/m2) B) Female patient no sarcopenia (BMI 42 kg/m2, L3 SMI 49 cm2/m2)

Log Rank, P<0.001 Log Rank, P<0.001 Log Rank, P<0.001 Log Rank, P<0.001

100 80 60

Survival (%)

No Muscular Abnormalities Sarcopenia Sarcopenic Obesity

Myosteatosis

Sarcopenic Obesity and Myosteatosis

0 0

Pt followed (no.) 210 291 135 353 77

176 206 95 265 59

159 168 73 226 46

145 134 149 128 65 56 193 171 39 33

10 12 14 16 Follow-up (months) 126 114 113 103 51 47 156 145 30 27

103 93 44 131 24

100 81 41 111 23

96 77 40 104 23

90 70 36 92 19

85 64 33 85 16

78 57 28 78 15

Montano-Loza AJ, et al. J Cachexia Sarcopenia Muscle 2016. doi: 10.1002/jcsm.12039. In press.

Importancia del Ejercicio para Mantener el MĂşsculo Impact After Liver Transplantation

P=0.005

Hospital Length of Stay (Days)

No Sarcopenia

Sarcopenia

Intensive Care Unit Length of Stay (Days)

P=0.001

T 0

Days Montano-Loza AJ, et al. Liver Transpl 2014;20:640-8.

Importancia del Ejercicio para Mantener el MĂşsculo Number of Patients with Infections After Liver Transplant 35

P=0.1 P=0.04

30 25 20

Sarcopenia No Sarcopenia

15 10

P=0.5

P=0.6

0 Overall Infections

Bacterial Infections

Viral Infections

Fungal Infections Montano-Loza AJ, et al. Liver Transpl 2014;20:640-8.

Importancia del Ejercicio para Mantener el Músculo Comparison of a Cirrhotic Patient Before and After LT • Image before LT showed sarcopenia with L3 SMI of 44.5 cm2/m2

• 20 mo after LT showed no sarcopenia with a L3 SMI of 54.8 cm2/m2

Montano-Loza AJ, et al. Liver Transpl 2014;20:640-8.

Importancia del Ejercicio para Mantener el MĂşsculo Survival after LT and Extreme Sarcopenia 100

Survival (%)

80 60

Log Rank, P=0.05

Male Patients with L3 SMI Other Sixtiles Male Patients Lowest Sixtile (L3 SMI <44)

20 0 0

Pt followed (no.)

77 10

72 10

65 10

60 9

56 8

Follow-up (mo) 143 26

134 24

130 120 23 18

107 15

99 13

91 11

84 11

Montano-Loza AJ, et al. Liver Transpl 2014;20:640-8.

Author & Year Konishi, 2011

Pattullo, 2013

Roman, 2014

Design

Population

Intervention

Intensity & Duration

Comparator (Adherence)

Results

Open noncontrolled clinical trial

17 non-cirrhotics

8-week exclusive dietary intervention (1.2-1.5 g/kg of protein, & adjusted calorie intake) followed by pedometer-guided intervention. Pedometer-guided intervention + behavioral therapy + nutritional therapy (protein 1.2 g/kg protein & adjusted calorie intake) to all

Light (50%)

Exercise (n=15)

HOMA-IR, BMI, subcutaneous and visceral fat, IL-6 and leptin all improved with exercise (when step target was achieved). Trend for vitality (SF36) HOMA-IR, hepatic ISI, CPE, weight, % body fat, WC, calorie intake, fatigue, mood, aminotransferases, and leptin improved with exercise.

Open noncontrolled clinical trial

RCT

3 cirrhotics, CTPA 100%

10 non-cirrhotics 6 cirrhotics, CTPA 83% (BMI ≥30) 20 cirrhotics MELD 7-13

Zenith, 2014

RCT

CTP-A 82% 20 cirrhotics MELD 10

Debette-Gratien, 2015

Macias-Rodriguez, 2016

Open noncontrolled clinical trial

RCT

CTP-A 84% 13 cirrhotics MELD 7-21 CTP-A 63% 29 cirrhotics MELD 7-14 CTP-A 64%

Berzigotti, 2017

Open noncontrolled clinical trial

29 cirrhotics MELD 9 ± 3 CTP-A 92% (BMI ≥25)

Supervised exercise (treadmill or cycle ergometry 1 h, t.i.w.) + L-Leucine to all

Supervised exercise (cycle ergometry 40 min t.i.w.) + nutritional therapy (1.2 g/kg of protein, & adjusted calorie intake)1 to all Supervised exercise (cycle ergometry ≥20 min + resistance training 20 min, biw)

No control 24 weeks

Possibly moderate

Exercise (n=16) No control

24 weeks

Moderate (6070%)

Exercise (n=8)

12 weeks

Control (n=9) Exercise (n=9)

Moderate (6080%) 8 weeks Moderate (7080%)

Control (n=10) Exercise (n=8)

12 weeks

No control

Supervised exercise (cycle Moderate (60ergometry 40 min + 80%) kinesiotherapy 30 min, t.i.w) + nutritional therapy (1.2-1.5 14 weeks g/kg of protein, & adjusted calorie intake) to all Gym-based exercise (60 Light-Moderate min/week) + hypocaloric diet (50-60%) (restriction 500-1000 Kcal/ day, 0.8g/kg protein) 16 weeks

Exercise (n=11) Control (n=15)

Exercise (n=29)

No control

CPE, muscle mass, weight, HRQoL, Cr, and albumin all increased with exercise. No changes in controls CPE, SMM, and HRQoL all improved with exercise. No changes in controls.

CPE, SMM, mean maximal power, mean ventilatory threshold power all improved with exercise.

HVPG, CPE, phase angle (BIA), and hyper-NH3 all improved with exercise. HVPG increased in controls

HVPG, CPE, heart rate, body weight, WC, fat mass, HOMA, QUICKI, adipokines and HRQoL all improved with exercise

Exercise Recommendations According To Guidelines From Some Professional Associations ADA70

ACC/AHA78

Type 1 and 2 diabetes

Patients with hypercholesterolemia or hypertension

Older adults

Adults

Type

Aerobic and resistance training

Aerobic training

Aerobic, resistance and flexibility training

Aerobic training

Intensity

Moderate-to-vigorous activities ≥150 min/week: at least 3 days/week and no more than 2 consecutive days without activity Flexibility and balance training for older adults

Moderate-to-vigorous activities 120-160 min/week: 34 sessions per week, each lasting 40 min on average

Moderate and vigorous activities 150-300 min/week: daily for 30-60 min

Moderate

Balance exercise in frequent fallers or if mobility problems

Resistance training 2 days/week for additional health benefits

Exercise Parameter Population

Duration and Frequency

Other

ACSM72

DHHS79

≥150 min/week: spread throughout the week (episodes ≥10 min)

ACC/AHA: American College of Cardiology / American Heart Association, ACSM: American College of Sports Medicine, ADA: American Diabetes Association, DHHS: U.S. Department of Health and Human Services

Examples of non-exercise activity thermogenesis (NEAT) and corresponding energetic cost Note: Actual calories burned per hour (Cal/hour) will vary depending on age, sex, weight, activity intensity, among other factors. Activity

Cal/hour

Sitting or riding in an automobile Standing Cooking dinner Cleaning Grocery shopping Sweeping or vacuuming Fishing Walking or pushing a stroller Climbing stairs Gardening or mowing lawn Dancing

0-50 50-100 50-100 100-200 100-200 100-200 100-200 200-300 200-400 200-400 250-500

• Exercise, including aerobic and resistance physical activity are important for the muscle metabolism • Complications of portal hypertension, such as ascites or hepatic encephalopathy, or symptoms associate to chronic illness including significant fatigue and reduced maximum exercise capacity • Screening for portal varices

Montano-Loza AJ. Minerva Gastroenterol Dietol. 2013;59:173

Exercise recommendations for our patients •

Drawing from other guidelines for physical activity in chronic disease

•

Moderate intensity (5-6/10 effort) x 30 min 5 days/week OR vigorous intensity (7-8/10) x 20 min 3 days/week

•

In addition 2 days/week of resistance training ~ 100-150 total reps and 10 min of daily flexibility exercises

Importancia del Ejercicio para Mantener el Músculo Loss of appetite: • Use external cues to stimulate intake ofamily members, oalarm clock on phone, otiming of various TV programs – eat before watching TV • Adopt philosophy that food needs to be dosed just like a medication • eat cold foods that require little preparation oCooking smells and/or labor associated with hot meal prep can negatively impact appetite

Importancia del Ejercicio para Mantener el Músculo

• Hospitalizations and Procedures: • Counsel patients on the importance of maintaining adequate nutrition and meal spacing before and after tests such as paracentesis, scopes, etc. • Pack nutrition supplements or bagged lunch when coming for paracentesis • Resume regular meal patterns as soon as able

Importancia del Ejercicio para Mantener el Músculo Using Nutrition assessment data (nutrient analysis of food record) it is important to comparatively assess caloric intake against caloric requirements •Estimated energy requirements • ESPEN Guidelines: 35-40 kcal/kg • ASPEN Guidelines: 25-40 kcal/kg •

Energy requirements based on estimated dry weight

Importancia del Ejercicio para Mantener el Músculo An Example: •50 kg (post tap weight) female with ETOH cirrhosis, refractory ascites. • Complaints of early satiety, weakness, poor appetite, and visible evidence of muscle mass wasting in temporal region, both upper and lower extremities. •BMI 17.5 using recent post tap weight •UBW of 65 kg 6 months ago - prior to initial presentation with ascites, prolonged hospital stay of 1 month

Estimated intake based on Food Record: •450 kcal/day on day of paracentesis (skipped breakfast and lunch, had only an ensure and piece of toast with peanut butter in evening once home). 1200 kcal/day on day following paracentesis – pt describes this as her “best” eating day out of the whole week Estimated requirements: 35-40 kcal/kg = 1750-2000 kcal/day

Importancia del Ejercicio para Mantener el Músculo Where do we start? Here is an example… • Counsel patient on caloric deficit – even in non-cirrhotic physiology: Energy in < Energy out = WEIGHT LOSS • Only accelerated in state of hypermetabolic state PLAN: •3 meals each providing ~400 kcal 400 kcal = 1 ensure plus, 1 piece of fruit 400 kcal = 2 slices bread, 1.5 tbsp peanut butter, 1 glass of milk 400 kcal = 3 oz meat, 1 medium potato •3 snacks each providing ~200 kcal 200 kcal = 100 g Greek yogurt, 1 banana 200 kcal = 6-8 crackers with cheddar cheese 200 kcal = 1 egg on toast with 1 tsp butter or margarine

Importancia del Ejercicio para Mantener el Músculo

• Loss of Body Protein • High protein diet: • ESPEN Guidelines 1.0-1.5 g/kg • What does this look like? What makes a high protein snack?

• Decreased hepatic glycogen stores • Small frequent meals • Bedtime snack/late evening meal

Importancia del Ejercicio para Mantener el MĂşsculo â&#x20AC;ŚBack to our 50 kg patient with 23% UBW loss over 6 month period 1.0-1.5 g/kg/day protein = 50-75 grams protein daily Due to severity of weight loss: counsel patient on higher end of estimated requirements Greek Yogurt (3/4 cup)

13 g protein

Red meat/poultry (1 oz)

7 g protein

Milk (1 cup)

9 g protein

Beans/peas/lentils (3/4 cup)

8-12 g protein

1 egg (large)

6 g protein

Peanut butter (2 tbsp)

7 g protein

Cheese (50 g)

12 g protein

Nuts/seeds (1/4 cup)

5-8 g protein

Whey protein powder (2 Tbsp)

20-25 g protein

Fish/Shellfish (1 oz)

6-7 g protein

Importancia del Ejercicio para Mantener el Músculo • • • •

Sarcopenia, deconditioning and frailty are all associated with a poor prognosis Exercise (in association with adequate nutritional therapy) is a key therapy Small studies support the role of supervised and home exercise therapy in improving exercise capacity and muscle mass in compensated disease Future studies will need to elicit the optimal exercise prescription, translation to patients with decompensated disease and mechanisms of improving adherence