Longevity / Protein, Muscle, and the Nutrition of Aging Well Transcript

Protein, Muscle, and the Nutrition of Aging Well Transcript

0:00

Well, hello there everyone. I'm Dr. Leslie Kernisan, board certified geriatrician and the founder of betterhealthwhileaging. net and this is the Better Health While Aging video podcast where we discuss common health problems that affect people over age 60 and the best ways to prevent and manage those problems. We also often address common concerns and dilemmas that come up with aging parents and other older loved ones, like what to do if you're worried about falls or safety or memory or even the quality of an older person's healthcare. In today's episode, I am going to talk about nutrition and aging. This is something that I'm often asked about. What should an older person be eating? What is the best diet for healthy aging? And so if you have been wondering what should I eat for better aging, this episode is for you. So I'm going to talk to you a little bit about my philosophy about nutrition and diet when it comes to older adults and maintaining health and well being. And then I'm also going to talk about some nutritional issues that come up in geriatrics, especially when it comes to frailer older adults, such as dealing with weakness or fatigue or unintended weight loss or even sarcopenia, which is a really common syndrome of age related muscle loss. It's what makes frail older adults often seem very weak and can affect their mobility. So that's what I'll be talking about in today's episode. And I wanted to cover this because nutrition is important and I think it's really easy to get confused. It gets covered quite a lot in the media. It's a very popular topic with the public and I think

1:33

it's really easy to get in a way, sort of conflicting signals or it's easy to just hear all kinds of things and you may be wondering what to believe or what's really true. So things you may have heard include things like a Mediterranean diet is the best one, lots of protein is important as you get older, berries are good for you, you should avoid sugar, you should avoid gluten, A low carb diet is better, a low salt diet is better, or maybe a low fat diet is better. But then again, there'll be those who say the amount of fat in your diet doesn't matter. So given all these different messages, what you know, what should you believe? What's important to know? And I'm going to tell you my philosophy. But I want to start off by saying that part of the reason why I think it's so easy to get confused is that nutrition science is particularly challenging to study. And a lot of it has been done, a lot of it has been published, but it's hard to get definitive answers. And some of the most important reasons include that, first of all, the vast majority of the studies that are published, what you hear about in the news, are based on what is called observational epidemiology. So they. They will basically, you know, ask people, what are you eating? And then gather data over how their health outcomes change over time and then draw conclusions about how their nutrition may have contributed to that. And those studies are useful and important, and even though they do their best to kind of account for different variables that account for why different people are eating

3:03

different things. So, for instance, it might be that somebody who's healthier in general chooses to eat a lot of vegetables. And so then when they have better health outcomes, know, five years later, is it the vegetables or just that they were healthier in the first place? And, of course, the researchers do try to account for this statistically, but it's. It's very hard to do it perfectly. So really, what's better, as far as studies go, are randomized control trials. But those are actually hard to do when it comes to food. It's one thing to randomize people and give them, you know, a medicine, a pill, and get them to all take it, but, you know, an actual diet or way of eating is much harder to randomize people to. It's expensive. And so we have relatively few randomized trials of large enough size to draw conclusions. Lastly, I think this is challenging because food is in itself a complicated substance, right? Not only do we have lots of different foods, but a certain type of food, whether it's a vegetable or animal product, might be nutritionally different, depending on where it was grown or if it's an animal, what the animal was fed. And that might affect our health differently. And the different foods are going to interact with each other, and then they're going to interact with our bodies, which are complicated mechanisms. Our bodies are all different from each other as well. So I think that's part of why it can be hard to really definitively sort out with nutrition science, how people should eat or which foods are better. That said,

4:33

I want to share two scientific facts that I think are important to highlight before I go into what I encourage older adults, how I encourage them to eat, and why. So the first is that it has been definitely proven that different people's bodies respond differently to the same nutritional input. So we have lots of examples of this where they've Taken a sort of, you know, standardized meals, either one or a series of meals, and fed them to different people and seen that the way people's bodies respond in terms of glucose response and other response can be extremely variable. So that's important to know that people might have different blood sugar curves or fat metabolism curves after eating the same thing. And that means, you know, why is this? First of all, it's undoubtedly because we have different genetics and also importantly, epigenetics means the way in which your different genes are activated or not activated by environmental factors, which can certainly include the foods that you are eating, along with other things, the exercise you're getting, you know, other aspects of life that are influencing your body. People also respond differently because we have different microbiomes. So we know now that each of us carries this whole ecosystem of bacteria in our gut, and that that's an extremely powerful factor in how we respond to foods and how those foods affect our bodies and the rest of our health. Also, what we eat ends up influencing the composition of that

6:04

microbiome as well. I'll talk just a little bit more about it briefly, but in general, a more diverse microbiome seems to be better, as far as we can tell. And then people, of course, have different ongoing health states, so they. They may have different ongoing chronic conditions. Your body composition probably makes a difference as well. The amount of fat, what kind of fat you have, the amount of muscle, what condition that muscle is in, will also affect how you metabolize different foods and respond to different foods and then just your state of being in a given day. We know that people might metabolize carbohydrates and glucose differently depending on how much they slept the night before when they last exercised. So it's. It's really a sort of, you know, complicated thing to figure out how people will respond. And I think ultimately what we need to know is different people will respond differently. So if you are looking for, you know, what is the right, how should you be eating? It's partly a question of figuring out what are the things that work well for your body. And we will talk more about that in a moment. But what this means is different people have different health responses to the same diet. So anybody who tells you this is the best diet for everyone is almost certainly going to be wrong. Diet is probably something that does need a certain amount of personalization. So another scientific fact to share as well is that what we don't have a lot of randomized trials of foods and diets, but what has been shown at least a few times is that foods and diets associated with better health do not always

7:35

improve outcomes in randomized trials. This is actually has been true of certain vitamins and supplements as well. And so in recent years there was a sort of significant trial of this type that came out which was the trial of the MIND Diet. So the MIND Diet stands for Mediterranean DASH Intervention for Neurodegenerative Delay. The DASH diet was developed quite a while back, dietary approaches to stopping hypertension and did you know, lower blood pressure in many people. The Mediterranean diet has also been studied actually, interestingly also in a randomized trial predimed which was done in Spain quite a while back. Although there they didn't. They gave people guidelines on how to eat. And the people who are randomized to the Mediterranean more Pred Med diet were given extra olive oil and extra nuts was the approach there. And did have actually a little bit better outcomes. But for quite a while it looked like people who ate something that was described as the MIND diet had better cognitive outcomes. So there was a lot of interest in this. But they finally randomized people and followed them for, for three years. But it failed to improve cognitive outcomes. And this was done in older adults who I believe were overweight and had at least like one risk factor for cognitive decline as well. So people who are already at higher risk now, does that mean it's a bad idea to eat the MIND Diet? You know, no, it's just an example of how when we actually try things in a randomized setting, they often are not working as well as we would have

9:07

hoped based on the observational studies. So given all this, let me share with you my overall view and philosophy on what is a nutritious diet for older adults or really for people of any age. Rather than focusing on what exactly is or isn't in the diet, I think it's good to focus on some sort of intermediate outcomes that we know are really good for people's health in general that tend to slow down aging related declines and tend to counter chronic illnesses. So a healthy nutritious diet is one that is going to achieve the following for you. First of all, it should keep your glucose, inflammation and weight in good control. When we look at the multiple chronic diseases, whether it is Alzheimer's or, you know, heart disease or other forms of diseases, we see a couple common pathways that tend to exacerbate the conditions for the cells and organs and lead to these diseases. And one is poor glucose metabolism, glucose being very high or very erratic, insulin levels Being very high, that tends to generate stressors on the body that dysregulates cells and organs, can lead, of course, to diabetes, but, you know, is also linked to developing a variety of other chronic, chronic conditions and then inflammation. Inflammation is also a common pathway in the development or progression of many chronic diseases. So a healthy nutritionist diet is one in which your body

10:39

maintains pretty good control of its glucose, pretty good control of inflammation, and then pretty good control of weight. Because we know that for many chronic conditions, being especially very overweight is associated with a higher risk of developing the chronic condition or of having it progress. A healthy nutritious diet is one that keeps you metabolically healthy. So that's again, you know, related to that, especially to that glucose metabolism, also to fat metabolism. And I'm gonna talk a little bit more in a moment about what specifically it means to be metabolically healthier. How we can know it's things that are actually like, pretty straightforward, usually to sort out with your primary care provider. A healthy, nutritious diet should also foster a healthy, diverse microbiome in your gut. The general trend of the research on the gut microbiome and associations with health is that people in better health tend to have more diverse microbiomes. Now, if you make it more diverse, does that lead to better health? You know, that's the kind of causation that is still being sorted out. But there's a lot of reason to believe that more diversity is better. And so a nutritious diet helps foster that diversity generally through offering a lot of vegetables. And fiber is usually the foundation of that. And then a healthy nutritious diet will also provide you with a variety of nutrients that your cells and that healthier gut microbiomes, the healthier gut microbiome needs. And it should minimize your consumption of toxins.

12:09

And I'll talk in a moment of what are the toxins that I think are worth looking out for. Lastly, if you have a chronic health condition, then a good diet for you helps you reverse or at least mitigate and manage that health condition. So again, if you have diabetes, which is associated with higher glucose levels, most of those people do have to, you know, be careful about their intake of carbohydrates and kind of monitor how their body is managing that glucose load. If you have heart failure, many of those people are especially sensitive to salt. And so then, you know, a better diet for them might be one that avoids really high levels of salt and maybe is even, you know, more aggressively low salt. So given that, how do you actually Eat a healthy, nutritious diet. So again, ultimately, I would say your goal should be to find out what works for your body to keep glucose, inflammation and weight under control. So for most people in the United States, the majority are tending towards being a little overweight rather than underweight. We have an abundance of calories available to us. So for, for most people, it's going to be not too, too many calories. And these are the general principles that I think work well for most people. More vegetables, greens, fiber, fruits, beans, lentils. These support a healthier microbiome, your gut bacteria. Now, some people are sensitive to some of these foods. They get a lot of, you know, bloating or, or other distress. If that's you, then you're gonna need to eat less of that, that type of food.

13:39

But in general, more vegetables and fiber and a diversity really seems to be help the body maintain its glucose and inflammation levels under control and then minimizing added sugars. Fast food, trans fat, and processed foods. These are foods that, that often, you know, in small quantities to moderate quantities, especially if you're eating them in conjunction with lots of vegetables, are probably not that bad. But in the United States, a lot of people are consuming quite a lot of these substances and they do not seem to be good for the body. They could even potentially be described as, you know, toxins by, by some people, you may potentially want to be careful about a high sodium intake, especially if you have high blood pressure. Now, for many people, a lot of the sodium that they are getting comes from these processed foods, ultra processed foods. Anything, you know, that's been really industrially packaged in the store often has relatively high sodium levels. So for some people, just cutting out processed food might be enough to avoid a very high sodium intake. And then some people, especially if there are signs that they are having some difficulty managing blood sugar. And I will talk more about what that looks like because we can see some signs that people aren't great at managing blood sugar well before they have diabetes, even before they have pre diabetes. I mean, in a moment, I will show you my own curve of how I manage sugar. For a person of my age and size, I am not great at managing sugar turns up. That's what I learned at one point when, when I did this assessment.

15:09

So potentially for some people, it's really worth it to be careful with simple starches, refined flowers, most sweets, if their blood work suggests problems managing their sugar. Another thing to be careful about is alcohol. So the, the thinking has really shifted on Alcohol over the past several years, you know, for a long time, it sort of seemed that, you know, a moderate amount in those observational studies was associated with living longer, was part of the Mediterranean diet. Now it increasingly seems that one, there might be a little bit of a healthy participant bias, but I think also that alcohol, especially in these Mediterranean countries, is associated with socializing, with leisurely meals, with relaxation. So for quite a while, we thought, you know, moderate amounts might even be good for you. But now it seems more and more that alcohol is essentially not good for health, is somewhat harmful. Now, in, you know, light to moderate amounts, is it super significant? We're not sure. But the surgeon general did recently come out with a warning to let people know that it was linked to certain forms of cancer. And alcohol definitely can worsen heart health, especially for people who have atrial fibrillation or who have heart failure. I have some videos on that, actually, a very good video with cardiologist Dr. Cara Pellegrini about atrial fibrillation. And she, you know, was explaining how they've really come to realize that in cardiology that often cutting back on alcohol can significantly improve the way people's hearts function.

16:39

So potentially being careful with alcohol is part of a healthy, nutritious diet as well. And then you want to check and see how your body responds to saturated animal fats, because we know that having a high level of certain harmful forms of cholesterol is not good for the body. And for some people, eating saturated fats really raises that up. And other people are better able to metabolize fats. So potentially being careful about saturated animal fats is worthwhile as. As well. Lastly, some people really do seem to feel better off of dairy, gluten, or other types of food. And I've had a number of older adults tell me that they're, you know, they're arthritis and their joints actually feel better when they cut out some of those foods that seem to generate some inflammation or irritation in them. So if you notice that, pay attention to your body. Now, what about, you know, are there any particular foods that are especially nutritious? These are foods that may be especially beneficial. They often have turned up in observational studies as associated with better outcomes. These include nuts and seeds, especially flaxseed, foods with polyphenols, such as olive oil and berries, cocoa and tea, especially green tea. They have antioxidant compounds. Seafood, especially oily fish, high in omega 3 fatty acids. Fermented foods, that effect might be mostly on the microbiome, but fermented Foods seem often associated with some better health outcomes. Healthy fats such as olive oil and then having enough protein.

18:12

And I'm going to talk more about protein in a moment because that also has been highly debated when it comes to older adults. So those are some foods that may be especially beneficial. But I think ultimately what's most important is probably to minimize, you know, quote, bad foods that tend to cause inflammation or are otherwise triggering harmful effects in the body. That's probably more important than making sure that you get any one specific healthy food, you know, such as, like, the berries or the walnuts. So I would encourage any older adult or adult of any age really to really be cautious about how much ultra processed foods, sugar, alcohol, junk food you're consuming if you're otherwise in good health, especially if it looks like your glucose, inflammatory levels and the rest. You know, I think these are things that can be eaten, you know, occasionally in moderation. But we know that in the United States there are quite a lot of people for whom this is a quite substantial part of their diet, and that is probably harmful. And then, you know, instead of getting too much into, like, which specific foods should you eat, generally eating a large, diverse quantity of vegetables and other minimally processed plant foods seems to be good for you. So this will provide fiber, it'll provide a variety of nutrients, of antioxidants, and then eating enough protein to support your muscle mass. It's actually really good. Really important as we get older to proactively try to build

19:43

and maintain muscle mass through strength training. I have a whole video that's about how to exercise as you get older and the importance of exercise and specifically of strength training. So do you need massive amounts of protein? Probably not, but you do want to be eating enough protein to support strength training. An added advantage of eating protein is that for many people, it's actually filling. Because part of eating nutritiously and also not eating too many calories is to figure out what leaves you feeling pleasantly full and how to avoid sort of feeling in this, like, hungry cycle, which sometimes I think for some people can be sparked by a lot of simple carb kinds of foods that tend to spike people's blood sugar. And in general, you want to try to be metabolically healthy. So what does it mean to be metabolically healthy? What are we doctors talking about? So this refers, you know, roughly to how well your body manages glucose and lipids. Lipids means fats in your bloodstream, organs and cells. So we start off becoming especially aware of this when it came to cardiovascular disease. People who often have, you know, high levels of certain kinds of cholesterol, especially the LDL cholesterol, and there are other subtypes, you know, would tend to build up plaques in their blood vessels. And that ends up having significant implications for the heart and also for the brain, because your brain has blood vessels as well. And they also saw that people who often had high glucose diabetics would have even worse cardiovascular disease because the elevated glucose

21:17

and what it triggers in the body also acts as an irritant that ends up inflaming blood vessels and otherwise harming other organs. It's not just the blood vessels. It's the liver and other parts of the body as well. So generally, when we're talking about metabolically healthy, that is what we're referring to. How well does your body manage glucose and lipids? Because worse management is associated with inflammation. That plaque that people get in their blood vessels that then affects their heart or can cause stroke, you know, is a result of inflammation in the lining of the blood vessels. Being metabolically unhealthy is associated with high blood pressure, higher glucose, which can lead to diabetes. And, you know, what we call atherosclerosis, which is, again, that process of buildup on the blood vessels in the body. And that's just, you know, a small sample of the. The effects. Metabolically healthy is also sometimes defined as, you know, absence of the components of metabolic syndrome. So a while back, you know, doctors decided to identify something that they called metabolic syndrome. It was a sort of combination of problem signs that they were seeing in a lot of adults. And the signs were abdominal obesity. So having an increased waist circumference. So those are people who are carrying weight, especially in their belly. Belly fat is generally worse for the health than fat that might be carried elsewhere in the body. Like for women, you know, in their hips or thighs, they often had high triglycerides. That's a type of fat in the bloodstream, and low HDL cholesterol. HDL cholesterol is the good type of cholesterol.

22:49

They often had high blood pressure above a systolic. That's the top number of 130 and diastolic of 85. And their fasting blood glucose was often over 100. So, and for reference, a fasting blood glucose over 126 is what used to be considered diagnostic for diabetes. So a hundred is nowhere near the level of diabetes. But, you know, many of these people had it higher than a hundred. And that was also kind of associated with, you know, they were kind of like trending towards pre diabetes. So that was metabolic syndrome. The less of those you have, you know, that would be one way to consider yourself more metabolically healthy. So a question that I think is important to consider as you're thinking about your health, healthy aging, what you should eat is, you know, do you know how is your own metabolic health? Because research shows that metabolic syndrome and obesity become much more common as we age. Now there's a lot of overlap between obesity and metabolic syndrome, but you can be obese and otherwise not have any of characteristics of metabolic syndrome, or you can be normal weight and have many of those signs that, that were listed. So national surveys of people's health, they do these, these big surveys. They don't just ask people how's your health? They actually will take a lot of tests of thousands of people. And what those studies have found is that at least 50%

24:20

of Americans over age 60 meet criteria for metabolic syndrome. And in general, the older people get, the more of them are falling into that, into that syndrome. Because people do often tend to first of all gain weight and become more sedentary as they get older. And also as we age, our metabolism otherwise changes and it's often not in our favor when it comes to metabolic health. So this has been attributed to a sedentary lifestyle and also the fact that many people in the United States are eating what is often called the sad, the standard American diet, sad, which is quite high in processed foods and industrially produced foods, in sugar, in sodium, in red meat, and tends to be relatively low in fiber and vegetables. And again, it is associated with obesity. However, it is totally possible to be normal weight and be metabolically unhealthy. So you really want to know how your metabolic health is. Because if you are the more of those signs of metabolic unhealth you are showing, the more important it is to review and revise your diet and also take other steps to try to correct that. Because we know that people who are metabolically unhealthy just tend to have age related problems sooner, tend to develop a variety of chronic illnesses sooner, whether it's cognitive issues, heart health issues, or other issues. So how can you learn more about your metabolic health? I would recommend working with your health provider to ask them to help you assess the following. So for obesity and abdominal obesity,

25:51

we would assess body mass index and also what is called the waist to hip ratio. So you measure around the waist and then you measure around the hips and a higher waist to hip ratio. So greater than 0. 9 for men or 0. 85 for women suggests abdominal obesity, which is a risk for heart health and brain health and for metabolic syndrome. For glucose metabolism, you can ask your provider to check your fasting blood glucose. You can also ask for a test that is called hemoglobin A1C. This is a measure that reflects your average blood glucose over the past three months. It's basically as sugar floats around in your blood. It what we call glycosylates, red blood cells. Uh, and so the more sugar you have floating in your blood, the higher the percentage of your red blood cells will be glycosylated. So, you know, a normal level is. I think they usually say the normal level is below. I want to say five, but, you know, being closer to five would be great. People who have diabetes are gonna be, you know, above 6. 5 and, and higher. So you can ask for your hemoglobin A1C if you wanna go the extra mile on this. I didn't list this on the slide, but you can also ask and see if it's possible to wear a continuous glucose monitor for two weeks. These have become, you know, more readily available. They look like a little disc. They get stuck, you know, often on the back of your arm right here. They connect to your smartphone and they will show you your

27:22

glucose curve, you know, all the time, for two weeks. And what's great about those is that you can really see what happens when you eat different foods, how much they spike your glucose. Um, you can also see how if you eat a certain carb in combination with a fat or protein, it generally will spike you less. One can learn just lots of interesting things from wearing a glucose monitor for two weeks and then for how you metabolize lipids and fats. You can ask your doctor to, you know, they. They're probably already doing this, checking on your cholesterol, your triglycerides, your hdl, your ldl. There are some additional sort of subsets of lipids that certain specialists, doctors, especially the ones who focus on applied longevity, like to do. But, you know, the basic cholesterol panel is a good starting point. And then you'll want to have your blood pressure checked as well if your blood pressure is higher. Blood pressure medication works wonderfully well and has been shown in multiple randomized trials to improve outcomes. So that's a type of medication that I, you know, encourage people to, to try and, and consider. So another option, it does cost money, but, you know, can be useful would be to do a program like Zoe. com and I actually did Zoe myself a few years ago. It's an app that will make nutrition recommendations to you. But what I thought was very interesting about it is that they start off with an assessment where they do an, an initial assessment period where you can wear a glucose monitor. And they will also give you some standardized, you know, muffins to eat at a certain point. And you'll kind of see where your curve of metabolizing the sugar and the cholesterol compares to,

28:53

to that of other people. So here, let me show you right now. So, for instance, this was my blood sugar curve right here. And these are sort of thousands of other people. And what Zoe told me was that my blood sugar curve was actually not that good. And they recommended that I be careful about glucose management. On the other hand, my fat management was much better than average. My body did a good job managing the fat load that was in the muffins, where there's other people who, you know, retain a very high level of lipids in their blood for hours afterwards. So that's an example of, first of all, how we metabolize things differently and how finding out more about how your body responds to things can help guide you when it comes to better eating for aging. I should add that, that I have no financial interest in Zoe, and they did not ask me to mention their, their product in the video. It's just something that I tried myself and I think it's an intriguing idea. And that, that kind of idea, I think can help a lot of people. So how do you improve your metabolic health if it is not optimal and most of us are not optimal? Um, so what you should know is that probably the most important thing that helps is increasing muscle mass through strength training and other forms of exercise. Diet is important as well, but only especially if you're quite sedentary and not exercising. Only changing your diet is only going to take you so far. And the most effective thing is a combination of generally

30:27

more muscle mass for most people and modifying the diet. So if you're metabolically not optimal, I would encourage more strength training and find out whether your body is struggling to manage glucose lipids, also known as fats, or both. I would recommend reducing ultra processed foods, and then you'll want to experiment to find a dietary approach that feels sustainable for you to maintain and improves your metabolic indicators. So so far we've been talking about the problem that most people face. Uh, so what most people face is, is that generally they're eating more calories than they need, they're often more sedentary. Than they should be. And they're often not entirely metabolically healthy. But there are some older adults who are facing other issues, Specifically malnourishment. So I want to speak briefly to malnourishment, because that is something that we see in geriatrics as it comes up, especially with older adults who are getting to the stage of being very old or very frail. So the risk factors for malnourishment include being frail, being cognitively impaired, if you're having difficulty with memory and thinking, People can become disorganized. They can forget to eat, they're not able to get their groceries or fix up their food. So especially if they live alone, people who are socially isolated are at higher risk for malnourishment. Some older adults are financially limited and are having difficulty affording enough food. And then certain medical conditions can also change your metabolism and actually, like, rev it up abnormally so that it becomes very hard to

31:58

maintain weight. Cancers can do that. Thyroid problems can do that. And there are a variety of other issues that might also change people's metabolism and essentially cause them to be malnourished. How do we know if somebody is malnourished? So there is an expert consensus statement put out by a dietitian association which says that basically, you know, one should be concerned if there are two or more of these characteristics. The person's not taking in enough calories, they're experiencing unintended weight loss, they're losing muscle mass, they're losing subcutaneous fat. So that's the fat layer under our skin. If they have been accumulating fluid, maybe because they're having heart failure or kidney problems or liver problems, that can sometimes mask weight loss. But accumulating fluid like that also often happens because people can have very low levels of protein in their blood, which is also associated with becoming malnourished, and they can have decreased hand grip strength and functional abilities. So if we're concerned about malnutrition, what should we do? So, first and foremost, any older adult with unexplained weight loss or signs of malnutrition absolutely should have a medical evaluation to identify the underlying causes. And so if you would like to learn more about that, I have an article at Better health while aging about evaluating unexplained weight loss. That will kind of walk you through what doctors are supposed to check and the most common causes. That said, often helping people have a diet that is higher in healthy

33:31

calories is often part of the management. But we always want to evaluate and understand what's going on because more calories, you know, is often not enough if a big part of the driver is an ongoing medical problem, for instance. And then we also want to think about increased protein if there is frailty or sarcopenia. So let me now talk about frailty and sarcopenia because the is a condition that can improve when we give older adults extra protein, provided it is combined with strength training. Extra protein by itself, it's not clear that it works all that well. So what are frailty and sarcopenia? Frailty is basically defined as an aging related syndrome of physiological decline. Now you may know it when you see it. You've probably seen how older adults at a certain point start to look frail, meaning they look a little bit fragile and they're moving kind of slowly. There's been an effort in geriatrics and in medicine in recent years to really define the syndrome of frailty and identify frail older adults, partly because they tend to do poorly with surgeries and other interventions. And so if somebody has become frail, it's often really a sign that we want to seriously consider modifying the type of healthcare that, that they are getting. An expert. Dr. Fried developed a freed frailty tool a while back with criteria for frailty. And they include weight loss, losing 5% or more of the body weight in the last year, getting exhausted by normal activities,

35:03

having muscle weakness, which can be assessed in the office, with decreased grip strength, hand grip strength, slow walking speeds such as taking more than six seconds to walk 15ft, and decreased physical activity overall. So three or more of those criteria would qualify people as frail. If they have one or two, they're considered pre frail. And then there's sarcopenia, which is not the same thing, but is often associated with frailty. So sarcopenia refers to generally as we age, we start losing muscle mass, but also our muscle cells become less effective and less strong. And that is a phenomenon that starts to a certain extent when people are in their 40s, but it tends to really accelerate at some point in later life. And so you might see how certain older adults, their muscles seem like very small. And often those are people who are struggling to do things like carry their groceries and go up the stairs. And so that is sarcopenia. So in geriatrics there's been more of an effort to identify people who have frailty and sarcopenia. And we're really trying to learn more about how do we prevent these conditions from coming on. And once an older person seems to substantially have them, you know, can we reverse them or what can we do? And so what is the role of nutrition in all this? So can diet prevent frailty or sarcopenia? We don't know. It seems to me that probably not that the most, by far the most important factor for prevention of both frailty and sarcopenia is exercise, especially strength training,

36:34

which is why I go into depth about strength training in my video on exercising and aging. And the earlier you start, so especially if you can build up more muscle mass when you are in your 50s, 60s, it's never too late to start. You can even start in your 70s, you can even start in your 80s. But the more you build up muscle mass earlier in life, the, in a way, the more of a reserve or cushion you have, you know, so that you can even lose some of it as you get older and still have enough to be doing the activities you want. So exercise is by far most important. And then we don't really know the role of nutrition otherwise. It has been studied, sort of additional protein supplementation for older adults. And if they're not frail, it's not clear that it does all that much. Now, can diet treat frailty or sarcopenia? This has been studied in randomized trials, and they did find that if you actually offer some supplemental protein plus resistance training that can help counter sarcopenia and can help older adults build back strength more effectively, you do have to combine the two. If you just give people extra protein without any exercise or additional exercise, they do not get stronger. So that brings me to the question of protein intake in aging. So this is a topic of a lot of debate and controversy right now. What I would say is that adequate protein is most important for those older adults who are frail or starting to show

38:06

signs of significant muscle weakness, and that you want to combine that extra protein with strength exercises. The US recommended daily allowance for protein is 0. 8 grams of protein per kilogram of body weight. Many experts believe that that is not enough, but it's unclear what the right level should be. I think it's persuasive that older adults probably need a little bit more than, than that amount. That amount seems to be kind of a minimum. Whether they need the level that some experts online are advocating for is unclear. So in frail adults, again, the research has shown more strength gain when you combine resistance training with higher protein intake. So my recommendation for older adults who are frail is to aim for a little higher. I like the level of about, you know, 1. 3 grams per kilogram per day, so 0. 6 grams per pound per day. You know, a little bit more than a half pound. Uh, you should check with a doctor. If kidney disease is present, you want to eat protein at every meal because your body can only absorb, I think it's about 25 grams of protein per meal. It just can't take in more than that. We also know that actually as older as people get older, they can be less efficient in absorbing the protein. So you want to eat protein at every meal and you can consider a supplement such as whey or another protein supplement. Animal protein is generally easier for the body to absorb and make use of. But if you choose to not consume animal products, which is a totally valid choice, you can manage it with plant protein.

39:36

You just might have to take in a little bit more of it. So, and then what about protein for older adults who are not frail? I think right now, given the sort of available evidence, if you're not frail, I'm not sure it's worth it to spend a lot of time counting your protein intake and worrying about it too much. I think it is more useful to first focus on getting metabolically healthy, on establishing a strength training routine, and then on doing other things that are good for healthy aging, such as tending to your emotional well being, optimizing other chronic conditions, maintaining social connections, and pursuing other healthy aging strategies. So lastly, a few words about vitamins and supplements, because I get asked about that a lot too. So people sometimes say, well, what vitamin or supplement should I be taking? Well, randomized trials often don't find an effect of various vitamins and supplements on health, whether it's brain health or other aspects of health. Antioxidant vitamins have been studied. Omega 3 vitamin D have especially been studied. So I think it's plausible that supplements can help some people. But you should also know that the quality of commercially available vitamins and supplements is highly variable. And selling health supplements is big, big business. So some of you know the relevant research. There have actually been a number of quite large randomized trials related to vitamins and supplements in the last several years. So notably in 2019, the VITAL trial, vitamin D and omega 3, they took 25, 000 healthy older adults. They were mean age 67, randomized them to a higher dose of vitamin D or fish

41:07

oil capsules, and the supplementation did not result in less cancer or cardiovascular events. There was another study done, I believe this one was in Australia, smaller study where they randomized people to a combination of vitamin D, fish oil, strength training or placebo treat for three years, and that too did not make a difference. Now Physical performance was a very specific physical performance test called the Short Physical Performance Battery. I continue to believe strength training is valuable despite that randomized trial. And then there was a study published Cosmos, where they randomized older adults to get a multivitamin or cocoa. And the daily multivitamin was associated with a little better cognition and memory. It wasn't even a fancy vitamin. I think it was a Centrum Silver. So my take is that generally I don't make any specific recommendations. I do lean towards a daily dose of vitamin D, 800 international units, and of vitamin B12, 1000 micrograms per day, because it's very common for older adults to be deficient in these substances. Now, what about higher levels of vitamin D? I have a whole video about vitamin D because not only has the research shown that higher doses such as 2, 000 international units per day or 4, 000, you know, are not helpful, but there's even some research suggesting it might actually be harmful and that older adults need vitamin D, but not too much of it. So I'm going with 800 international units right now. And then I think it's reasonable to consider a high quality

42:38

multivitamin. There's other data on omega 3s. I don't think it's the slam dunk that a lot of people think it is, but that, you know, I think that one's reasonable as well. But overall, I think what's most important is to exercise and to eat a reasonably nutritious diet. And a reasonably nutritious diet, you know, is one. It may be more important to avoid sort of things that are bad for the body than it is to get any particular specific things. So my take on nutrition is we, we want to try to avoid bad nutrition, promote better eating, and consider the specifics of each older person. So what chronic conditions does this person have? How is this older person's weight? Are there signs of glucose dysregulation? Are there signs of lipid dysregulation? Might this person be malnourished? Is this person showing signs of frailty or sarcopenia? And again, sarcopenia is that syndrome of progressive muscle loss and weakness. So to recap, there is no particular diet that is best for everyone because everybody's body is different. A good diet for you is one that keeps glucose, inflammation and weight in good control, keeps you metabolically healthy, fosters a healthy, diverse microbiome in your gut, provides you with a variety of nutrients that your body and microbiome need, including fiber, and minimizes your consumption of toxins. So what's likely most important is minimizing, you know, quote unquote bad foods that cause inflammation or are otherwise harmful. And generally those are going to be ultra processed foods. Sugar, alcohol, junk food doesn't mean you can't ever have them.

44:08

But you know, small to moderate quantities are going to be better. And then what's important is eating large, diverse quantities of vegetables and other minimally processed plant foods that will give you fiber, that will give you all kinds of, like, nutritious compounds that is going to be really good for your microbiome. And then you want to eat enough protein to support strength training and you want to overall try to be metabolically healthy. So I encourage you to find out if you are sensitive to sugar or saturated fats. Older adults with weight loss or other signs of malnourishment should definitely be medically evaluated. They may need the sort of, you know, higher calorie diet. And then frailty and sarcopenia can be improved with a combination of supplemental protein and strength training. But otherwise it's not clear that it's otherwise worth spending a lot of time fine tuning your protein intake. So with that, thank you so much for watching. And if you found this video podcast helpful, if you're here on YouTube, please go ahead and subscribe. It does help more people find the channel. If you have been listening to the audio version on the podcast feed, come and take a look at the video if you get a chance. You'll see my key points being displayed on the screen. So thank you once again and I look forward to seeing you all again on a future episode of the Better Health While Aging video podcast.