Wang Jialin, Zhou Yi, Yuan Weijie. Relationship between Body Mass Index and Mortality in Hemodialysis Patients: A Meta-Analysis. Nephron Clin Pract 2012;121:c102-c111 (DOI: 10.1159/000345159)





Background: Previous studies have reported that reduced mortality rates in hemodialysis (HD) patients were negatively related to body mass index (BMI). The potentially protective effect of increased BMI in HD patients has been referred to as ‘reverse epidemiology’. Our meta-analysis was conducted to examine the relationship between different BMI ranges and mortality in HD patients.

Methods: Eligible studies assessing the effects of BMI ranges on all-cause mortality (published from 1966 to February 2012) were searched, using ‘hemodialysis’ or ‘haemodialysis’ and ‘obese’ or ‘body mass index’ or ‘overweight’ as key words, in combination with ‘mortality’, ‘survival’, ‘reverse epidemiology’ and ‘obesity paradox’. Inclusion criteria were that trials reported mortality in HD patients according to the traditional World Health Organization/National Institutes of Health BMI classification, and BMI levels are acceptable within 2 index points. The quality of the trials was evaluated using the risk of bias assessment in studies included in Cochrane reviews. The mortality rates in HD patients were the primary end point of the study. With no significant heterogeneity, a fixed-effects model was used for analyses.

Results: Four studies with a total of 81,423 patients met final inclusion criteria. Compared to individuals with non-elevated BMI, those with elevated BMI (BMI ≥25, OR 0.67, 95% CI 0.65–0.68) had a lower all-cause mortality. In a risk-adjusted sensitivity analysis, elevated BMI levels (adjusted hazard ratio 0.94, 95% CI 0.92–0.96) remained protective against mortality.

Conclusion: High BMI levels were associated with lower all-cause mortality rates in HD patients. It is possible that more stable hemodynamic status, cytokine and neurohormonal alternations contribute to the protective effects of BMI on mortality in HD patients. There is a need for prospective studies to elucidate mechanisms behind this relationship.



Susann Fülster, et al. Muscle wasting in patients with chronic heart failure: results from the studies investigating co-morbidities aggravating heart failure (SICA-HF). Eur Heart J (2012) doi: 10.1093/eurheartj/ehs381 First published online: November 23, 2012






Aims To assess the prevalence and clinical impact of reductions in the skeletal muscle mass of patients with chronic heart failure (HF). Chronic HF is accompanied by co-morbidities that influence the quality of life and outcomes.
Methods and results We prospectively enrolled 200 patients with chronic HF. The appendicular skeletal muscle mass of the arms and the legs combined, was assessed by dual energy X-ray absorptiometry. We analysed the muscle strength in arms and legs, and all patients underwent a 6-min walk test, a 4-m walk test, and spiroergometry testing. Muscle wasting was defined as the appendicular muscle mass 2 SD below the mean of a healthy reference group of adults aged 18–40 years, as suggested for the diagnosis of muscle wasting in healthy ageing (sarcopenia). Muscle wasting was detected in 39 (19.5%) subjects. Patients with muscle wasting had significantly lower values for handgrip and quadriceps strength as well as lower total peak oxygen consumption (peakVO2, 1173 ± 433 vs. 1622 ± 456 mL/min), lower exercise time (7.7 ± 3.8 vs. 10.22 ± 3.0 min, both P < 0.001), and lower left ventricular ejection fraction (LVEF, P = 0.05) than patients without.
The distance walked during 6 min and the gait speed during the 4-m walk were lower in patients with muscle wasting (both P < 0.05). Serum levels of interleukin-6 were significantly elevated in patients with muscle wasting (P = 0.001). Logistic regression showed muscle wasting to be independently associated with reduced peak VO2 adjusted for age, sex, New York Heart Association class, haemoglobin, LVEF, distance walked in 6 minutes, and the number of co-morbidities (odds ratio 6.53, p = 0.01).
Conclusion Muscle wasting is a frequent co-morbidity among patients with chronic HF. Patients with muscle wasting present with reduced exercise capacity and muscle strength, and advanced disease.



Anker MS, von Haehling S, Springer J, Banach M, Anker SD. Highlights of the mechanistic and therapeutic cachexia and sarcopenia research 2010 to 2012 and their relevance for cardiology. Int J Cardiol. 2012 Nov 19. pii: S0167-5273(12)01393-9. doi: 10.1016/j.ijcard.2012.10.018. [Epub ahead of print]

2012年10月までの心臓悪液質とサルコペニアの文献のレビューです。選択的アンドロゲン受容体調節剤(enobosarm)とグレリン(anamorelin)は、phase IIIの研究が行われています。多くの医療人に関心をもってほしい領域ですね。

ただ、Journal of Cachexia, Sarcopenia and Muscleからの引用論文が多すぎるという印象です。この雑誌のImpact Factorを高めるためのレビュー論文ではないかという見方もできます。確かに悪液質とサルコペニアの研究は、この雑誌の掲載が多いですが…。


Sarcopenia and cachexia are significant medical problems with a high disease related burden in cardiovascular illness. Muscle wasting and weight loss are very frequent particularly in chronic heart failure and they relate to poor prognosis. Although clinically largely underestimated, the fields of cachexia and sarcopenia are of great relevance to cardiologists. In cachexia and sarcopenia a significant number of research publications related to basic science questions of muscle wasting and lipolysis were published between 2010 and 2012. Recently, the two processes of muscle wasting and lipolysis were found to be closely linked. Treatment research in pre-clinical models involves studies on a number of different therapeutic entities, including ghrelin, selective androgen receptor modulators (SARMs), as well as drugs targeting myostatin or melanocortin-4. In the human setting, studies using enobosarm (a SARM) and anamorelin (ghrelin) are in phase III. The last 3years has seen significant efforts to define the field using consensus statements. In the future, these definitions should also be considered for guidelines and treatment trials in cardiovascular medicine. The current review aims to summarize important information and development in the fields of muscle wasting, sarcopenia and cachexia focussing on findings in cardiovascular research, in order for cardiologists to have a better understanding of the progress in the still not well enough known field.




Gurgun A, Deniz S, Argın M, Karapolat H. The Effects of Nutritional Supplementation Combined with Conventional Pulmonary Rehabilitation in Muscle Wasted Chronic Obstructive Pulmonary Disease: A Prospective, Randomised and Controlled Study. Respirology. 2012 Nov 20. doi: 10.1111/resp.12019. [Epub ahead of print]








Nutritional depletion in COPD adversly affects health status and mortality. We aimed to evaluate the effects of nutritional supplementation (NS) with pulmonary rehabilitation (PR) on body composition, mid-thigh cross-sectional area (CSA), dyspnea, exercise capacity, HRQoL, anxiety and depression in advanced COPD patients.


Forty-six patients were randomised to PRNS, PR or the control group. Dyspnea was measured with Medical Research Council (MRC) and BORG scales. Exercise capacity was measured through 6MWT and shuttle tests, HRQoL was assessed with SGRQ. Psychological status was measured with Hospital Anxiety and Depression Scale. Body weight and body mass indexes were also evaluated. Fat free mass was measured through bioelectrical impedance analyzer. The CSA of quadriceps was calculated in mid-level of the thigh with magnetic resonance imaging.


Dyspnea and total scores of SGRQ improved in both groups (p<0 .05=".05" 0.1="0.1" 0.2="0.2" 0.6="0.6" 43.3="43.3" 63.3="63.3" 69.3="69.3" 6mwt="6mwt" a="a" after="after" although="although" and="and" anxiety="anxiety" as="as" bmi="bmi" body="body" both="both" change="change" cm="cm" csa="csa" depression.="depression." distances="distances" ffmi="ffmi" groups="groups" improved="improved" in="in" increase="increase" increased="increased" intervention.="intervention." iswt="iswt" kg="kg" m="m" mid-thigh="mid-thigh" no="no" only="only" p="0.04).</p" patients="patients" pr="pr" prns="prns" significant="significant" significantly="significantly" the="the" there="there" was="was" weight="weight" whereas="whereas">


The combination of NS with PR resulted in improvements particularly in lean body mass and mid-thigh CSA. This study suggests combining NS with PR in reversing weight loss and muscle wasting in COPD.




Coats AJ. Research on cachexia, sarcopenia and skeletal muscle in cardiology. J Cachexia Sarcopenia Muscle. 2012 Nov 16. [Epub ahead of print]




The awareness of cardiac cachexia, i.e. involuntary weight loss in patients with underlying cardiovascular disease, has increased over the last two decades.


This mini-review looks at recent research in the cardiovascular literature that is relevant to the areas of interest of the Journal of Cachexia, Sarcopenia and Muscle. It identifies significant research in the last 3 years on the obesity paradox, the causes and effects of skeletal muscle wasting, animal models of cachexia and emerging treatment ideas in cardiac cachexia.


Assuming a similar literature in the fields of cancer, chronic obstructive pulmonary disease, chronic renal failure and chronic liver failure, the emergence of cachexia as a vibrant area of clinical and experimental research seems assured.



von Haehling S, Morley JE, Anker SD. From muscle wasting to sarcopenia and myopenia: update 2012. J Cachexia Sarcopenia Muscle. 2012 Nov 17. [Epub ahead of print]







Human muscle undergoes constant changes. After about age 50, muscle mass decreases at an annual rate of 1-2 %. Muscle strength declines by 1.5 % between ages 50 and 60 and by 3 % thereafter. The reasons for these changes include denervation of motor units and a net conversion of fast type II muscle fibers into slow type I fibers with resulting loss in muscle power necessary for activities of daily living. In addition, lipids are deposited in the muscle, but these changes do not usually lead to a loss in body weight. Once muscle mass in elderly subjects falls below 2 standard deviations of the mean of a young control cohort and the gait speed falls below 0.8 m/s, a clinical diagnosis of sarcopenia can be reached. Assessment of muscle strength using tests such as the short physical performance battery test, the timed get-up-and-go test, or the stair climb power test may also be helpful in establishing the diagnosis. Serum markers may be useful when sarcopenia presence is suspected and may prompt further investigations. Indeed, sarcopenia is one of the four main reasons for loss of muscle mass. On average, it is estimated that 5-13 % of elderly people aged 60-70 years are affected by sarcopenia. The numbers increase to 11-50 % for those aged 80 or above. Sarcopenia may lead to frailty, but not all patients with sarcopenia are frail-sarcopenia is about twice as common as frailty. Several studies have shown that the risk of falls is significantly elevated in subjects with reduced muscle strength. Treatment of sarcopenia remains challenging, but promising results have been obtained using progressive resistance training, testosterone, estrogens, growth hormone, vitamin D, and angiotensin-converting enzyme inhibitors. Interesting nutritional interventions include high-caloric nutritional supplements and essential amino acids that support muscle fiber synthesis.



Marco Brotto. Lessons from the FNIH-NIA-FDA sarcopenia consensus summit. IBMS BoneKEy(2012) 9,Article number:210(2012)doi:10.1038/bonekey.2012.210



FNIH: Foundation of National Institutes of Health
NIA: National Institutes of Aging
FDA: Federal Drug Adminstration


sarcopenia is the loss of muscle quality during aging characterized by a decline in muscle strength that if untreated can lead to weakness, disability, an increased risk of falls and loss of independence.





Kenjiro Kunieda, Tomohisa Ohno, Ichiro Fujishima, Kyoko Hojo, Tatsuya Morita. Reliability and Validity of a Tool to Measure the Severity of Dysphagia: The Food Intake LEVEL Scale. Journal of Pain and Symptom Management, http://dx.doi.org/10.1016/j.jpainsymman.2012.07.020


No oral intake
Level 1: No swallowing training is performed except for oral care
Level 2: Swallowing training not using food is performed
Level 3: Swallowing training using a small quantity of food is performed
Oral intake and alternative nutrition
Level 4: Easy-to-swallow food less than the quantity of a meal (enjoyment level) is ingested orally
Level 5: Easy-to-swallow food is orally ingested in one to two meals, but alternative nutrition is also given
Level 6: The patient is supported primarily by ingestion of easy-to-swallow food in three meals, but alternative nutrition is used as a complement
Oral intake alone
Level 7: Easy-to-swallow food is orally ingested in three meals. No alternative nutrition is given.
Level 8: The patient eats three meals by excluding food that is particularly difficult to swallow
Level 9: There is no dietary restriction, and the patient ingests three meals orally, but medical considerations are given.
Level 10: There is no dietary restriction, and the patient ingests three meals orally (normal).


Lv.1 :嚥下訓練を行っていない
Lv.2 :食物を用いない嚥下訓練を行っている
Lv.3 :ごく少量の食物を用いた嚥下訓練を行っている



Lv.10:摂食・嚥下障害に関する問題なし (正常)
結果ですが、検者内信頼性、検者間信頼性とも高く、FOIS(Functional Oral Intake Scale、こちらは7段階)とも高い相関を認めました。これより嚥下重症度評価にFILSを使用できるという結論です。


Dysphagia is one of the most prevalent and distressing symptoms among palliative care patients, and a practical assessment tool is required.


The aim of this study was to examine the reliability and validity of a tool to measure the severity of dysphagia: the Food Intake LEVEL Scale (FILS), a 10-point observer-rating scale.


The inter- and intrarater reliability was evaluated by three clinicians in 30 patients using weighted kappa statistics. The convergent validity was evaluated by examining correlations of FILS with the Functional Oral Intake Scale (FOIS) and patient-reported satisfaction levels with oral intake.


Weighted kappa coefficients for interrater reliability ranged from 0.70 to 0.90 and those for intrarater reliability ranged from 0.83 to 0.90. The FILS score was highly associated with FOIS (ρ = 0.96–0.99) and patient-reported satisfaction (ρ = 0.89).


FILS seems to have fair reliability and validity as a practical tool for assessing the severity of dysphagia. Further study on the reliability, validity, and sensitivity of FILS compared with FOIS is needed.




van der Meij BS, Schoonbeek CP, Smit EF, Muscaritoli M, van Leeuwen PA, Langius JA. Pre-cachexia and cachexia at diagnosis of stage III non-small-cell lung carcinoma: an exploratory study comparing two consensus-based frameworks. Br J Nutr. 2012 Nov 16:1-9. [Epub ahead of print]


Muscaritoli M, Anker SD, Argiles J, et al. (2010) Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics”. Clin Nutr 29, 154–159.

Fearon K, Strasser F, Anker SD, et al. (2011) Definition and classification of cancer cachexia: an international consensus. Lancet Oncol 12, 489–495.



がん不応性悪液質は、がん悪液質に該当、がんは異化期で抗がん治療が無効、身体機能低下(Karnofsky Performance Scoreが50未満)、生命予後3カ月未満に該当で診断しています。

Evans WJ, Morley JE, Argiles J, et al. (2008) Cachexia: a new definition. Clin Nutr 27, 793–799.

6か月で5%以上の体重減少(またはBMI20未満)に加えて以下の3 つ以上に該当。
⑤生化学検査の異常:a)炎症マーカーの増加(CRP>0.5mg/dl ,IL-6>4.0pg/ml ),b)貧血(<12 g/dl),c)血清アルブミン<3.2g/dl」




Despite the development of consensus-based frameworks to define cancer cachexia, the validity and usefulness of these frameworks are relatively unknown. The aim of the present study was to study the presence of pre-cachexia and cachexia in patients with stage III non-small-cell lung carcinoma (NSCLC) by using a cancer-specific framework and a general framework for cachexia, and to explore the prognostic value of pre-cachexia and cachexia. In forty patients at diagnosis of stage III NSCLC, weight loss, fat-free mass, handgrip strength, anorexia and serum biochemistry, assessed before the first chemotherapy, were used to define 'cancer cachexia' or 'cachexia'. The cancer-specific framework also classified for pre-cachexia and refractory cachexia. Additionally, quality of life was assessed by the European Organisation for Research and Treatment of Cancer - Quality of Life Questionnaire C30. Groups were compared using independent t tests, ANOVA, Kaplan-Meier and Cox survival analyses. Based on the cancer-specific framework, pre-cachexia was present in nine patients (23 %) and cancer cachexia was present in seven patients (18 %). Cancer cachexia was associated with a reduced quality of life (P = 0·03) and shorter survival (hazard ratio (HR) = 2·9; P = 0·04). When using the general framework, cachexia was present in eleven patients (28 %), and was associated with a reduced quality of life (P = 0·08) and shorter survival (HR = 4·4; P = 0·001). In conclusion, pre-cachexia and cachexia are prevalent in this small population of patients at diagnosis of stage III NSCLC. For both frameworks, cachexia appears to be associated with a reduced quality of life and shorter survival. Further studies are warranted to more extensively explore the validity and prognostic value of these new frameworks in cancer patients.


第3回ヨーロッパ嚥下障害学会(ESSD:European Society for Swallowing Disorders)は、2013年9月12-14日にスウェーデンのマルメで開催されます。下記のESSDのHPにはまだ掲載されていません。






Bowen ME. The relationship between body weight, frailty, and the disablement process. J Gerontol B Psychol Sci Soc Sci. 2012 Sep;67(5):618-26. doi: 10.1093/geronb/gbs067.




前虚弱と虚弱でもObesity Paradoxを認めるのかもしれません。ただ、虚弱でない場合には正常体重が望ましいわけですし、日本人ではObesity Paradoxを認めない可能性もあります。それでも前虚弱と虚弱になったら、減量はしないほうがよいのかもしれません…。



To prospectively examine the relationship between body weight, frailty, and the disablement process.


Longitudinal data from the Health and Retirement Study (1998-2006) were used to examine the relationship between being underweight, overweight, or obese (compared with normal weight) and the onset and progression of functional limitations and disabilities in instrumental activities of daily living (IADL) and activities of daily living (ADL) among a nationally representative sample of community-dwelling older adults (aged 50 and older) with characteristics of frailty (n= 11,491). Nonlinear multilevel models additionally adjusted for demographic characteristics and intra-individual changes in body weight, socioeconomic status, health behaviors, and health conditions over the course of 8 years.


Compared with their nonfrail normal weight counterparts, prefrail obese respondents have a 16% (p ≤ 0.001) reduction in the expected functional limitations rate and frail overweight and obese respondents have a 10% (p ≤ 0.01) and 36% (p ≤ 0.001) reduction in the expected functional limitations rate, respectively. In addition, frail obese respondents have a 27% (p ≤ 0.05) reduction in the expected ADL disability rate.


This study's findings suggest that underweight, overweight, and obese status differentially affect the risk for functional limitations and disabilities in IADL and ADL. Among prefrail and frail adults, some excess body weight in later life may be beneficial, reducing the rate of functional limitations and disability.



Kang SH, Park JW, Yoon KW, Do JY. Limb/Trunk Lean Mass Ratio as a Risk Factor for Mortality in Peritoneal Dialysis Patients. J Ren Nutr. 2012 Nov 7. pii: S1051-2276(12)00183-5. doi: 10.1053/j.jrn.2012.09.004. [Epub ahead of print]






This study was performed to determine the clinical relevance of limb/trunk lean mass ratio (LTLM) in continuous ambulatory peritoneal dialysis (CAPD) patients.


This retrospective cohort study included 534 CAPD patients. Body compositions were measured using a dual-energy X-ray absorptiometry apparatus.


In males, the sensitivity and specificity for the diagnosis of sarcopenia were 70.3% and 85.9%, respectively. Respective values in females were 62.3% and 83.8%. The initial low LTLM tertile was associated with mortality in male CAPD patients and in female CAPD patients. Among patients who maintained CAPD for a year, the maintenance of low LTLM tertile was associated with mortality.


LTLM is associated with other lean mass indices, nutritional status, and mortality in CAPD patients. Therefore, LTLM is a novel marker that is useful for the prediction of the nutritional status and mortality in patients with CAPD.




M. E. Levine and E. M. Crimmins. Sarcopenic Obesity and Cognitive Functioning: The Mediating Roles of Insulin Resistance and Inflammation? Current Gerontology and Geriatrics ResearchVolume 2012 (2012), Article ID 826398, doi:10.1155/2012/826398




This study examined the influence of insulin resistance and inflammation on the association between body composition and cognitive performance in older adults, aged 60–69 and aged 70 and older. Subjects included 1127 adults from NHANES 1999–2002. Body composition was categorized based on measurements of muscle mass and waist circumference as sarcopenic nonobese, nonsarcopenic obese, sarcopenic obese, and normal. Using OLS regression models, our findings suggest body composition is not associated with cognitive functioning in adults ages 60–69; however, for adults aged 70 and over, sarcopenia and obesity, either independently or concurrently, were associated with worse cognitive functioning relative to non-sarcopenic non-obese older adults. Furthermore, insulin resistance accounted for a significant proportion of the relationship between cognitive performance and obesity, with or without sarcopenia. Additionally, although high CRP was significantly associated with poorer cognitive functioning in adults ages 60–69, it did not influence the association between body composition and cognitive performance. This study provides evidence that age-related physiological maladaptations, such as metabolic deregulation, which are associated with abdominal fat, may simultaneously contribute to lower cognition and muscle mass, reflecting a degradation of multiple physiological systems.



M. Siervo, et al. Intentional weight loss in overweight and obese individuals and cognitive function: a systematic review and meta-analysis. Obesity Reviews 12, p968–983, 2011





High adiposity in middle age is associated with higher dementia risk. The association between weight loss and cognitive function in older adults is still controversial. A meta-analysis was undertaken to estimate the effectiveness of intentional weight loss on cognitive function in overweight and obese adults. A structured strategy was used to search randomized and non-randomized studies reporting the effect of intentional and significant weight loss on cognitive function in overweight and obese subjects. Information on study design, age, nutritional status, weight-loss strategy, weight lost and cognitive testing was extracted. A random-effect meta-analysis was conducted to obtain summary effect estimates for memory and attention–executive domains. Twelve studies met inclusion criteria. Seven were randomized trials and the remaining five included a control group. A low-order significant effect was found for an improvement in cognitive performance with weight loss in memory (effect size 0.13, 95% CI 0.00–0.26, P = 0.04) and attention/executive functioning (effect size 0.14, 95% CI 0.01–0.27, P < 0.001). Studies were heterogeneous in study design, sample selection, weight-loss intervention and assessment of cognitive function. Weight loss appears to be associated with low-order improvements in executive/attention functioning and memory in obese but not in overweight individuals.



Alagiakrishnan, K, et al., Evaluation and management of oropharyngeal dysphagia in different types of dementia: A systematic review. Arch. Gerontol. Geriatr. (2012), http://dx.doi.org/10.1016/j.archger.2012.04.011










Dysphagia, or swallowing impairment, is a growing concern in dementia and can lead to malnutrition, dehydration, weight loss, functional decline, and fear of eating and drinking as well as a decrease in quality of life (QOL).


The aim of this article is to do a systematic review of the literature to determine the patterns of swallowing deficits in different types of dementia and to look at the usefulness of different diagnostic and management strategies.


An electronic literature search was done using five electronic databases from 1990 to 2011. One thousand and ten records were identified and 19 research articles met the inclusion criteria. These studies were heterogeneous in design and methodology, type of assessment and outcomes, so only descriptive analysis (narrative reporting) was possible.


Prevalence of swallowing difficulties in patients with dementia ranged from 13 to 57%. Dysphagia developed during the late stages of frontotemporal dementia (FTD), but it was seen during the early stage of Alzheimer's dementia (AD). Limited evidence was available on the usefulness of diagnostic tests, effect of postural changes, modification of fluid and diet consistency, behavioral management and the possible use of medications. Use of Percutaneous Endoscopic Gastrostomy (PEG) tubes in advanced dementia, did not show benefit with regards to survival, improvement in QOL, or reduction in aspiration pneumonia. Significant gaps exist regarding the evidence for the evaluation and management of dysphagia in dementia.








1章 サルコペニアの基本















2章 サルコペニアの摂食・嚥下障害







3章 主な疾患・病態の摂食・嚥下リハビリテーション栄養



















R.W. Dal Negro, A. Testa, R. Aquilani, S. Tognella, E. Pasini, A. Barbieri, F. Boschi . Essential amino acid supplementation in patients with severe COPD: a step towards home rehabilitation. Monaldi Archives for Chest Disease, 2012; 77:2, 67-75




P:COPD(GOLD クラス3-4でBMI23未満)の外来患者に

結果ですが、 必須アミノ酸投与群で身体機能、QOLとも有意に改善しました。また、除脂肪体重、筋力、酸素飽和度、血清アルブミン値、認知機能にも改善を認めました。これより、GOLD クラス3-4でBMI23未満の外来COPD患者に対する必須アミノ酸投与は有効という結論です。





Yabunaka K, Konishi H, Nakagami G, Sanada H, Iizaka S, Sanada S, Ohue M. Ultrasonographic evaluation of geniohyoid muscle movement during swallowing: a study on healthy adults of various ages. Radiol Phys Technol. 2012 Jan;5(1):34-9.





Our purpose in this study was to investigate the application of B+M-mode ultrasound (B/M-mode) imaging as a new approach to quantifying activity patterns of the geniohyoid muscles during swallowing and to assess how these patterns differ according to age and gender. Sixty healthy volunteers (30 men, 30 women) were divided into three age groups (20-39, 40-59, 60-79 years). The subjects were then given 10 ml of mineral water. Ultrasonographic imaging was repeated 5 times and measurements were averaged. Simultaneous B/M-mode images were captured at two regions along the lateral geniohyoid muscle wall. All geniohyoid muscle movement was recorded by real-time B/M-mode. In all cases, ultrasonographic images of the geniohyoid muscle movement during swallowing were easily visualized with the use of real-time B/M-mode. The average moving distance and the duration of movement of the geniohyoid muscle during contraction increased gradually with age. There was a significant difference in ultrasonic measurements of the moving distance and the duration of movement during swallowing between males and females in the three age groups (P < 0.05). B/M-mode imaging provides a simple, noninvasive technique for visual assessment of the lateral geniohyoid muscle wall and may provide a clinical method for evaluating swallowing.



Steele CM, Bailey GL, Chau T, Molfenter SM, Oshalla M, Waito AA, Zoratto DC. The relationship between hyoid and laryngeal displacement and swallowing impairment. Clin Otolaryngol. 2011 Feb;36(1):30-6. doi: 10.1111/j.1749-4486.2010.02219.x.






Reduced range of hyoid and laryngeal movement is thought to contribute to aspiration risk and pharyngeal residues in dysphagia. Our aim was to determine the extent to which movements of the hyoid and larynx are correlated in the superior and anterior directions in swallowing, and whether movement range is predictive of penetration-aspiration or pharyngeal residue.


Prospective, single-blind study of penetration-aspiration and pharyngeal residue with objective frame-by-frame measures of hyoid and laryngeal excursion from videofluoroscopy.


Tertiary hospital and rehabilitation teaching hospital.


Twenty-eight participants referred for videofluoroscopy: 13 women, aged 57-77; 15 men, aged 54-70. Individuals with known neurodegenerative diseases or prior surgery to the neck were excluded. Each swallowed three boluses of 40% w/v thin liquid barium suspension.


Two speech-language pathologists independently rated penetration-aspiration, vallecular and pyriform sinus residue. Cervical spine length, hyoid and laryngeal displacement were traced frame-by-frame. Predictive power was calculated.


Cervical spine length was significantly greater in men. Hyoid displacement ranged from 34-63% of the C2-4 distance. Arytenoid displacement ranged from 18-66%, with significantly smaller anterior displacement in men. Positive hyoid-laryngeal movement correlations in both axes were the most common pattern observed. Participants with reduced displacement ranges (≤ first quartile) and with abnormal correlation patterns were more likely to display penetration-aspiration. Those with reduced anterior hyoid displacement and abnormal correlation patterns had a greater risk of post-swallow pharyngeal residues.


It is difficult for clinicians to make on-line appraisals of the extent to which hyoid and laryngeal movement may be contributing to functional swallowing consequences during videofluoroscopy. This study suggests that it is most important for clinicians to discern whether reduced anterior displacement of these structures is contributing to a patient's swallowing impairment. Measures of structural displacement in thin liquid swallowing should be corrected for variations in participant height. Reductions in anterior hyoid and laryngeal movement below the first-quartile boundaries are statistically associated with increased risk for penetration-aspiration and post-swallow residues.










Evelyn B. Parr, Vernon G. Coffey, John A. Hawley. ‘Sarcobesity’: A metabolic conundrum. Maturitas, doi:10.1016/j.maturitas.2012.10.014


この論文の特徴は、サルコペニア肥満をSarcopenic ObesityではなくSarcobesityという造語で示したことだけかもしれません。確かにSarcobesityのほうが言いやすいですが、日本では「サルコペニア肥満」で普及しそうです。


Two independent but inter-related conditions that have a growing impact on healthy life expectancy and health care costs in developed nations are an age-related loss of muscle mass (i.e., sarcopenia) and obesity. Sarcopenia is commonly exacerbated in overweight and obese individuals. Progression towards obesity promotes an increase in fat mass and a concomitant decrease in muscle mass, producing an unfavourable ratio of fat to muscle. The coexistence of diminished muscle mass and increased fat mass (so-called ‘sarcobesity’) is ultimately manifested by impaired mobility and/or development of life-style-related diseases. Accordingly, the critical health issue for a large proportion of adults in developed nations is how to lose fat mass while preserving muscle mass. Lifestyle interventions to prevent or treat sarcobesity include exercise and energy-restricted diets. The optimal energy deficit to reduce body mass is controversial. While energy restriction in isolation is an effective short-term strategy for rapid and substantial weight loss, it results in a reduction of both fat and muscle mass and therefore ultimately predisposes one to an unfavourable body composition. Aerobic exercise promotes beneficial changes in whole-body metabolism and reduces fat mass, while resistance exercise preserves lean (muscle) mass. Current evidence strongly supports the inclusion of resistance and aerobic exercise to complement mild energy-restricted high-protein diets for healthy weight loss as a primary intervention for sarcobesity.




Butler SG, Stuart A, Wilhelm E, Rees C, Williamson J, Kritchevsky S. The effects of aspiration status, liquid type, and bolus volume on pharyngeal peak pressure in healthy older adults. Dysphagia. 2011 Sep;26(3):225-31.




The reasons for aspiration in healthy adults remain unknown. Given that the pharyngeal phase of swallowing is a key component of the safe swallow, it was hypothesized that healthy older adults who aspirate are likely to generate less pharyngeal peak pressures when swallowing. Accordingly, pharyngeal and upper esophageal sphincter pressures were examined as a function of aspiration status (i.e., nonaspirator vs. aspirator), sensor location (upper vs. lower pharynx), liquid type (i.e., water vs. milk), and volume (i.e., 5 vs. 10 ml) in healthy older adults. Manometric measurements were acquired with a 2.1-mm catheter during flexible endoscopic evaluation. Participants (N = 19, mean age = 79.2 years) contributed 28 swallows; during 8 swallows, simultaneous manometric measurements of upper and lower pharyngeal and upper esophageal pressures were obtained. Pharyngeal manometric peak pressure was significantly less for aspirators (mean = 82, SD = 31 mmHg) than for nonaspirators (mean = 112, SD = 20 mmHg), and upper pharyngeal pressures (mean = 85, SD = 32 mmHg) generated less pressure than lower pharyngeal pressures (mean = 116, SD = 38 mmHg). Manometric measurements vary with respect to aspiration status and sensor location. Lower pharyngeal pressures in healthy older adults may predispose them to aspiration.




Merriwether EN, Host HH, Sinacore DR. Sarcopenic indices in community-dwelling older adults. J Geriatr Phys Ther. 2012 Jul-Sep;35(3):118-25. doi: 10.1519/JPT.0b013e31823c4bef.

筋肉量はDEXAで測定して、四肢除脂肪体重÷身長÷身長(ALM/ht²)と骨格筋指数(SMI)でサルコペニアの有無を評価しています。身体機能はmodified Physical Performance Testと歩行速度、下肢筋力は等速性筋力計で評価しました。






Sarcopenic (SP) indices are used to estimate loss of skeletal lean mass and function and to determine the prevalence of SP in older adults. It is believed that older women and men with lower skeletal lean mass will be weaker and have more functional limitations.


(1) To classify community-dwelling older adults using 2 common SP indices: appendicular lean mass/height² (ALM/ht²) and skeletal muscle index (SMI), and (2) to determine each indices value as indicators of lower extremity strength and physical function.


The sample consisted of 154 community-dwelling older adults (111 women and 43 men; mean age = 82.4, SD = 3.6 years; mean body mass index = 25.8, SD = 4.4 kg/m). Each underwent whole-body dual-energy x-ray absorptiometry to assess lean mass. The 9-item modified Physical Performance Test and self-selected walking speed were used to evaluate function. Lower extremity strength was measured bilaterally using isokinetic dynamometry.


The ALM/ht² index classified 75 participants (49%) as SP and 79 (51%) as nonsarcopenic (NSP). The SMI classified 129 participants (84%) as SP and 25 (16%) as NSP. There were no differences in functional measures between groups by gender using either index after classification. The ALM/ht index was more strongly correlated with peak torque of all lower extremity muscle groups (r = 0.276-0.487) compared with the SMI (r = 0.103-0.344). There was no relationship between SP index and physical function.


There were marked differences in how 2 SP indices classified community-dwelling older adults. Lower extremity strength was lower in older women classified as SP than NSP using the ALM/ht index, but LE strength was not different in older men. However, no lower extremity strength differences were observed between SP and NSP men or women using the SMI classification. None of the SP index uniformly identified community-dwelling older adults with functional or strength deficits.


Detection of strength deficits using SP indices alone may be gender-specific and may not reflect strength or functional decline in community-dwelling men aged 80 years or older. Given associations between lower extremity strength and physical function, strength measures remain a better predictor of physical performance than SP indices for community-dwelling older men and women.









Ouppatham Supasyndh, et al. Effect of Oral Anabolic Steroid on Muscle Strength and Muscle Growth in Hemodialysis Patients. Clinical Journal of the American Society of Nephrology, Published online before print November 2012, doi: 10.2215/​CJN.00380112






Background and objectives Sarcopenia is common in hemodialysis patients. This study examined whether the anabolic steroid oxymetholone improves muscle mass and handgrip strength in hemodialysis patients and possible mechanisms that might engender such changes.
Design, setting, participants, & measurements Forty-three eligible hemodialysis patients were randomly assigned to ingest oxymetholone or placebo for 24 weeks. Body composition, handgrip strength, and quality of life were measured during the study. Muscle biopsies were performed and analyzed for mRNA levels for myostatin, IGF-I, IGF binding proteins, and myosin heavy chains and protein expression. Muscle fiber types and diameter were assessed by reduced nicotinamide–adenine dinucleotide staining.
Results There was a significantly greater increase in fat-free mass and handgrip strength and decrease in fat mass in the oxymetholone compared with the placebo group. Moreover, compared with baseline values, patients given oxymetholone exhibited an increase in fat-free mass, handgrip strength, physical functioning scores, and type I muscle fiber cross-sectional area and a decrease in fat mass, whereas patients receiving placebo did not undergo changes. There was a significantly greater increase in muscle mRNA levels for myosin heavy chain 2×, IGF-I, and IGF-II receptor with oxymetholone treatment than placebo. Liver enzyme rose significantly in the oxymetholone group, but the number of values greater than three times the upper limit of normal were not different between these groups.
Conclusions In hemodialysis patients, ingesting oxymetholone was associated with an increase in fat-free mass, handgrip strength, and muscle mRNA levels for several growth factors and a decrease in fat mass, but it also induced liver injury.



Langmore S, Krisciunas GP, Miloro KV, Evans SR, Cheng DM. Does PEG use cause dysphagia in head and neck cancer patients? Dysphagia. 2012 Jun;27(2):251-9. doi: 10.1007/s00455-011-9360-2.







Percutaneous endoscopic gastrostomy (PEG) use is common in patients who undergo radiotherapy (RT) for head and neck cancer to maintain weight and nutrition during treatment. However, the true effect of PEG use on weight maintenance and its potential impact on long-term dysphagia outcomes have not been adequately studied. This retrospective study looked at swallowing-related outcomes among patients who received prophylactic PEG vs. those who did not, and among patients who maintained oral diets vs. partial oral diets vs. those who were nil per os (NPO). Outcomes were assessed at the end of RT and at 3, 6, and 12 months post RT. A comprehensive review of patients' medical charts for a 6-year period yielded 59 subjects with complete data. Results showed no difference in long-term percent weight change between the prophylactic PEG patients vs. all others, or between patients who, during RT, had oral diets vs. partial oral diets vs. NPO. However, those who did not receive prophylactic PEGs and those who maintained an oral or a partial oral diet during RT had significantly better diet outcomes at all times post RT. Dependence on a PEG may lead to adverse swallowing ability in post-irradiated head and neck cancer patients possibly due to decreased use of the swallowing musculature.




Xin Feng, et al. Aging-Related Geniohyoid Muscle Atrophy Is Related to Aspiration Status in Healthy Older Adults. J Gerontol A Biol Sci Med Sci (2012) doi: 10.1093/gerona/gls225 First published online: October 30, 2012





Background. Age-related muscle weakness due to atrophy and fatty infiltration in orofacial muscles may be related to swallowing deficits in older adults. An important component of safe swallowing is the geniohyoid (GH) muscle, which helps elevate and stabilize the hyoid bone, thus protecting the airway. This study aimed to explore whether aging and aspiration in older adults were related to GH muscle atrophy and fatty infiltration.
Method. Eighty computed tomography scans of the head and neck from 40 healthy older (average age 78 years) and 40 younger adults (average age 32 years) were analyzed. Twenty aspirators and 20 nonaspirators from the 40 older adults had been identified previously. Two-dimensional views in the sagittal and coronal planes were used to measure the GH cross-sectional area and fatty infiltration.
Results. GH cross-sectional area was larger in men than in women (p < .05). Decreased cross-sectional area was associated with aging (p < .05), and cross-sectional area was significantly smaller in aspirators compared with nonaspirators, but only among the older men (p < .01). Increasing fatty infiltration was associated with aging in the middle (p < .05) and posterior (p < .01) portions of the GH muscle. There was no significant difference in fatty infiltration of the GH muscle among aspirators and nonaspirators.
Conclusion. GH muscle atrophy was associated with aging and aspiration. Fatty infiltration in the GH muscle was increased with aging but not related to aspiration status. These findings suggest that GH muscle atrophy may be a component of decreased swallowing safety and aspiration in older adults and warrants further investigation.                    



Keevil V, Mazzuin Razali R, Chin AV, Jameson K, Aihie Sayer A, Roberts H. Grip strength in a cohort of older medical inpatients in Malaysia: A pilot study to describe the range, determinants and association with length of hospital stay. Arch Gerontol Geriatr. 2012 Oct 29. pii: S0167-4943(12)00209-9. doi: 10.1016/j.archger.2012.10.005. [Epub ahead of print]





Grip strength is a marker of sarcopenia, the age-related decline in muscle mass and function, and has been little researched in Asian populations. We aimed to describe the feasibility and acceptability of measuring grip strength in hospitalized, older people in Malaysia and to explore its range, determinants and association with length of stay. Patients admitted acutely to the geriatrics ward of a teaching hospital were consecutively recruited. Inability to consent or use the dynamometer led to exclusion. Maximum grip strength, anthropometric data, length of hospital stay, discharge destination, 3-point Barthel score, mini-mental state examination, falls history and number of co-morbidities and medications on admission were recorded. 80/153 (52%) eligible patients were recruited (52 women; age range 64-100 years). 9/153 (6%) refused to participate and 64/153 (42%) were excluded (34 too unwell, 24 unable to consent, 4 unable to use the dynamometer, 2 other reasons). 76/80 patients (95%) reported that they would undergo grip strength measurement again. Determinants were similar to those of Caucasian populations but grip strength values were lower. After adjustment for sex, age and height, stronger grip strength was associated with shorter length of stay [hazard ratio 1.05 (95% CI 1.00, 1.09; P=0.03)]. This is the first report of grip strength measurement in hospitalized older people in Malaysia. It was feasible, acceptable to participants and associated with length of stay. Further research is warranted to elucidate the normative range in different ethnic groups and explore its potential use in clinical practice in Malaysia.



Chalé A, Cloutier GJ, Hau C, Phillips EM, Dallal GE, Fielding RA. Efficacy of Whey Protein Supplementation on Resistance Exercise-Induced Changes in Lean Mass, Muscle Strength, and Physical Function in Mobility-Limited Older Adults. J Gerontol A Biol Sci Med Sci. 2012 Oct 31. [Epub ahead of print]







Whey protein supplementation may augment resistance exercise-induced increases in muscle strength and mass. Further studies are required to determine whether this effect extends to mobility-limited older adults. The objectives of the study were to compare the effects of whey protein concentrate (WPC) supplementation to an isocaloric control on changes in whole-body lean mass, mid-thigh muscle cross-sectional area, muscle strength, and stair-climbing performance in older mobility-limited adults in response to 6 months of resistance training (RT).


Eighty mobility-limited adults aged 70-85 years were randomized to receive WPC (40g/day) or an isocaloric control for 6 months. All participants also completed a progressive high-intensity RT intervention. Sample sizes were calculated based on the primary outcome of change in whole-body lean mass to give 80% power for a 0.05-level, two-sided test.


Lean mass increased 1.3% and 0.6% in the WPC and control groups, respectively. Muscle cross-sectional area was increased 4.6% and 2.9% in the WPC and control groups, respectively, and muscle strength increased 16%-50% in WPC and control groups. Stair-climbing performance also improved in both groups. However, there were no statistically significant differences in the change in any of these variables between groups.


These data suggest that WPC supplementation at this dose does not offer additional benefit to the effects of RT in mobility-limited older adults.