IAGGのpress article

6月にソウルで開催されたIAGG(国際老年学会)で発表した内容が、press articleとしてネスレヘルスサイエンスのHPにアップされました。vicious cycle of dysphagia-sarcopenia-dysphagiaがキーワードです。



The vicious cycle of dysphagia-sarcopenia-dysphagia
Dysphagia is a key cause of malnutrition leading to sarcopenia. But sarcopenia itself may weaken the muscles involved in swallowing, and lead to more severe dysphagia and the related risks of aspiration and pneumonia6. The importance of dysphagia management in the rehabilitation of frail elderly was addressed by Dr Hidetaka Wakabayashi of Yokohama City University Medical Center, Department of Rehabilitation Medicine, Japan. In a study of Japanese older adults with swallowing difficulty, sarcopenic dysphagia was suggested by an association between thin mid-upper arm circumference and poor swallowing function7. “A general reduction in lean body mass including those muscles involved in swallowing is responsible for this association” explained Dr Wakabayashi. These results suggest the novel concept of sarcopenic dysphagia; “however, a definition and diagnostic criteria are yet to be established”.

Screen for malnutrition and dysphagia to help those under threat of adverse events
An estimated 75% of dysphagia sufferers are undiagnosed, so Dr Wakabayashi emphasized the importance of identifying those elderly people at risk of, or already suffering from, dysphagia and malnutrition. The gold standard for screening elderly for malnutrition is the Mini Nutritional Assessment (MNA®), a simple 6-item questionnaire on appetite, weight loss, mobility, acute disease, depression/dementia and body mass index or calf circumference8. Dr Wakabayashi described a new dysphagia screening tool that has recently been developed: the 10-item Eating Assessment Tool (EAT-10). EAT-10 is a questionnaire comprising 10 questions measuring a person’s perceptions of swallowing difficulty. It is designed to rapidly identify dysphagia symptom severity. A score of three or higher indicates dysphagia risk.

 An EAT-10 validation study has been conducted in a Japanese population of 393 frail elderly people (130 men, 263 women), with a mean age of 83 years. The results, publication in press, were described. Only 21% (n=82) of respondents had normal swallowing; 44% (n=172) had dysphagia with aspiration (material in the airway) and 35% (n=139) had dysphagia without aspiration. “Although more testing is required, I am confident that the high sensitivity and specificity of EAT-10 will make it an effective tool for future routine screening for dysphagia” said Dr Wakabayashi. Rehabilitation is the next step for those people identified to suffer dysphagia, and multidomain intervention with oral hygiene, resistance exercise, and modified foods and liquids is important to combat sarcopenic dysphagia, prevent pneumonia, and avoid the spiral of decline into severe frailty.

Key References
6. Wakabayashi H, Fujimoto A. Dysphagia due to sarcopenia: potential and practice of rehabilitation nutrition. 2012. Ishiyaku, Tokyo [Japanese]
7. Kuroda Y, Kuroda R. Relationship between thinness and swallowing function in Japanese older adults: implications for sarcopenic dysphagia. J Am Geriatr Soc. 2012;60(9):1785-6.




Julie A. Y. Cichero, et al. The Need for International Terminology and Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia Management: Foundations of a Global Initiative. Current Physical Medicine and Rehabilitation Reports, doi: 10.1007/s40141-013-0024-z



嚥下調整食は国内では日本摂食・嚥下リハ学会が基準化に向けて活動していますが、国際的にはInternational Dysphagia Diet Standardisation Initiative (IDDSI)が活動しそうです。



The Japanese Society of Dysphagia Rehabilitation
(JSDR) appears to be the most advanced in providing
measurable specifications for both liquids and foods. The
JSDR is also in the process of converting rheological
measures for liquids expressed in mPa s to line-spread
measure values (cm) [41]. The Japanese system of identifying
texture-modified foods is very advanced, incorporating
energy content (kcal), protein (g) and measures of
hardness, adhesiveness and cohesiveness for each food
level. Measures are also differentiated on whether the food
is served cold (15 C) or warm (45 C). With extremely
texture-modified foods, Japanese clinicians also determine
whether pure´e or jelly textures are safer or easier to
swallow. The Japanese system also includes a recommendation
for 30–40 % weight/volume for barium sulfate to be
added to foods/liquids to ensure substances are radiopaque
for videofluoroscopy examination. Addition rates of locally
available thickening agents (gels, powder thickener, agar)
per 100 ml liquid barium are also available.



 Conservative estimates suggest that dysphagia
(difficulty swallowing) affects approximately 8 % of the
world’s population. Dysphagia is associated with malnutrition,
dehydration, chest infection and potentially death.
While promising treatments are being developed to
improve function, the modification of food texture and
liquid thickness has become a cornerstone of dysphagia
management. Foods are chopped, mashed or pure´ed to
compensate for chewing difficulties or fatigue, improve
swallowing safety and avoid asphyxiation. Liquids are
typically thickened to slow their speed of transit through
the oral and pharyngeal phases of swallowing, to avoid
aspiration of material into the airway and improve transit to
the esophagus. Food texture and liquid modification for
dysphagia management occurs throughout the world.
However, the names, the number of levels of modification
and characteristics vary within and across countries. Multiple
labels increase the risk to patient safety. National
standardization of terminology and definitions has been
promoted as a means to improve patient safety and interprofessional
communication. This article documents the
need for international standardized terminology and definitions
for texture-modified foods and liquids for individuals
with dysphagia. Furthermore, it documents the
research plan and foundations of a global initiative dedicated
to this purpose.






 横浜市立大学附属市民総合医療センター 若林秀隆
 京都府立医科大学附属病院 安江友世

 筑波大学 日高紀久江
 浅草病院 建宮実和

 宇治徳洲会病院 岡田裕子
 仁風会日高病院 英 裕子
 協立総合病院 近藤奈美

 湯布院厚生年金病院 木本ちはる






















ISRNM(国際腎臓栄養代謝学会)による慢性腎臓病(CKDのStage3~5)のPEW(protein energy wasting) の予防と治療に関するコンセンサス論文を紹介します。

Ikizler TA, Cano NJ, Franch H, Fouque D, Himmelfarb J, Kalantar-Zadeh K, Kuhlmann MK, Stenvinkel P, Terwee P, Teta D, Wang AY, Wanner C. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 2013 May 22. doi: 10.1038/ki.2013.147. [Epub ahead of print]




Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.Kidney International advance online publication, 22 May 2013; doi:10.1038/ki.2013.147.


dysmobility syndrome

骨粗鬆症、サルコペニア、肥満(サルコペニア肥満)を別々に評価せず、で障害、転倒、骨折のリスクが高い高齢者をdysmobility syndromeと呼ぼうという論文です。内容的には日本のロコモに似ている気もします。リハ栄養でも重要です。


Binkley N, Krueger D, Buehring B: What's in a name revisited: should osteoporosis and sarcopenia be considered components of "dysmobility syndrome?" Osteoporos Int. 2013 Aug 1. [Epub ahead of print]

Sarcopenia and osteoporosis are age-related declines in the quantity and quality of muscle and bone respectively, with shared pathogeneses and adverse health consequences. Both absolute and relative fat excess, i.e., obesity and sarcopenic obesity, contribute to disability, falls, and fractures. Rather than focusing on a single component, i.e., osteoporosis, sarcopenia, or obesity, we realized that an opportunity exists to combine clinical factors, thereby potentially allowing improved identification of older adults at risk for disability, falls, and fractures. Such a combination could be termed dysmobility syndrome, analogous to the approach taken with metabolic syndrome. An arbitrary score-based approach to dysmobility syndrome diagnosis is proposed and explored in a small cohort of older adults. Further evaluation of such an approach in large population-based and prospective studies seems warranted.