カルシウム摂取量とサルコペニア

カルシウム摂取量とサルコペニアの関連をみた論文を紹介します。

Seo MH, Kim MK, Park SE, Rhee EJ, Park CY, Lee WY, Baek KH, Song KH, Kang MI, Oh KW. The association between daily calcium intake and sarcopenia in older, non-obese Korean adults: the fourth Korea national health and nutrition examination survey (KNHANES IV) 2009. Endocr J. 2013 Jan 26. [Epub ahead of print]

対象は正常体重の高齢者1339人です。サルコペニアは四肢骨格筋量÷体重が若年の2SD以下の場合としています。結果ですが、カルシウム摂取量は体脂肪率と負の相関、四肢骨格筋量と正の相関をそれぞれ認めました。サルコペニアの高齢者は夕にカルシウム摂取量が少なかったです。

カルシウム摂取量で3群に分類すると、サルコペニアの有病割合は、少ない群で6.3%、中央群で4.3%、多い群で2.7%でした。年齢、性別、BMI、総エネルギー摂取量、ライフスタイルで調整後も、カルシウム摂取とサルコペニアに独立した関連を認めました。

カルシウム摂取量とサルコペニアに関連を認めることは納得できますが、因果関係ではないと思います。カルシウム摂取不足が顕著なサルコペニアの高齢者に、カルシウムのサプリメントを使用することはありえます。カルシウム投与がサルコペニア治療に有用とは考えにくいです。

Abstract

Recent data suggest that variations in calcium intake may influence body weight and composition; however, the relationship between daily calcium intake and muscle mass has not been well established. The objective of this study was to assess the relationship between daily calcium intake and sarcopenia. We analyzed data for older adults (over 60 years) from the fourth Korea National Health and Nutrition Examination Survey (KNHANES) conducted in 2009. A total of 1339 Non-Obese (BMI between 18.5 and 25 kg/m(2)), older adults (592 men and 707 women) were enrolled. Dietary variables were assessed using a nutrition survey that used a 24-hour recall method. Daily calcium intake based on the consumption of each food item was calculated. Sarcopenia was defined as an appendicular skeletal muscle mass divided by body weight less than 2 SD below the sex-specific mean for young adults. We found that daily calcium intake was negatively correlated with total body fat percentage and positively correlated with appendicular skeletal mass (p<.001). Participants with sarcopenia
appear to have significantly lower daily calcium intakes than participants without sarcopenia (p<.001) The unadjusted prevalence of sarcopenia according to daily calcium intake tertiles were 6.3%, 4.3%, and 2.7% in tertiles 1, 2, and 3, respectively. After adjustment for age, sex, BMI, total energy intake, and lifestyle factors, compared with those in the lowest tertile of daily calcium intake, participants in the highest tertile had an odds ratio for sarcopenia of 0.295 (95% confidence interval, 0.087-0.768; p for trend = 0.014). We found that daily calcium intake, corrected for total energy intake and serum 25(OH)D status, was significantly lower in subjects with sarcopenia than in those without. Our results suggest a strong inverse association between daily calcium intake and sarcopenia in non-obese, older Korean adults.

リハ栄養フォーラム2013

 

 

リハ栄養フォーラム2013の案内をさせていただきます。今年は全国10か所で、クリニコさん共催でリハ栄養フォーラムを開催することになりました。この企画は、リハ栄養セミナーとは異なり、日本リハビリテーション栄養研究会の会員でなくても参加可能です。

私は8月3日の広島、8月4日の福岡、8月24日の金沢、8月25日の東京、9月28日の高松でリハ栄養総論の講演をさせていただきます。多くの方にお近くのリハ栄養フォーラムに参加していただけると嬉しいです。よろしくお願い申し上げます。

コアマッスル減少と食道がん術後予後

コアマッスルの筋肉量減少は食道がん術後の生存期間悪化と関連するという論文を紹介します。

K. H. Sheetz, et al. Decreased core muscle size is associated with worse patient survival following esophagectomy for cancer. Diseases of the Esophagus, Article first published online: 25 JAN 2013, DOI: 10.1111/dote.12020

対象は非開胸食道切除術を施行した食道がん患者230人です。コアマッスルの筋肉量は、腹部CTでL4椎体レベルの腰筋（大腰筋）の筋肉量で評価しました。結果ですが、単変量解析では筋肉量は全体の生存期間と無病生存期間と有意な関連を認めました。

多変量解析では、術前補助療法を行わなかった64人で、筋肉量は全体の生存期間と無病生存期間と有意な関連を認めました。がんのステージ分類と同等以上に重要でした。一方、術前補助療法を行わなかった166人では、筋肉量と生存期間に有意な関連を認めませんでした。

以上より、コアマッスルの筋肉量は全体の生存期間と無病生存期間の独立した予測因子と思われるという結論です。術前の治療による筋肉量変化が交絡となっている可能性があります。術前のコアマッスルの筋肉量評価は、より客観的なリスク重症度分類に有用かもしれません。

消化器がんではCTを行いますので、コアマッスルのみにせよ全体の筋肉にせよ、その気になれば筋肉量評価が可能であり、行うべきだと考えます。これによって予後予測だけでなく、Prehabilitationを行ったほうがよい患者と行わなくてもよい患者を判別できる可能性があるのではと感じます。

Summary
Preoperative risk assessment, particularly for patient frailty, remains largely subjective. This study evaluated the relationship between core muscle size and patient outcomes following esophagectomy for malignancy. Using preoperative computed tomography scans in 230 subjects who had undergone transhiatal esophagectomy for cancer between 2001 and 2010, lean psoas area (LPA), measured at the fourth lumbar vertebra, was determined. Cox proportional hazards regression was employed to analyze overall survival (OS) and disease-free survival (DFS) adjusted for age, gender, and stage, and the Akaike information criterion was used to determine each covariate contribution to OS and DFS. Univariate analysis demonstrated that increasing LPA correlated with both OS (P = 0.017) and DFS (P = 0.038). In multivariate analysis controlling for patient and tumor characteristics, LPA correlated with OS and DFS in patients who had not received neoadjuvant treatment (n = 64), with higher LPA associated with improved OS and DFS. Moreover, LPA was of equivalent, or slightly higher importance than pathologic stage. These measures were not predictive among patients (n = 166) receiving neoadjuvant chemoradiation. Core muscle size appears to be an independent predictor of both OS and DFS, as significant as tumor stage, in patients following transhiatal esophagectomy. Changes in muscle mass related to preoperative treatment may confound this effect. Assessment of core muscle size may provide an additional objective measure for risk stratification prior to undergoing esophagectomy.

筋肉量とIADL低下のリスク

筋肉量と機能低下のリスクを地域在住高齢女性で調査した前向きコホート研究（EPIDOS Study）を紹介します。

Isabelle Amigues, et al. Low Skeletal Muscle Mass and Risk of Functional Decline in Elderly Community-Dwelling Women: The Prospective EPIDOS Study. Association, Available online 18 January 2013, http://dx.doi.org/10.1016/j.jamda.2012.12.002

EPIDOS Studyという骨粗鬆症の前向きコホート研究のデータを活用した二次研究です。対象は研究参加者の75歳以上の障害のない女性で、筋肉量のデータがあった975人です。筋肉量はDEXAで評価し、機能低下はIADLの1つ以上の障害と定義しています。

結果ですが4年間のフォローで452人(46.4%)に機能低下を認めました。多変量解析で機能低下と関連を認めた因子は、筋肉量、高齢、1つ以上の併存疾患、椅子立ち上がりテストの障害でした。

筋肉量で4群に分けると、下から2番目の群で機能低下と有意に関連があり、最も下の群で有意な傾向でした。機能低下と負の関連（要するに機能低下しにくい）を認めた因子は、独居、握力高値、歩行速度でした。

以上より、年齢、筋力、身体機能、併存疾患で調整した後も、筋肉量低下は4年後の機能低下と独立した関連を地域在住高齢女性で認めるという結論です。

筋力だけでなく筋肉量低下が独立してIADLの障害と関連するというのは意味があると考えます。ただ、95%信頼区間（1SD低下で1.01–1.24)を見るとかろうじて統計学的有意差があるという結果です。臨床的に強い関連があるとは言えないかもしれません。

Abstract

Objectives

To assess relationships between low skeletal muscle mass (SMM) and functional decline in community-dwelling elderly women.

Design

Secondary analysis of data from EPIDOS, a French prospective observational multicenter cohort study of osteoporosis epidemiology.

Setting

One center in France between 1992 and 1994.

Participants

Women aged 75 years or older without disability and with available baseline SMM measurements.

Measurements

SMM was assessed using dual-energy X-ray absorptiometry and functional decline was defined as loss of at least one Instrumental Activity of Daily Living component. Associations linking low SMM to functional decline were estimated using the Cox proportional hazards model.

Results

Of 975 women followed for 4 years, 452 (46.4%) experienced functional decline. Factors independently associated with functional decline were decreased SMM (adjusted hazard ratio [aHR] per SD decrease, 1.12; 95% confidence interval [95% CI], 1.01–1.24), older age (aHR per SD increase, 1.28; 95% CI, 1.17–1.39), one or more comorbidities (aHR, 1.65; 95%CI, 1.05–2.59), and impaired chair-stand test (aHR, 1.35; 95% CI, 1.01–1.82). The second SMM quartile was associated with functional decline (aHR, 1.39; 95% CI, 1.06–1.84) and the lowest quartile showed a nearly significant association (aHR, 1.29; 95% CI, 0.98–1.72). Factors negatively associated with functional decline were living alone (aHR, 0.76; 95% CI, 0.59–0.96), higher handgrip strength (aHR per SD increase, 0.88; 95% CI, 0.78–0.88), and walking speed (aHR per SD increase, 0.86; 95% CI, 0.77–0.96).

Conclusion

Low SMM was independently associated with functional decline within 4 years after adjustment for age, muscle strength, physical performance, and comorbidities in community-dwelling elderly women.

終末期肝疾患のCT身体組成評価

腹部CTで終末期肝疾患の身体組成を評価した論文を紹介します。

Cruz RJ Jr, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Fontes P, Dimartini A. Objective Radiologic Assessment of Body Composition in Patients with End-Stage Liver Disease: Going Beyond the BMI. Transplantation. 2013 Jan 23. [Epub ahead of print]

対象は肝移植を希望している234人の終末期肝疾患患者です。結果ですが、BMIは皮下脂肪、内臓脂肪と高い相関を認めました。しかし、筋肉量で評価した悪液質を肥満患者でもよく認めました。BMI30以上の患者の56%が悪液質でした。

非アルコール性脂肪肝炎では他の肝疾患と比較して、内臓脂肪がより多く筋肉量がより少なかったです。探索的解析では、身長で補正した筋肉量は、肝移植後の生存期間の有意な予測因子でした。腹部CTは肥満と筋肉減少の評価に有用で、予後予測にはさらなる研究が必要という結論です。

肝疾患患者で筋肉量が少ないことは、臨床的に十分納得できます。BMIでの評価だけでは不十分で、検査機器で体組成を評価すべきです。重症な肝疾患であれば必ず腹部CTを行っているでしょうから、腹部CTによる評価がルーチンとなればいいなあと思います。

Abstract

BACKGROUND:

Body mass index (BMI) is a commonly used but likely inexact measure of body composition for patients with end-stage liver disease. For this reason, we examined whether body composition measurements from direct visualization on computed tomography (CT) scans provide new insights in both the degree of malnutrition and the discordant combinations such as obesity with muscle mass loss. This technology is widely used in other medically ill populations but not yet in liver transplantation.

METHODS:

We examined actual body composition using abdominal CT scan data and software designed to measure fat and muscle compartments.

RESULTS:

In 234 liver transplant candidates, we found that BMI was highly and significantly correlated to subcutaneous and visceral fat. However, we additionally found that, even among obese patients, cachexia, as defined by muscle mass, was common, with 56% of those with BMI above 30 being cachexic. We also found that patients with nonalcoholic steatohepatitis, compared with other types of liver diseases, were significantly more likely to have larger amounts of visceral fat while also having less muscle. In an exploratory analysis, muscle mass corrected for height was a significant predictor of posttransplantation survival.

CONCLUSIONS:

Body composition by CT scan data provides a specific method to identify obesity and muscle wasting for end-stage liver disease patients. Whether these data can aid in the prognostication of outcomes and survival requires further investigation.

TKAとTHAの術前理学療法：系統的レビュー

人工膝関節置換術（TKA）と人工股関節置換術（THA）の術前の理学療法は術後のアウトカムを改善するか？という系統的レビューを紹介します。

Justina A. Gawel, Sarah E. Brown, Jenna C. Collins, Christine McCallum. Does pre-operative physical therapy improve post-surgical outcomes of patients undergoing a total knee and/or total hip arthroplasty? A systematic review. Physiotherapy Practice and Research, Volume 34, Number 1 / 2013, p9-20

10のRCT論文をレビューしています。結果ですが、TKA、THAとも術前理学療法群でリハ施設への転院が減少し、疼痛が減少し、患者満足度が向上しました。しかし機能予後に関しては一致した見解を認めませんでした。アウトカムの改善はまだ結論が出ていません。

プレハビリテーションは対象を選べば有用だと私は考えています。しかし、万人に行っても有意差を出すことはおそらく容易ではないと思います。プレハビリテーションを行うべき対象（患者と疾患・術式）を選定して、その中でRCTを行うのが望ましいのではと感じます。

Abstract
Background and purpose: Pre-operative physical therapy (PT) has been used in clinical practice to improve post-surgical outcomes after a total hip and/or knee replacement. The purpose of this systematic literature review was to investigate the ability of pre-operative physical therapy to improve post-surgical outcomes of patients undergoing a total knee and/or total hip arthroplasty. Methods: This review used the search engines PubMed, CINAHL, Cochrane library and the PEDro database and investigated all articles that studied the influence of pre-operative therapy on post-surgical results in patients that underwent a total knee and/or total hip arthroplasty. The studies included were randomized controlled trials (RCTs), English written, and compared pre-surgical outcomes to post-surgical outcomes in physical therapy interventions. Quality scoring was assessed using the PEDro scale for RCTs. Results: Ten articles met the inclusion criteria. The quality score ranged from 4–7 on the PEDro scale. Results found pre-operative PT in both total knee and total hip arthroplasty reduced the risk of discharge to a rehabilitation facility. Pain reduction (p < 0.05) was found with pool interventions versus land interventions immediately following an exercise session. Discussion: The results indicate there were benefits in the use of pre-operative PT on improving patient satisfaction, pain reduction, and discharge to a lower cost of care setting. The use of pre-operative physical therapy resulted in mixed findings in functional outcomes however. Conclusions: This updated systematic review suggests the current literature on pre-operative physical therapy is inconclusive regarding impact of improving post-surgical outcomes on patients receiving total knee and/or hip arthroplasty.

ICU看護の早期離床プロトコール

ICUでの看護による早期離床プロトコールの研究を紹介します。

Zomorodi M, Topley D, McAnaw M.　Developing a mobility protocol for early mobilization of patients in a surgical/trauma ICU.　Crit Care Res Pract. 2012;2012:964547. doi: 10.1155/2012/964547.

下記のHPで全文見ることができます。

http://www.hindawi.com/journals/ccrp/2012/964547/

ICUでの早期離床はリスクがないわけではありませんが、人工呼吸器管理下でも安全に実現可能というエビデンスがあります。このような患者は廃用性筋萎縮のリスクが高いので、重症患者看護師による早期離床プロトコールの実践は重要です。

当パイロット研究では、早期離床プロトコールの安全性と実現可能性を検証しています。3人の患者さんで行っただけですので本当にパイロット研究ですが、早期離床プロトコールを各施設で導入するためには必要な過程だと思います。

Abstract

As technology and medications have improved and increased, survival rates are also increasing in intensive care units (ICUs), so it is now important to focus on improving the patient outcomes and recovery. To do this, ICU patients need to be assessed and started on an early mobility program, if stable. While the early mobilization of the ICU patients is not without risk, the current literature has demonstrated that patients can be safely and feasibly mobilized, even while requiring mechanical ventilation. These patients are at a high risk for muscle deconditioning due to limited mobility from numerous monitoring equipment and multiple medical conditions. Frequently, a critically ill patient only receives movement from nurses; such as, being turned side to side, pulled up in bed, or transferred from bed to a stretcher for a test. The implementation of an early mobility protocol that can be used by critical care nurses is important for positive patient outcomes minimizing the functional decline due to an ICU stay. This paper describes a pilot study to evaluate an early mobilization protocol to test the safety and feasibility for mechanically ventilated patients in a surgical trauma ICU in conjunction with the current unit standards.