Malnutrition and Sarcopenia

Abstract

Malnutrition caused by aging or disease can be defined as a state resulting from the lack of intake or uptake of nutrition, which leads to a change in body composition and the consequent impairment of physical and mental functions. Sarcopenia is a geriatric syndrome characterized by a progressive loss of skeletal muscle mass, strength, and performance. In this chapter, we (a) summarize the relationship between malnutrition and sarcopenia in various subjects, (b) review nutritional epidemiological evidence related to the prevention of sarcopenia, and (c) show evidence for the efficacy of nutrient supplementation in attenuating muscle atrophy in several patients. Malnutrition is closely related to severe sarcopenia, especially in older hospitalized adults, patients with chronic kidney disease (CKD), those undergoing hemodialysis, and those with cancer. Healthy diets (i.e., those ensuring a sufficient intake of beneficial foods, such as vegetables, fish, nuts, fruits, low-fat foods, and whole-grain products) are useful in preventing sarcopenia. The Mediterranean diet is a particularly healthy diet, but other diets, such as the healthy Nordic diet and traditional Asian diet, also help attenuate sarcopenia in older adults. Proteins, vitamins, minerals, and n-3 polyunsaturated fatty acids are important nutrients for patients with CKD, those on hemodialysis, and those with cancer.

1. Introduction

Adequate nutrition is important for all generations, especially the elderly, and is known to contribute significantly not only to maintaining good health and reducing the risk of chronic diseases but also to prevent future diseases [1, 2, 3]. The risk for malnutrition increases with age and is often attributed to inadequate recommended nutrient intake. Malnutrition in the elderly exacerbates their risk of developing several health problems and chronic diseases, such as sarcopenia and cardiovascular disease [4]. There is an ever-increasing need to implement nutritional screening as a method of routine health screening for older patients. Malnutrition in the elderly tends to be overlooked owing to physical and physiological changes associated with aging [5, 6]. There are three main approaches to nutritional assessment—the use of physiological and clinical indicators; a connection of physical measurements, motor skills, and cognitive status; and self-perception of health and nutrition [7].

The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends that individuals at risk for malnutrition be identified using defined screening tools. Moreover, the diagnosis of malnutrition should be made by a composite finding of either a low body mass index (BMI) value (<18.5 kg/m²) or a low fat-free mass index, with BMI cutoffs for age, weight loss, and sex [8]. The Global Leadership Initiative on Malnutrition (GLIM) was formed by the world’s leading clinical nutrition societies. A two-step approach was opted to diagnose malnutrition: first, screening to identify “at risk” conditions; and second, assessment to diagnose and grade the severity of malnutrition. Diagnostic assessment includes three phenotypic criteria (low BMI, nonvolitional weight loss, and decreased muscle weight) and two classifications by etiology (inflammation or disease burden and reduced food intake or assimilation) (Table 1).

Risk screening	At risk for malnutrition; Use validated screening tools
Diagnostic assessment	Assessment criteria; Phenotypic; Non-volitional weight loss; Low BMI; Reduced muscle mass; Etiologic; Reduced food intake or assimilation; Inflammation or disease burden
Diagnosis	Meets criteria foy malnutrition diagnosis; Requires at least 1 phenotypic criterion; and 1 etiologic criterion
Severity grading	Determine severity of malnutrition; Severity determined based on phenotypic criterion

Table 1.

GLIM diagnostic scheme for screening, assessment, diagnosis and grading malnutrition.

Recently, Maeda et al. have reported the optimal BMI threshold for identifying severe malnutrition using the GLIM criteria and the prevalence of malnutrition by GLIM definition in clinical practice [9]. Patients with GLIM-defined malnutrition were found to exhibit significantly higher inpatient mortality compared to patients with adequate nutritional intake. On the contrary, Clark et al. compared the prevalence of and risk for malnutrition in patients admitted to a subacute geriatric rehabilitation facility using both GLIM and ESPEN criteria [10]. According to the GLIM criteria, approximately half of the elderly rehabilitation patients were malnourished. However, when the ESPEN definition was applied, the prevalence of malnutrition was found to be much lower. The authors suggest that various studies are needed to clarify the diagnostic accuracy of the GLIM and ESPEN criteria. Furthermore, overlap with syndromes such as cachexia and sarcopenia should be identified, and information dissemination and validation studies should be accelerated with the cooperation and support of nutrition-related professional societies.

2. Sarcopenia

Sarcopenia is defined as age-related loss of skeletal muscle mass, function, and strength [11]. Four years ago, the European Working Group on Sarcopenia in Older People (EWGSOP) revised the definition of sarcopenia [12]. The revised version proposed a simple decision tree for diagnosing sarcopenia (Figure 1). The most significant part of this revision is that muscle strength and function are the primary factors considered, which shows that they are more important than muscle mass [13].

Figure 1.

Decision tree for the diagnosis of sarcopenia.

Handgrip strength is used as an indicator of muscle strength. The simple and available methods of assessing physical ability contain the short physical performance battery and walking speed measurement that combines the get-up-and-go test, walking speed, and a balance measurement [14]. In addition, a sarcopenia-screening questionnaire is useful for patients over 65 years of age [15].

Approximate muscle weight can be estimated from simple measurements that calculate the corrected arm muscle area after measuring the skin thickness of the triceps skinfold thickness [16]. The bioimpedance method has the advantage of rapidly measuring lean body mass, but it cannot assess muscle volume directly. Data from dual-energy X-ray absorptiometry is typically utilized to calculate a skeletal muscle volume by correcting four limbs lean body mass by height or BMI [15, 17].

A remarkable decline in muscle strength (2.5%–3.0% per year) and mass (approximately 1% per year) has been reported in those over age 60 [18]. The prevalence of sarcopenia in people aged 65–70 years is 13–24%, and in those >80 years of age, it is >50% [19]. The prevalence of sarcopenia based on sex in individuals aged the 60s is 80% in women and 10% in men, whereas, in those >80 years of age, it is 18% in women and 40% in men [20].

Sarcopenia exerts major adverse effects on metabolism, function, mortality, and morbidity. The condition is associated with quality-of-life impairments, osteoporosis, functional disabilities, falls, metabolic syndrome, cardiovascular disease, and other problems. Loss of both muscle function and muscle mass increases mortality by 3.7-fold [21] and increases the risk of falls by 2-fold [22].

The muscle is a biocontractile organ that enables movement by applying force to the bone. Muscle is essential for metabolic homeostasis because of its critical role in energy production, lipid oxidation, amino acid release, glycogen storage, and glucose uptake. In addition, muscle is indirectly involved in mediating immune responses and is also a reservoir of amino acids that can be used by immune cells and other cells. Although the molecular and cellular mechanisms of sarcopenia require clarification, certain common biological mechanisms, such as oxidative stress, mitochondrial dysfunction, hormonal regulation impairment, nutritional deficiency, and inflammation, have been suggested to be involved. Therefore, sarcopenia needs a multimodal management approach that combines nutrition, exercise, and anabolic and anti-inflammatory drugs (Figure 2).

Figure 2.

Mechanisms underlying sarcopenia.

3. Malnutrition and sarcopenia

The relationship between malnutrition and sarcopenia has been investigated in a range of subjects, particularly in studies published in the last 10 years, all of which concluded that malnutrition is strongly correlated with severe sarcopenia. We reviewed articles published after 2015, with a minimum of 67 subjects, that statistically revealed an association between malnutrition and sarcopenia (Table 2).

Reference	Population	Malnutrition prevalence	Sarcopenia prevalence	Findings
Dolores et al. [23]	411 community-dwelling heathy adults over 65 years old	7.3% (n = 30) by the ESPEN criteria, 23.4% (n = 96) by the GLIM criteria	3.9% (n = 16) by the European Working Group on Sarcopenia in Older people 2 criteria	Malnutrition was associated with an approximately fourfold higher risk of developing sarcopenia during 4-year follow up.
Gerdien et al. [24]	2506 older hospitalized adults	28.7% (n = 719) in malnourished, 47.2% (n = 1182) in risk of malnutrition	46.9% (n = 1175), including 41.6% (n = 1043) the overlapping prevalence of sarcopenia with malnutrition	The association between and prevalence of pre-frailty or sarcopenia and risk of malnutrition in older hospitalized adults in substantial.
Sato et al. [25]	77 ± 2 years in the older adults (n = 27) and 86 ± 4 years in the long-living older adults (n = 73)	Normal nutritional status in the older adults, nutritional risk in the long-loving older adults	45% (n = 45), most of these were from the long-living older adults (n = 38)	Older adults with malnutrition or at nutritional risk ran 13 times higher risk of sarcopenia.
Verstraeten et al. [26]	78–88 years in geriatric rehabilitation inpatients (n = 506)	51% (n = 257) by the GLIM criteria	49% (n = 250) in probable sarcopenia, 0.4% in confirmed sarcopenia (non-severe) (n = 2) and 19% (n = 94) in severe sarcopenia	23% had both malnutrition and probable sarcopenia, 0.2% had both malnutrition and confirmed sarcopenia (non-severe) and 13% had both malnutrition and severe sarcopenia.
Dolores et al. [27]	Older patients (84 ± 9 years) admitted to the post-acute geriatric care unit for functional loss resulted from a non-disabling medical disease (n = 88)	19.3% (n = 17) by the new ESPEN diagnostic criteria	37.5% (n = 33) in sarcopenia	The prevalence of sarcopenia was significantly higher in patients with malnutrition: 82.3% vs. 45.1%.
Beatriz et al. [28]	n = 339 sarcopenic primarily independent-living older adults, 85 ± 8 years	32.4% (n = 110) in the risk of malnutrition, 42.5% (n = 144) in malnutrition by the mini nutritional assessment	38.1% (n = 129) in sarcopenia, with a higher prevalence in women	The prevalence of malnutrition was statistically higher in individuals with sarcopenia compared with those without it.
Simone et al. [29]	n = 113 patients with CKD stages 3b-5, 80 ± 6 years	28% (n = 32) in the presence protein energy wasting syndrome	24% (n = 27) in sarcopenia	CKD sarcopenic patients were more malnourished than non-sarcopenic ones.
Catarina et al. [30]	n = 170 patients on hemodialysis, 71 ± 7 years	58.8% (n = 100) by the 7-point-subjective global assessment	35.3% (n = 60) in pre-sarcopenia, 14.1% (n = 24) in sarcopenia	The group with sarcopenia and malnutrition showed a higher hazard ratio 2.99 for mortality when compared to a group with no-sarcopenia and no-malnutrition.
Blauwhoff-Buskermolen et al. [31]	n = 67 patients with metastatic colorectal cancer, 66 ± 11 years	55% (n = 37) in overweight, 8% (n = 5) in obese, 57% (n = 38) in low skeletal muscle index	6.1% of skeletal muscle area decreased in 3 months by chemotherapy	Muscle loss of 9% or more during chemotherapy was associated with nutritional status and poor survival.

Table 2.

Summary of malnutrition and sarcopenia in various subjects.

Dolores et al. investigated the association between malnutrition diagnosed according to the ESPEN and GLIM criteria and the development of severe sarcopenia/sarcopenia judged by the EWGSOP2 criteria [23]. In this study, 411 subjects were recruited, and their risk of developing severe sarcopenia/sarcopenia was assessed during the 4-year follow-up period. The results showed that those who were malnourished by the ESPEN definition had sarcopenia (adjusted hazard ratio of 4.28) and severe sarcopenia (adjusted hazard ratio of 3.86) and that those who were malnourished by the GLIM criteria had sarcopenia (adjusted hazard ratio of 3.23) and severe sarcopenia (adjusted hazard ratio of 2.87). The authors emphasized the importance of early action against malnutrition because it was shown to increase the risk of developing severe sarcopenia/sarcopenia two-fold during the 4-year follow-up.

Gerdien et al. summarized the association between sarcopenia and the prevalence of malnutrition in elderly hospitalized patients [24]. While reviewing seven studies (2506 patients), the researchers found a high association and overlap between sarcopenia and malnutrition. The results revealed that about half of the older hospitalized patients suffered from sarcopenia and malnutrition.

Sato et al. evaluated the prevalence and associated factors of sarcopenia in long-lived elderly people [25]. In this study, 100 eligible older adults were examined, and the mean age was 77.2 years in the elderly and 86.3 years in the long-lived elderly. The authors summarized that the risk of sarcopenia was 6 times higher in the elderly individuals >80 years of age and 13 times higher in the malnourished elderly individuals and those at risk for malnutrition.

Verstraeten et al. evaluated the prevalence of malnutrition and sarcopenia and the association between them in geriatric rehabilitation inpatients [26]. Out of the 506 geriatric rehabilitation inpatients, 51% were malnourished, 19% were severely sarcopenic, 49% were probably sarcopenic, and 0.4% were sarcopenic (nonsevere). Malnutrition with confirmed/severe sarcopenia and malnutrition with probable sarcopenia coexisted in 13% and 23% of the subjects, respectively. Almost half of the rehabilitation patients exhibited both malnutrition and sarcopenia.

Dolores et al. investigated malnutrition (diagnosed as per ESPEN) in elderly inpatients debilitated by acute illness and its connection to sarcopenia [27]. The 88 inpatients (mean age: 84.1 years, 62% women) with a BMI of <30 kg/m² were assessed with biochemical markers, and mini nutritional assessment strips were used to investigate the risk of malnutrition and sarcopenia. The results showed that the prevalence of malnutrition was 19.3% as per the ESPEN definitions. The prevalence of sarcopenia was 37.5%, of which 90.9% were malnutrition due to ESPEN, further indicating a strong association between the two.

Beatriz et al. investigated the association between sarcopenia diagnosis and nutritional status in nursing home residents [28]. This cross-sectional study included 339 elderly patients (mean age: 84.9 years, population: 64.3% women) in nursing homes, and their nutritional status was assessed using the ®Mini Nutritional Assessment. More than one-third of the residents had sarcopenia, and its prevalence was particularly high in women. Of the participants, 32.4% were at risk of malnutrition and 42.5% were malnourished. Rates of malnutrition were statistically higher in sarcopenia than in non-sarcopenia. Furthermore, the prevalence of malnutrition was the highest among those with reduced grip strength (62.8%) and in patients with severe sarcopenia (60.8%).

Simone et al. investigated the relationship of nutrition with sarcopenia, behavior, and inflammatory patterns in 113 older adults with advanced CKD [29]. Psychological and physical performance were assessed. The nutritional condition was evaluated by an inflammatory score for malnutrition, which also confirmed the presence of protein–energy wasting syndrome (PEW). The results demonstrated that 24% of the patients had sarcopenia. Patients with sarcopenia had relatively low creatinine clearance levels and low BMI values. Furthermore, patients with sarcopenia showed not only a higher prevalence of PEW (52% vs. 20%, p < 0.0001), but also a trend toward higher inflammation scores indicating malnutrition (6.6 vs. 4.5, p = 0.09).

Catarina et al. assessed the relationship of sarcopenia with malnutrition and nutrition-related markers, quality of life, and mortality in a cohort study of elderly patients undergoing chronic hemodialysis [30]. The subjects were 170 patients receiving hemodialysis for at least 3 months who were aged ≥60 years. Malnutrition, sarcopenia, and pre sarcopenia were found in 58.8%, 14.1%, and 35.3% of the patients, respectively. Patients with malnutrition and sarcopenia were older and showed significantly lower BMI, body fat, mid-arm muscle and calf circumferences, phage angle, and somatic cell mass. In addition, subjects with sarcopenia and malnutrition had a significantly higher hazard ratio for mortality (2.99) than those without these conditions.

Kiss et al. reported that all cancer patients are recommended to be screened for malnutrition and sarcopenia at the time of diagnosis or when clinical conditions change during treatment and recovery [31]. Malnutrition occurs with all cancer diagnoses, but certain cancers, such as neck and head, lung, and gastrointestinal cancers, exhibit up to a four-fold higher risk of malnutrition than breast cancer. In addition, Blauwhoff-Buskermolen et al. examined skeletal muscle changes during palliative chemotherapy in patients with metastatic colorectal cancer [32]. The muscle area of these patients decreased significantly by 6.1% during 3 months of chemotherapy. Additionally, patients who experienced a muscle loss of >9% during treatment had a significantly lower survival rate than those who faced a muscle loss of <9%.

4. Nutritional approach for the prevention of sarcopenia

The effects of diet quality on sarcopenia prevention in elderly individuals have been summarized as per the results of nutritional epidemiological studies. We reviewed epidemiological studies published since 2011 with at least 192 subjects that confirmed the impact of dietary quality on muscle function (Table 3).

Reference	Population	Nutritional status	Physical function
Martin et al. [33]	n = 628 community-dwelling men (n = 348) and women (n = 280), 68 ± 3 years (men) 68 ± 3 years (women)	Administered FFQ pertaining to the 3-month period preceding the interview; Data-driven: PCA. A “prudent” dietary pattern was identified.	In women, a higher prudent diet score was associated with a shorter 3-m walk time, shorter chair-rise time, and better balance.
Bollwein et al. [34]	n = 192 community-dwelling men and women, 83 ± 4 years	Administered FFQ of the German part of the EPIC study.; Dietary indices: Adherence to a Mediterranean dietary pattern was assessed using the MED score	A relationship was observed between a high MED score and lower risk of a slow walking speed.
Granic et al. [35]	n = 791 men (n = 302) and women (n = 489), living either at home or in a care facility, 69 ± 0.3 years	Three dietary patterns were identified.; (a) DP1, High Red Meat; (b) DP2, Low Meat; (c) DP3, High Butter	Men in DP1 had worse overall hand grip strength and slower timed up and go than those in DP2. Women in DP3 had slower timed up and go than those in DP2. Men in DP3 had a steeper decline in hand grip strength than those in DP1.
Perälä et al. [36]	n = 1072 participants, elderly men and women, 61 ± 0.2 years	Dietary indices: The a priori-defined Nordic diet score (NDS) was calculated as a measure of a healthy Nordic diet.	Women in the highest fourth of the NDS had a 5-point higher Senior Fitness Test score on average than those in the lowest fourth.
Suthutvoravut et al. [37]	n = 1241 community-dwelling men (n = 646) and women (n = 595), 75 ± 6 years	Three dietary patterns were identified.; (a) DP1, high factor loading for fish, tofu, vegetables, and fruits; (b) DP2, high factor loading for fish, rice, and miso soup; (c) DP3, high factor loading for noodles	Men with the lowest tertile of the DP1 score had a higher likelihood of being sarcopenic.; Women with the lowest tertile of the DP2 score had a moderate likelihood of being sarcopenic.
Davis et al. [38]	n = 552 men from the baseline and 15-year follow-up of the Geelong Osteoporisis Study	FFQ data were used to calculate the ARFS and the DIIscores.; The ARFS is validated diet quality index.; The DIIscore measures dietary inflammatory potential.	An anti-inflammatory diet and higher scores on a traditional dietary pattern both predicted greater skeletal mass index, while a pro-inflammatory diet predicted slower the timed up-and-go test.

Table 3.

Summary of nutritional epidemiological studies on the diet of quality in preventing sarcopenia.

Six studies have conducted human trials on the relationship between sarcopenia and diet quality (i.e., the intake of specific nutrients via food and/or the amount of nutrients consumed) [33, 34, 35, 36, 37, 38].

Martin et al. explored the connection between physical ability (a short physical performance battery) and diet in the residents of West Hertfordshire [33]. Nutrient intakes were determined for the foods consumed using the manufacturer’s composition data or the nutrients indicated in the UK National Food Composition Database. The preferred dietary patterns involved a high consumption of fish, shellfish, vegetables, and fruits but low consumption of sugar, fat, chips, and white bread. In women, the higher the dietary score, the greater the reduction in 3-min walking time and chair rise time. In addition, an inverse correlation was observed between the intake of vegetables, white fish, and shellfish and physical function. These findings indicated the presence of a relationship between diet quality and physical function in elderly women.

Bollwein et al. investigated whether the risk for frailty was lowered in subjects with higher Mediterranean diet (MED) consumption scores [34]. This score replaces the MED score proposed by Fung et al. [39]. The basic MED score introduced by Trichopoulou et al. was utilized [40]. The authors found that the MED score and walking speed were inversely correlated. Additionally, they observed a strong correlation between slow walking speed and good diet quality (high in vegetables, legumes, fruit, unrefined cereals, nuts, and fish) in aging people.

Granic et al. summarized the correlation between diet and decline in muscle power and physical performance in elderly people [35]. The study followed 791 elderly people for 5 years and detected changes in the Timed Up and Go test (TUG) scores and grip strength. Dietary intake was entered in a Microsoft Access dietary data system based on unique food codes (2000 above) and 118 additional categories by food groups based on the McCance and Widdowson food composition [40, 41]. The participants were divided into dietary pattern 1 (DP1—high in red meat), dietary pattern 2 (DP2—low in meat), and dietary pattern 3 (DP3—high in butter) based on the results of the dietary survey. The results showed that men with DP1 had decreased grip strength, and men with DP3 had a steeper decrease in grip strength than men with DP2. Furthermore, the TUG scores were significantly higher in DP1 men and DP3 women than in DP2 men and women. The results, therefore, suggested that a diet high in potatoes, red meat, butter, and gravy may exert a negative effect on physical performance and muscle strength in older adults.

Perälä et al. focused on the healthy Nordic diet and studied whether it was associated with improved physical performance indicators [36]. The 1072 subjects (mean age of 67 years) were investigated using the 128-item food frequency questionnaire (FFQ), after which an a priori Nordic diet score was derived. Physical ability was assessed using the Senior Fitness Test (SFT). The results of the SFT score showed that in women with the highest dietary score, the walking ability was improved by 17%, arm curl by 16%, and chair stand by 20% compared with women with the lowest dietary score. These results were considered meaningful evidence that women consume the healthy Nordic diet, which is based on fruits and berries (berries, pears, and apples), vegetables (lettuce, tomatoes, cabbages, lettuce, roots, roots, and legumes), cereals (oats, rye, and barley), low-fat milk (fat-free milk and milk with fat content <2%), and fish (Baltic herring, salmon), exhibit improved physical performance (upper and lower body muscular strength and aerobic endurance) after 10 years.

Suthutvoravut et al. studied the dietary contents and the development of sarcopenia in community-dwelling elderly Japanese people [37]. The subjects included 1241 individuals aged over 65 years who were not undergoing long-term medical treatment. The participants’ diets were assessed using a simple descriptive dietary questionnaire. The dietary contents were surveyed by both Principal Component Analysis and Japanese dietary scores (fish, vegetables, fruits, soy products, mushrooms, pickles, and seaweed). The participants were categorized into dietary pattern 1 (DP1—typical Japanese diet, with high factor loadings for fish, fruits, vegetables, and tofu), dietary pattern 2 (DP2—high-factor loadings for rice, miso soup, and fish), and dietary pattern 3 (DP3: high factor loadings for noodles). The results suggest that men with the lowest DP1 are more likely to develop sarcopenia, and women with the lowest DP2 are moderately likely to develop sarcopenia. Furthermore, the findings alluded that low adherence to the Japanese dietary pattern, which comprises rice, fish, miso soup, tofu, vegetables, and fruits, was associated with a high prevalence of sarcopenia, regardless of sex.

Davis et al. investigated the alterations in the skeletal muscle mass and muscle function due to diet quality and dietary patterns over a 15-year period in 522 men [38]. The dietary survey was extracted from an FFQ and calculated the Australian Recommended Food Score and the Inflammation Index. Three dietary patterns were characterized—plant-based, Western, and traditional (Anglo–Australian). Higher scores in an anti-inflammatory diet rich in protein and vegetables predicted greater skeletal muscle mass, whereas the inflammatory diet was associated with lower TUG scores during the 15-year period. These associations were also significant when adjusted for the confounding variables.

Nutrition is an important factor that regulates muscle mass and muscle function and developing effective nutritional strategies to reduce muscle loss in several diseases warrants further studies. A few studies that have assessed the efficacy of nutritional interventions have been discussed below.

Kishimoto et al. demonstrated the changes in nutritional status and outcomes in adult stroke patients admitted for rehabilitation [41]. The 134 enrolled patients were divided into two categories—those with improved or normal nutritional conditions and those with poor or reduced nutritional status. Functional recovery was better in the category with improved nutritional status than that in the other categories. The authors concluded that improved or maintained nutritional condition was correlated with improved functional recovery in the rehabilitation of adult patients with stroke.

Patients with CKD are known to have a high prevalence of protein–energy malnutrition; hence, it is necessary to meet the patient’s energy requirements and maintain the nitrogen balance to avoid the extra breakdown of muscle protein. Hoshino reported that a dietary protein intake of 1.0–1.2 g/kg/day, which is 1.2 times higher than that recommended for healthy individuals, is advised for patients with CKD [42]. In addition to the protein intake, an energy intake of 30–35 kcal/kg/day is necessary because the estimated energy leak during dialysis is approximately 300 kcal. Furthermore, an adequate intake of vitamins and minerals, such as vitamin D and iron, is essential to prevent protein catabolism.

Kiebalo et al. summarized the recommendations of the Society of Nephrology regarding the nutritional intake for dialysis patients [43]. The Polycystic Kidney Disease (PKD) Foundation has set the daily protein recommendation at 1.2–1.4 g/kg/day, slightly higher than the European guideline of 1.0–1.2 g/kg/day. The Foundation further suggests a daily calcium intake of 1000 mg and up to 3000 mg of sodium per day. For dietary phosphorus, the Kidney Disease Improving Global Outcome states that the daily intake should not exceed 4000 mg, which includes mineral as well as protein.

Ford et al. investigated the appropriate amount of dietary protein for preventing or treating skeletal muscle mass loss in cancer patients [44]. 40 patients with diagnosed stage II–IV colorectal cancer who were to receive chemotherapy were randomly assigned to a 12-week high-protein (HP) or normal-protein (NP) diet, with the HP group receiving 2.0 g/kg/day and the NP group receiving 1.0 g/kg/day of protein. The energy recommendations were based on the measured energy expenditure. The results showed that changes in skeletal muscle mass and physical functional muscle strength were higher in the HP group than that in the NP group, suggesting the importance of protein intake in cancer patients.

Schueren et al. published a systematic review of randomized trials using high-energy oral nutraceuticals (ONS) or ONS fortified with protein and n-3 polyunsaturated fatty acids to modulate cancer-related metabolic changes [45]. Interventions fortified with protein diets (i.e., an extra 32–33 g/day) and n-3 polyunsaturated fatty acids (i.e., an extra 2.0–2.2 g/day) of eicosapentaenoic acid) were observed to significantly improve cancer-related markers compared with the isocaloric controls.

Malnutrition during cancer chemotherapy is a factor associated with delayed disease improvement. Many investigations have been conducted on nutritional interventions during cancer treatment, but the evidence is highly limited. Hence, there is a need for further research to establish the desired timing and duration of nutritional intake and the know-how necessary for continuous nutritional intake.

5. Conclusions

In this chapter, we have summarized the relationship between malnutrition and sarcopenia in various subjects, reviewed the nutritional epidemiological evidence related to preventing sarcopenia, and showed data on the efficacy of nutrient intake in attenuating muscle atrophy in several patients. Malnutrition is closely related to severe sarcopenia, especially in older hospitalized adults, geriatric rehabilitation inpatients, patients with CKD, those undergoing hemodialysis, and those with cancer. An appropriate quality diet pattern (i.e., one that provides an adequate intake of beneficial foods, such as low-fat foods, fish, vegetables, fruits, nuts, and whole-grain products) is effective in preventing sarcopenia. The MED is a particularly popular healthy diet, but other diets of appropriate quality, such as a healthy Nordic diet or a traditional Asian diet, are useful in preventing sarcopenia in older adults worldwide. Proteins, vitamins, minerals, and n-3 polyunsaturated fatty acids are key nutrients for patients with CKD, those undergoing hemodialysis, and those with cancer. Further high-quality studies with large sample sizes, isocaloric placebo supplementation, and controlled diet quality are needed to clearly understand the effect of nutrient dose and duration on the prevention of malnutrition and sarcopenia.

Conflict of interest

The authors declare no conflict of interest.