Count me among those who celebrate every effort to keep our hearts and minds healthy as we age! I enjoy puzzles and games, reading books to discuss with friends, as well as reading all the contentious literature about nutrition and general health advice. I encourage my patients to find some mentally challenging activity they enjoy, as well as activities that bring meaning and pleasure to their lives.
Let's not, however, forget what we can and must do to maintain the health of our very physical bodies. Our physical sturdiness has a great impact on our overall level of health and well-being. In a recent TED talk, neurobiologist Daniel Wolpert remarked that we developed brains so that we can move our bodies around in the world. It's important that our modern brains make an assessment of our body's movement abilities and strengthen our bones and muscles before serious age-related weakness becomes a health problem.
I imagine each of us can recall an image of someone we know who became very frail as they aged. Current medical understanding links physical frailty to decline on many levels - physiological, emotional, neurological, hormonal - and stresses the importance of intentionally maintaining physical strength with aging. We also know that muscle deterioration can occur in individuals of any weight: obesity is indeed strongly associated with loss of muscle mass.
Current medical strategies focus a great deal on bone strength, which we call bone density: diagnosis, prevention, and treatment. We are keenly aware of the possibility of osteopenia and osteoporosis. The medical attention is worthy even if the recommendations leave a great deal to be desired.
We ought also to consider the natural process of sarcopenia, the wasting and weakening of muscles. As individuals we can ask ourselves: how's my balance, the strength of my gait? Can I walk rapidly across a parking lot? Are my muscles maintaining their size and strength? And for physicians - often sitting long days at a desk ourselves - we tend to forget the importance of examination and counseling regarding the strength of the muscles of the body. We would serve our patients better if we remembered that the identification, reversal and prevention of muscle weakness is part of a good physical exam.
Sarcopenia and Osteopenia
Osteopenia refers to a condition of the bones where the mineral density is lower than normal, within a specific range. The testing units are called T-scores, where 0 = normal bone density, -1.0 to -2.5 indicates osteopenia, and -2.5 and beyond a reflection of osteoporosis. The greater the negative T value, the higher likelihood of fracture resulting from minor incidents that would not cause a fracture in a young and healthy person.
The medical world has attended to osteoporosis quite seriously for the last 30 years, with some advice about prevention and quite a bit of effort encouraging screening tests to diagnose bone density levels and research into pharmaceutical treatments. The prescription medications are all non-physiological, with a mix of helpful and hazardous effects. Many of the recommendations I will offer for preventing sarcopenia are actually quite helpful for preventing or reversing osteopenia. More about osteopenia and osteoporosis in another article!
Sarcopenia refers to the degenerative loss of muscle mass, which starts spontaneously sometime after the age of 25 and progresses at a rate of 0.5-1% loss annually unless efforts are made to reverse the trend. As part of the “frailty syndrome”, progressive sarcopenia is a good predictor of many illnesses, physical and mental, as well as premature mortality. Importantly, an accurate assessment of muscle health should include both muscle size and muscle function, as both are clinically significant. While a physician can write a simple order for a bone density scan, a muscular assessment must be done by a human being - either a physician or a physical therapist.
Note: An excellent indication for a course of physical therapy appointments would be the loss of muscle mass or strength. As a physician, I can request that the physical therapist evaluate and treat the patient for 4-6 visits, incorporating exercise programs and monitoring of progress. I have found physical therapists to be incredibly valuable partners in my work with many patients. Skye - a good friend and a Physical Therapist - passed along her particular insight. “Write into the PT prescription a request to urge the patient's involvement in a community-based program, such as exercise classes at the Y, for better long-term success.” Great idea!
Just as bone density is progressively lost, so does sarcopenia have a natural progression, initiated by atrophy - loss of muscle bulk - and subsequent loss of muscle quality, strength and physiological connections. Muscles lose their ability to store and use energy, to recover from exertion, to produce and respond to signal hormones, and to respond effectively to neurological input. Unchecked and unexercised, aging muscles become helpless and diminish life quality and length. Frail muscles can progressively weaken other body systems as well, leading to a general decline. Lose muscle strength, you may lose the ability to chew your steak, to put away dishes on a top shelf, to navigate a hillside walk. Progressive loss can lead to serious frailty.
Healthy muscles are well-fed and well-exercised, and exist in a carefully orchestrated complex relationship with our bones, brains, nervous, hormonal and immune systems. A bit of attention to our food and our activities is well worth the effort if we can keep our muscles vital as we age.
Muscles lose their bulk and usefulness primarily as a result of aging and lack of use, but other factors contribute as well. As we grow, our bodies naturally make growth hormone, which stimulates muscle health. Without some effort to stimulate secretion, our levels of growth hormone can be quite minimal with age. More than one study has documented the marked increase in growth hormone levels in response to high intensity, interval exercise.
Walking is great, but does not stimulate the same growth hormone response. Inadequate intake of calories, and in particular protein calories, can inhibit the body's ability to synthesize protein. Older persons have a higher risk of inadequate protein intake. (Visit www.fightmalnutrition to learn more.) Our muscles are in a constant cycle of rest, activity, breakdown, and repair. Muscle repair depends on adequate dietary protein with the full complement of essential amino acids. The recipe for my Whey Protein Smoothie (link) describes one way to get whey protein, which has been found particularly beneficial in increasing muscle and tendon size and strength when taken after exercise. Metabolic syndrome, insulin resistance, and pre-diabetes all contribute to the problem of sacropenia, so addressing those conditions, as described here would be helpful for muscle strength. It is very likely that the same process of inflammation that leads to metabolic dysfunction and sarcopenia also inhibits effective immune function. Visit www.impactaging to learn more.
Elevated blood levels of both inflammation and coagulation markers are also associated with an increased risk of sarcopenia and frailty. Read here for more information on this topic.
Muscle strength of menopausal women and older men can sometimes benefit from bio-identical hormone replacement therapy. Testosterone is particularly helpful for both sexes to stimulate muscle health.
For the greatest change with the fewest changes to your life, incorporate the following:
- Protein is the most valuable food for repairing and building muscle fibers. A variety of animal protein is more useful than a single source; eat 3-8 ounces of animal-based protein at every meal. The size of your portion depends on YOUR size: petite folks might do fine with 3 ounces, but anyone 5'7" or above would do well with 6-8 ounces!
- Count protein grams! Many smart phone apps (I'm accustomed to MyFitnessPal, there are others) convert the weight of a serving into the actual grams of protein.
- Take your actual weight, or ideal weight if you are a little overweight, and lop off 20-30 % of that weight, that's your recommended grams of protein
- (calculating 10% is easy, multiply that by 2 and 3 to get the 70-80% numbers)
- 150 pound person should be eating 105-120 grams of protein daily.
- Whey protein powder has been shown to enhance the muscle-building effects of exercise, particularly resistance exercise. Take 1-1/2 scoops of grass-fed whey protein after a walk or more vigorous workout, daily. Recent studies have shown beef protein powder to be equally if not more effective. (Designs for Health makes a Paleo Protein Powder in multiple milk-shake type flavors, not meat flavors!)
- Strength training is the most efficient way to maintain or rebuild muscle mass and strength. Short sessions of intense work, two to three times weekly, help to strengthen muscles, normalize weight and balance metabolism by its particular ability to boost growth hormone levels. A sample of an interval routine is described below.
Based on what we have learned about the development of sarcopenia, a comprehensive program to slow and even reverse the process of muscle loss can be initiated one step at a time, or all at once. Start by following basic nutrition and healthy lifestyle guidelines, with the following important points.
Savor Helpful Foods
- Protein is the most valuable food for repairing and building muscle fibers. A variety of animal protein is more useful than a single source; animal proteins being naturally rich in the muscle-building amino acid leucine. It is helpful to spread the protein throughout the day, so at each and every meal, include one of the following in a 3-8 ounce serving:
- Pasture-raised eggs. Both the white and the yolk are valuable. The yolk can be consumed raw (added to a smoothie), but not the white. Cook eggs gently. Three eggs is a good protein serving.
- Meat from grass-fed ruminant animals, which might include beef, lamb, venison, elk, or bison.
- Poultry and rabbit meat, also ideally free-range animals.
- Include liver and other organ meats.
- Seafood selected through the safe seafood guidelines of the Monterey Bay Aquarium's guide to seafood.
- Nuts can provide a good high protein snack, when properly prepared, as in the Crispy Nuts recipe on this site.
- Fats are currently being studied for their effect on muscle mass when eaten with protein. Because fats and proteins are generally better absorbed when taken together, my current recommendation - pending further research - is to make sure to include healthy sources of fat with each protein meal. The fat normally included with the naturally lean grass-fed protein should suffice, perhaps enhanced by a pat of butter, drizzle of coconut milk, or dollop of sour cream where appropriate!
- A wide array of colorful fruits and vegetables can provide all the micronutrients and co-factors necessary for proper muscle functioning.
Avoid Problematic Foods
- Distracting foods are those that replace protein in the diet, either because of palatability or ease of eating. Grain products are prominent in this category. Limit or eliminate grains, so that you have plenty of appetite for the proteins, fats, fruits and vegetables in your diet.
- Vegetable protein sources are less than optimal, lacking essential fatty acids as well as essential amino acids. Leucine is more prominent and more easily absorbed from animal protein sources.
- Normalize vitamin D levels. Take vitamin D3 as necessary to maintain levels between 40-65 ng/mL.
- Creatine is widely available as a "body-building" supplement in powder form. Taking 5 grams a day is a simple stir into half a glass of water.
- Metagenics Omegagenics for Omega 3 fatty acids. A normal sized adult can benefit from about 1500 mg a day of combined EPA and DHA, which would be 2 capsules of the Omegagenics.
- Pure Encapsulations BCAA's (branched chain amino acids) includes leucine. Leucine is the most potent stimulator of protein synthesis. Take 2-6 capsules daily with meals.
- Whey and beef protein powder have both been shown to enhance the muscle-building effects of exercise, particularly resistance exercise. Take 1-1/2 scoops to substitute for one of your mealtime servings of protein.
Working against weight, or resistance exercise, is the most efficient way to maintain or rebuild muscle mass and strength. Two sessions a week of intense work can help to strengthen muscles, normalize weight and even to balance metabolism by its particular ability to boost growth hormone levels. If you are unfamiliar with resistance exercise, check out your local gym for a personal trainer. A TRX class is a good way to learn about body weight exercise. If you choose a personal trainer, please ask them to school you on safely lifting heavy weights, not tiny weights repeatedly--that is for a different purpose!
Body weight exercises you can do at home:
- The plank: facing the floor, support your full body on just your toes at one end and either your palms or forearms at the other. How long can you hold that? That's great! Repeat 4-5 times, two days a week, and see if you can increase your time!
- Tricep dips: do you have a sturdy chair that has arms? Sit at the edge of the chair and use your arms to push yourself quickly up, followed by lowering back into the chair as slowly as you can. Repeat til you can't do it anymore, and then do that again on your second weight day, after the plan,
- Squats: can you lower yourself onto a chair or a bench without using your arms? That's great! Now stand back up quickly and slowly lower yourself back down. Keep your back up straight, keep your knees tracking over your feet (not collapsing toward each other) and your arms extended in front of you.
Incorporate physical activity in every day's activities. Get up from your computer desk every 45 minutes and walk around. Make two trips if you left two things upstairs! And, as you've no doubt heard before: arrive early at your destination so you can park your car far from the front door!
Many successful exercise programs include activities you enjoy and time spent with friends. Make walking or hiking dates with friends, check out your local resources for masters level swimming, running and rowing.
Personal Trainers and Physical Therapists are your team! If you are in reasonably good shape and primarily interested in increasing strength and preventing sarcopenia, a certified personal trainer can assist you in the development of an individualized exercise program. Check with your local gym or YMCA for resources.
Physical Therapists can provide wonderful services to those who are already noticing significant fatigue, weakness, or muscle wasting. A good physical therapy program will evaluate current ability levels, assess and treat any injuries or pain that might interfere with suggested activities, and formulate a personal activity program. In my practice I make frequent physical therapy referrals, and suggest that the physical therapy plan include a transition to ongoing physical activity, ideally in a community based program that the client finds appealing.
There is no way to prevent the physiological tendency to sarcopenia, which is a natural part of aging. What we each can prevent is severe loss of muscle mass, strength and agility. I would recommend to everyone a daily intake of 12 ounces of high quality protein, and regular exercise that includes both mobility (yoga, walking, dancing, swimming) and strength building (intervals, running, hiking, rowing).
What are your favorite activities that help you maintain your strength?