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you

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Hey everyone, it's Mikki here. You're listening to Mini Mikkipedia and I came across a great paper that I wanted to summarize for you in and around muscle preservation during hospitalization. And this is written by Dr. Fuchs and Professor Luke Banloon. And Luke Banloon is really well known for his work in the protein space. And essentially it is talking about the critical role of protein

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and exercise for people, as the name suggests, who are hospitalized. And paper itself goes into a number of super important points, which we often miss or aren't even aware of, and then talks through some basic recommendations. So you get some really practical take homes, which I really like. So essentially, I mean, just as by way of introduction, hospitalization leads to rapid and substantial muscle loss.

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I've talked about this on my podcast before with the likes of Professor Brendan Egan and in otherwise healthy individuals, short-term bed rest results in approximately 0.5 % of leg muscle loss per day, which is not insubstantial. During critical illness, this process accelerates dramatically with reports showing that patients may lose nearly 3 % of

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leg muscle mass per day in the ICU. Earlier work by the laboratory by Fuchs and Loon have demonstrated that up to 15 % or more of leg muscle mass can be lost within just one week in critically ill or comatose patients. Collectively, these findings underscore not only the early onset of disuse atrophy, but also its rapid progression to acute muscle wasting and the potential development of psychopenia, particularly in critically

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ill patients. Within a hospital duration of 4-44 days, example, around 20 % of hospitalized patients develop psychopenia, the highest incidence observed among trauma patients in the ICU. interestingly, this is pretty dramatic too, studies do show that critically ill patients with reduced muscle mass require mechanical ventilation more frequently and for longer durations.

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They have higher rates of trichotomy and experience prolonged ICU stays. In addition, low muscle mass is associated with reduced quality of life, increased risk of falls and fractures, and ultimately a substantially elevated mortality rate. And this is super important. This is one of the reasons why we bang on all the time about how important it is to strength train and get your protein in. So these findings highlight not only the clinical severity, but also the

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economic and social burden of in-hospital muscle loss, reinforcing the urgent need for effective interventions to preserve muscle mass during periods of bed rest. For what it's worth, I can't tell you the number of times that our clients and followers of mine have sent me pictures of what food is served in hospital. So outside of exercise component, like just how woefully inadequate protein is in hospital-based meals, which obviously I'm going to delve into a little bit more further anyway.

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So just to remind you, we maintain muscle mass with a balance between both muscle protein synthesis, so the repair and rebuild of muscle, and muscle protein breakdown, with approximately one to two percent of muscle proteins being synthesized, integrated each day. Clearly, physical activity and food intake acutely stimulate muscle protein synthesis, thereby supporting the maintenance of muscle mass under typically ambulatory and healthy conditions. So just walking around,

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doing your daily thing, activity and food is going to support muscle mass. However, during periods of hospitalization, this balance is clearly disrupted. Physical activity is substantially reduced or even absent because of bed rest. And as a result, lower rates of MPS are typically observed in bedridden individuals. More specifically, both a rapid decline in basal muscle protein synthesis and the development of anabolic resistance.

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So the brain needing more protein to get that muscle protein synthetic response is seen. And it's been reported in response to short term muscle inactivity. So that is interesting as well. So the more inactive you are, the more of a hit of protein your brain needs to get the signal that it's got enough protein on board. In addition to reduced absent or physical activity, to reduced or absent physical activity, food intake

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is often compromised in hospitalized patients, particularly in those who are critically ill. The resulting energy restrictions suppresses basal NPS and induces anabolic resistance as well. So in otherwise healthy individuals, even a modest energy deficit of around 20%, which is often what is recommended in fat loss diets, for 10 days has already been shown to reduce muscle protein synthesis by 20 % when you're not protecting protein.

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Consequently, a negative energy balance exacerbates muscle loss, and recent work has shown a correlation between lower caloric intake and greater muscle atrophy within just the first three days of an ICU admission. The lower energy intake is typically accompanied with a lower protein intake, further compromising postprandial protein synthesis rates, that's post-meal, and exacerbating that muscle mass loss. Daily protein intake

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in hospitalized patients is generally well below what the RDI is, which is woefully low anyway, 0.8 grams per kg body weight, and doesn't even come close to guidelines for clinically compromised patients. Those guidelines are 1.2 to 1.5 grams per kg body weight. So still relatively low if you are in the protein space as all of us are. Low is actually exaggerating that. It's just not high. I think that's a better way to describe that.

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In support of these findings, lower protein intakes have also been associated with greater muscle atrophy in patients admitted to ICU. So in addition to compromised muscle protein synthesis, and there's an increase in muscle protein breakdown, potentially because of high levels of systemic inflammation and hormonal disruptions associated with critical illness, because that muscle protein breakdown doesn't seem to be elevated in otherwise healthy, bedridden individuals. So it does.

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imply that that decline in the basal and postprandial muscle protein synthesis play a more dominant role in the observed loss of muscle mass in most hospitalized patients. So essentially, if you've got a high level of inflammation and say trauma, like uh body trauma, injury, that kind of thing, then you're going to also have an accelerated breakdown of muscle in addition to that lower muscle protein synthesis. To be fair,

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I think any of you listening here, I'm probably just putting words around what you already know and what you already see from people you might see in a hospital, your parents coming out of hospital or being sick for 10 days and then, you know, they're looking very frail. There's a lot of muscle loss that can occur. So the first thing that is really important for anyone hospitalized to help maintain and hold onto that muscle is maintaining that energy balance and habitual protein intake.

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Even if you are like me, otherwise healthy, active, and generally you maintain your weight, when you do fall sick, it's almost by default, we just don't eat as much. One of the reasons we don't eat as much is because we just lose the appetite because we're not as active. But also for some of us, they'll be in the back of your head going, well, I don't really need the amount of calories that I usually consume, so I'm just gonna dial it back.

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And that might not be the best approach. It's certainly not if you're bedridden. Obviously achieving a perfect energy balance can be challenging. It's important to aim for as in addition to the detrimental impact of an energy deficiency, as I mentioned earlier, overfeeding during prolonged bed rest may also increase fat mass and could exacerbate muscle loss. And that's important as well. So getting a balance right is key. But of course, if you can't assess your energy needs via the sort of indirect kilometer tree that is required

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why is it and then you sort of got to be guided a little bit by available equations and what you already know of your energy intake but if this is unavailable if you are unable to use indirect. Which is determining someone's resting energy expenditure by measuring the oxygen consumption and carbon dioxide production which to be here very few people gonna be able to do that when you can it's actually pretty good.

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improving outcomes, but if that's unavailable, using VO2 measurements might provide an alternative in the ICU. But again, in the absence of these methods, simple estimations based on body mass, so 20 to 25 calories per kg may be used, although they should be interpreted with caution. Overall though, a personalized approach to energy intake is recommended. And I've got to say, this is just another reason to get quite engaged in how many calories

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is required for you to maintain your healthy body weight and the level of activity that you're in. Like just having this knowledge is really powerful and clearly in other ways than just for our sport and to improve and maintain a good healthy body composition. We never think sort of further ahead as to what happens if I am in hospital for several days or weeks at a time whereby I'm unable to be active yet I need to maintain like, you

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to preserve as much muscle as possible. So maintaining or slightly increasing habitual protein intake is likely to, is important. And so as mentioned before, at least like a minimum of 1.2 to 1.5 grams would be ideal. And interestingly, what the study talks about is that super high protein intakes might actually not be ideal because it could increase gastrointestinal intolerances

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or impede health related quality of life after discharge. And I looked at the research around this because they referenced a particular paper. And what I will say is, is if you're listening to this podcast and your typical protein intake is at least 1.6 grams per kg body weight per day, and a lot of us do, then that's what you wanna be aiming to maintain. The gastrointestinal issues of up to two grams per day probably isn't an issue if you habitually have a higher protein intake.

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albeit when you're not as active, what you don't want to do is fill up a whole lot on protein and run the risk of falling short of calories and energy from calories because that is also important. So again, it's this fine line. Interestingly, they've got a stat here that most hospitalized patients fail to reach even minimal intake levels with average protein intake reported at about 0.7 grams per kg body mass in general hospitalized populations.

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and as low as 0.55 grams per kg body mass in patients in ICU, which sort of makes sense because those in ICU super critical, probably getting it through a tube and may not even be awake, right? So for relatively healthy patients who are able to eat normally despite being hospitalized, increasing protein and energy intake through oral nutrition may be manageable, though individual tolerance varies. recent work from the lab of

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Fuchs and Van Loon have demonstrated that providing an energy-dense and protein-dense snack prior to sleep can effectively enhance daily intake in this population, enabling 12 % of patients to meet habitual protein targets. So this is not a bad option if you or your parents are in hospital, getting in a good, decent whey protein isolate powder or a decent uh plant-based protein powder and having them have that after dinner before going to sleep, that is going to help

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maintain that muscle protein synthesis response. Of course, and this is even more important if you can't consume sort of larger volumes of food or additional snacks, and notably even small doses of essential amino acids may be applied to stimulate muscle protein synthesis. And they talk about doses of 3.6 grams of essential amino acids. And if we're thinking about it in a two-one-one ratio, which

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of branch chain, and I'm not sure if this is what they're referring to, but that's got to be at least 2 grams of blue cene here. Even when achieving energy balance is difficult or impossible, providing adequate absolute amounts of protein and or amino acids remain critical. Indeed, the addition of these easily digestible proteins or essential amino acids has been shown to stimulate muscle protein synthesis, even under conditions of energy deficiency. Collectively, these findings

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underscore the importance of optimizing protein and amino acid provision during hospitalization. And of course, they do say that more research is warranted to identify the most effective oral nutrition strategies. And the paper, of course, then goes on to talk about patients who are unable to take on anything sort of orally, and they need nutritional support by enteral or perenteral routes, and that it's critical. So to my mind, I just think

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doing what you can to assist with that protein intake, getting the protein powders, getting the essential amino acids. If they tolerate dairy, getting high protein, yogurt, super easy to digest. Obviously not relying on just hospital-based food, I think is really important. And keeping it, even getting a digestive enzyme if you can, if they're going to struggle. If you're bringing in any sort of meat, I would make it sort of slow cooked, easy to digest, ground beef, mince beef, that kind of thing.

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And also they talk about preventing muscle disuse. And clearly this is going to be a challenge. You know, if someone's in ICU and can't move, you really can't do a lot about it. But stimulating muscle contractions through maintaining or increasing physical activity forms a key pillar in preserving basal and postprandial, post-meal muscle protein synthesis in hospitalized patients. Physical activity enhances the muscle sensitivity to the anabolic properties of protein, so the muscle building properties of protein.

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and amino acid administration. So it does offset some of that anabolic resistance. Even a minimal level of habitual physical activity such as transferring from the bed to a chair or walking to the bathroom may attenuate the decline in basal and postprandial muscle protein synthesis and attenuate muscle loss during hospitalization. Supporting this concept, recent work has shown that performing a single bout of resistance exercise

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prior to a five day bed rest period can significantly attenuate subsequent declines in myofibular protein synthesis rates and preserve muscle mass throughout bed rest. And that's super interesting. The fact that such a intervention exerted protective effects over several days highlights the potency of even short bouts of physical activity or exercise to mitigate muscle loss during disuse. So if you've got some surgery coming up, you've got something where you know you are out of action,

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absolutely bear that in mind. It remains to be established what this minimum effective dose is. they do, the researchers do say that, you know, establishing this threshold is going to be essential to develop some sort of low intensity exercise interventions tailored to the patients. However, it's important for you to know what you're used to doing and being as active as you can in the lead up to surgery and the lead up to bed rest is going to be important. But they also note that

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not all patients, such as those who are comatose or experiencing severe functional limitations, are able to perform habitual daily living activities, such as that bed to chair, chair to walk type activity. alternative, like passive strategies to stimulate muscle protein synthesis and prevent muscle atrophy may be considered. So such things which they term exercise mimetics, such as muscle contractions should be

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actively induced through alternative strategies to help preserve muscle mass. Among the available options, you've got neuromuscular electrical stimulation. It's currently the most established and clinically feasible approach to counteract local disuse atrophy. The application of this has been shown to increase MPS, muscle protein synthesis, and may help attenuate muscle loss in immobilized or critically ill patients.

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Beyond this, additional strategies aimed at inducing those anabolic effects in the absence of voluntary movement are being explored. One area of interest is blood flow restriction, which appeared initially promising, but in the absence of muscle contractions, it may not preserve muscle mass. It doesn't seem to be as effective in a setting of disuse.

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what they say is it's just so important to continue to explore innovative options that can be applied safely and effectively in patients unable to participate in traditional physical activity or in patients with limb immobilization. And ultimately, they talk about pre-habilitation. And I think this is super important. So hospitalization due to disease or trauma is often unpredictable. And as such, strategies to mitigate muscle loss are typically implemented through our admission or

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subsequent post-to-charge rehab. But in the case of elective surgery, it is possible to apply prehabilitation measures as a potential strategy to enhance physical reserves. Given that muscle can be lost up to five times faster than it is gained, increasing muscle mass and the function of it prior to hospitalization may be of benefit to the patient's needs. So in the context of planned hospitalizations, prehabilitation should be actively encouraged. Keep that protein high,

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do that exercise prior to surgery, so you've got that uh potential to offset some of the anabolic resistance. So in summary, key strategies for muscle preservation during hospitalization include energy balance. Energy deficits can accelerate muscle atrophy. Patients should be stimulated to maintain their caloric intake during hospitalization. Protein intake. A decline in habitual protein accelerates disuse atrophy and should be prevented.

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Patients should aim to consume between 1 to 1.5 grams of KG body mass per day or whatever they're habituated to in their everyday life. And for you, I'm hoping it's gonna be more than that. Physical activity. Muscle loss during hospitalization is largely attributed to a substantial decline in physical activity level. Maintaining or increasing physical activity level enhances the muscle sensitivity to protein and amino acid intake and attenuates the decline in muscle mass. Alternative strategies for patients

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partly or unable to engage in voluntary physical activity include exercise mimetics such as neuromuscular electrical stimulation to allow for local muscle contractions and to preserve muscle mass. So I thought this was pretty interesting. I'll pop a link of it in the show notes for you to have a read and I look forward to hearing what you think. And I've got to say, like I talked to a lot of people who have either elective surgery or, you know, God forbid,

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unplanned surgery. think strategies like these are just so important to help keep you well, particularly in light of how fragile you can be upon sort of discharge from hospital, regardless of age. Like I'm 48 and I think about this stuff because I'm not young. All right, team, let me hear what you think. I'm over on threads mikkiwilliden.com. Book a call to discuss.

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your particular needs around this or anything. Have a great day.