Prevention and optimal management of sarcopenia: a review of combined exercise and nutrition interventions to improve muscle outcomes in older people

Figures & data

Figure 1 Flow diagram of literature search.

Table 1 Characteristics of included studies

References	Setting, study participants	N*	Study design	Exercise training intervention	Nutritional supplement	Outcome measures
Arnarson et al^Citation19	Iceland. Healthy community-dwelling men and women, aged 65–91 years.	161	12-week intervention. All participants received exercise training, but randomized to i) intervention group given a whey protein supplement or ii) control group. Research staff blinded to group allocation.	Resistance exercise program; participants exercised three times per week	Whey protein drink (250 mL) providing 20 g protein, 20 g carbohydrate, 1 g fat (169 kcal) (intervention) or isocaloric drink containing 40 g carbohydrate, 1 g fat (control) consumed immediately after exercise.	Two group comparison: muscle strength (quadriceps), lean body mass (DXA), physical function (timed up and go; 6-minute walk for distance).
Rosendahl et al^Citation20; Carlsson et al^Citation21	Sweden. Older men and women in residential care with dependence on assistance for one or more activities of daily living, aged 65+ years.	191	3-month intervention, factorial design. Participants randomized to four groups: i) protein-enriched drink, control activity, ii) exercise training + placebo drink, iii) protein-enriched drink + exercise training or iv) neither (control activity, placebo drink). Both drinks served in same non-transparent package.	High intensity multicomponent exercise program, including resistance exercise training and balance exercises; participants exercised five times per fortnight	Milk-based protein-enriched drink (200 mL), providing 7.4 g protein, 15.7 g carbohydrate, 408 kJ per 100 g. Placebo drink (200 mL) contained 0.2 g protein, 10.8 g carbohydrate, 191 kJ per 100 g. Drinks offered within 5 minutes of exercise session. If participant did not attend exercise training drink was offered when possible.	Four group comparison: muscle strength (lower-limb), muscle mass (bio-electrical impedance), balance (Berg Balance Scale), gait ability (2.4 m timed test).
Tieland et al^Citation22	the Netherlands. Frail older men and women, aged 65+ years.	62	24-week intervention. All participants received exercise training but randomized to i) protein supplementation or ii) placebo drink of similar appearance. Research staff and participants blinded to group allocation.	Resistance-type exercise training; participants exercised twice per week	Protein-supplemented drink (250 mL), (15 g protein, 7.1 g lactose, 0.4 g calcium) and placebo drink (no protein, 7.1 g lactose, 0.4 g calcium) consumed twice per day – immediately after breakfast and lunch.	Two group comparison: muscle strength (leg press, leg extension, handgrip), lean mass (DXA), physical performance (SPPB).
Verdijk et al^Citation23	the Netherlands. Healthy older men, living independently, mean age 72±2 years.	28	12-week intervention. All participants received exercise training but randomized to i) protein supplemented drink or ii) water. All drinks were flavored to mask their contents.	Resistance-type exercise training; participants exercised three times per week in the morning, at same time of day	Protein drink (10 g casein hydrolysate, 250 mL) or placebo drink (250 mL) given immediately before and following exercise sessions.	Two group comparison: muscle strength (leg press, leg extension), lean mass (DXA), cross-sectional area of quadriceps (CT scan).
Godard et al^Citation24	USA. Older men, aged 65–80 years.	17	12-week intervention. All participants received exercise training but randomized to i) amino acid supplementation or ii) no dietary supplementation (control).	Progressive knee extensor resistance training program; participants exercised three times per week	Amino acid-containing drink (400 mL) providing 12 g essential amino acids, 72 g fructose and dextrose; consumed immediately after training or at same time each day.	Two group comparison: muscle strength (knee extensor), whole muscle cross-sectional area of right thigh (CT).
Kim et al^Citation25	Japan. Sarcopenic, community-dwelling older women, aged 75+ years.	155	3-month intervention, factorial design. Participants randomized to four groups: i) amino acid supplementation, ii) exercise training, iii) supplementation + exercise or iv) health education (once per month).	Multicomponent exercise program including resistance exercise training; participants exercised twice per week	Powdered amino acid supplements provided to be taken twice daily with water or milk, supplying 6 g essential amino acids per day.	Four group comparison: strength (knee extension), muscle mass (BIA), usual and maximum walking speed.
Vukovich et al^Citation26	USA. Healthy older men and women, aged 70±1 years.	32	8-week intervention. All participants received exercise training but randomized to i) HMB (β-hydroxy-β-methylbutyrate) supplementation or ii) a placebo supplement. Treatments were administered double-blind	Multicomponent exercise training including resistance exercise; participants exercised 5 days per week (2 days strength training, 3 days walking and stretching)	Supplement capsules contained 250 mg Ca-HMB; participants consumed four capsules, three times per day (3 g/day). Placebo capsules were identical in appearance, providing 3 g/day rice flour.	Two group comparison: upper and lower body strength fat-free mass (skinfolds, DXA), muscle area (CTscan).
Bonnefoy et al^Citation27	France. Frail men and women resident in retirement homes, aged 72+ years.	57	9-month intervention, factorial design. Participants randomized to four groups: i) nutritional drink + control activity (memory), ii) exercise training + placebo drink, iii) nutritional drink + exercise training or iv) control activity + placebo drink. Participants were not aware of supplementation status.	Multicomponent exercise training including resistance exercise; participants exercised three times per week. Three weekly memory sessions served as controls for exercise.	Nutritional drinks (200 mL) (providing 200 kcal, 15 g protein, vitamins and minerals) or placebo (providing no nutrients) given twice daily. The nutritional drink increased energy intake by approximately 20% and provided ~50% RDA vitamins and minerals.	Four group comparison: maximum muscle power (explosive leg extension), fat-free mass (^18O dilution), physical function (gait speed, six-step stair climb, chair rise, balance abnormalities).
Fiatarone et al^Citation28; Fiatarone et al^Citation29	USA. Frail nursing-home residents men and women, aged 70+ years.	100	10-week intervention, factorial design. Participants randomized to four groups: i) multinutrient supplementation, ii) exercise training, iii) supplementation + exercise or iv) neither (control). Supplement and placebo drinks provided in unmarked containers; nursing staff not aware of supplementation group.	Progressive resistance exercise training of hip and knee extensors; participants exercised 3 days per week. Other participants offered alternative recreational activities.	Nutritional supplement provided as a daily drink to be consumed in the evening (240 mL), supplying 360 kcal, 15 g protein and vitamins and minerals (~1/3 of RDA). Participants who were not supplemented were given a minimally nutritive drink of equal volume (4 kcal).	Four group comparison: muscle strength (grip strength, hip and knee extensors), thigh muscle area (CT), physical function (including gait speed, stair climb, balance).
Miller et al^Citation30	Australia. Nutritionally at risk older men and women hospitalized following a fall-related lower-limb fracture, aged 70+ years.	100	12-week intervention, factorial design. Participants randomized to four groups: i) oral nutritional supplementation, ii) exercise training, iii) supplementation + exercise or iv) attention control (home visits only, general nutrition and exercise advice)	Progressive resistance exercise training program; participants exercised three times per week.	Complete oral nutritional supplement prescribed to provide 45% of individually estimated energy requirement, administered in four daily doses while hospitalized or two doses after discharge home.	Four group comparison: muscle strength (quadriceps), gait speed.
Sugawara et al^Citation31	Japan. Older men and women with COPD, mean age 77.2±5.3 years.	36	3-month intervention. All participants received exercise therapy but randomized to i) nutritional supplementation or ii) no dietary supplementation (normal meals alone, with dietary instruction).	Combined resistance and aerobic exercise training (low intensity); participants instructed to exercise daily at home.	Nutritional supplement containing whey peptide, fatty-acids and antioxidant vitamins. One pack (200 mL), providing 200 kcal, 10 g protein (4.5 g essential amino acids), to be consumed twice per day.	Two group comparison: quadriceps muscle force, fat free mass, 6-minute walking distance.
Bunout et al^Citation32; Bunout et al^Citation33	Chile. Community-dwelling poor older men and women, aged 70+ years.	149	18-month intervention, factorial design – evaluation at 12 and 18 months. Half the participants provided with nutritional supplement; within each group participants randomized to receive exercise training.	Resistance exercise; participants exercised twice per week.	Nutritional product (prepared as a soup or porridge, given as two daily snacks), to provide 400 kcal, 13 g protein, ~25% daily requirements for micronutrients.	Four group comparison: muscle strength (handgrip, quadriceps, biceps), fat-free mass (DXA), walking capacity (m).
Chin A Paw et al^Citation34; de Jong et al^Citation35	the Netherlands. Frail community-dwelling older men and women, aged 70+ years.	217	17-week intervention, factorial design. Participants randomized to four groups: i) supplementation, ii) exercise training, iii) supplementation + exercise or iv) neither (control). The nutritional intervention was double-blinded.	Multicomponent exercise training (gradually increasing intensity); participants exercised twice per week. A social program served as control for other participants.	Supplemented group asked to consume one fruit and one dairy product enriched with vitamins and minerals per day (to provide up to 100% Dutch RDA of vitamins and minerals). Other participants received same products that were not enriched.	Four group comparison: muscle strength (handgrip, quadriceps), lean body mass (DXA), physical function and fitness (including gait speed, chair rise, balance, flexibility).
Binder^Citation36	USA. Nursing-home residents (men and women) with dementia, mean age 88 years.	34	8-week intervention. All participants received exercise training and daily calcium carbonate supplements (1,000 mg), but randomized to i) vitamin D supplementation or ii) control.	Multicomponent but mainly resistance-type exercise; participants exercised three times per week.	Intervention group given bolus dose (orally) of 100,000 U vitamin D3at start of study, then weekly supplements 50,000 U.	Two group comparison: muscle strength (knee extensor, lower extremity), gait speed, balance.
Bunout et al^Citation37	Chile. Community-dwelling older men and women, with low vitamin D status (25-hydroxyvitamin D ≤16 ng/mL), aged 70+ years.	96	9-month intervention, factorial design. Participants randomized to receive exercise training or no training, and further randomized to receive supplementation (double blind) with vitamin D/calcium or calcium alone.	Resistance exercise training; participants exercised twice per week.	Combined oral vitamin D/calcium supplement (400 IU/800 mg) or calcium-only supplement (800 mg) provided, to be taken in the evening.	Four group comparison: muscle strength (handgrip, quadriceps), lean mass (DXA), physical performance (including timed up and go, SPPB).
Brose et al^Citation38	Canada. Healthy-community dwelling older men and women, aged 65+ years.	30	14-week intervention. All participants received exercise training, but randomized to i) intervention group given a creatine supplement or ii) placebo (double blind allocation).	Resistance exercise training; participants exercised three times per week.	Daily creatine monohydrate supplement (5 g +2 g dextrose) (intervention) or placebo (7 g dextrose) (control).	Two group comparison: muscle strength (handgrip, ankle dorsiflexion, knee extension), fat-free mass (DXA), physical performance (chair rise, stair climb, walking speed).
Tarnopolskyet al^Citation39	Canada. Community-dwelling older men and women, aged 65+ years.	39	6-month intervention. All participants received exercise training but randomized to i) supplementation with creatine monohydrate and conjugated linoleic acid, ii) placebo (double-blind allocation).	Resistance exercise training program; participants exercised twice per week.	Daily supplementation with creatine monohydrate (5 g) + conjugated linoleic acid (6 g) +2 g dextrose or placebo (7 g dextrose +6 g safflower oil).	Two group comparison: muscle strength (handgrip, ankle dorsiflexion, knee extension), endurance, fat free mass (DXA), physical performance (chair rise, stair climb, walking speed, balance).

Note:

* N, randomized.

Abbreviations: DXA, dual-energy X-ray absorptiometry; SPPB, short physical performance battery; BIA, bioelectrical impedance analysis; COPD, chronic obstructive pulmonary disease; CT, computed tomography; m, metres; RDA, recommended daily allowance.

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