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Nutritionalappoachto mitigating injury-associated muscleloss By Iris Zieler (Medical StudentatUniversity College London) Kindly hosted byUCL LifestyleMedicine Society Special thanks to Dr. Oliver Witard & Dr.CourtneyKippsfortheir expertise and guidance ©️ Iris Zieler Outline 1.0 Injury/disuse-associated muscularatrophy 2.0 Nutritionalconsiderations forthe immobilised athlete 2.1 Wound healing 2.2 Crutching 2.3 Positive energy balance 3.0 Proteininterventions 3.1 Dose 3.2 Pattern 3.3 Source 4.0 The role ofothernutrients 4.1 Creatine 4.2 Omega-3 FAs 4.2.1 CriticalAnalysis 4.3 Alcohol 5.0 Nutritionrecommendations ©️ Iris Zieler Loss of musclemassis measurableafteronly5 daysofinjury-stimulatedimmobilisation Changes in muscle mass Quadriceps CSA % change 0 -1 5d 14d -2 -3 The initial rate of muscle atrophy during limb immobilization is 0.5% per day -5 -6 -7 -8 ? -9 ← No/restricted weight bearing & physical exercise → Acta Physiol2013 ©️ Iris Zieler Loss of musclestrength is measurableafteronly 5 days ofinjury-stimulatedimmobilisation Wall et al. Acta Physiol2013 ©️ Iris Zieler Muscleloss duringimmobilisation isunderpinned by anegativenetmuscleproteinbalance Areaof B> Area ofA= Decrease inmuscle mass Phillips etal. JACN 2005 ©️ Iris Zieler Whatismuscleprotein synthesis(MPS)and whyshouldaninjuredathletecare? ©️ Iris Zieler Immobilisation leads toAnabolicResistance Mixed muscleproteinsynthesis(%/h) + indirect evidence from static markers that MPB may be transiently increased during the early stages (<1 week) of immobilization JCEM 2013. ©️ Iris Zieler Low-gradeinflammationimpairs stimulation ofMPS inresponsetofoodintake(in rats) 6 Fasted Fed t b r s h a a a n ) 4 s / a % i S c ( f 2 l s u M 0 No ninflm med Low grade infmamed Balageetal. J Nutr Biochemistry2010 ©️ Iris Zieler Nutritionalconsiderationsforthe immobilisedathlete ©️ Iris Zieler 2 PhasesofInjurywith differentrequirements 1 Phase1: Immobilisation Counter negativeconsequencesof injury-induced immobilisation ➢ ↓ Energy expenditure ~0-14 dayspost-injury 2 Phase 2: Recovery Acceleratemuscleregeneration &recovery ➢ ↑ Energy expenditure ~14days– 6 weekspost-injury ©️ Iris Zieler Magnitudeof decreasein energy expenditure following injury with limb immobilisationislikelynotasgreatas oftenthought ©️ Iris Zieler 1.Woundhealing increases metabolicrate • Surgery ↑ MR by ~20% • Burn injury ↑ MR by up to 100% • Wound, infection,traumatic injury ↑ MR by up to 50% ©️ Iris Zieler 2.Ambulation withcastedleg increases metabolicrate Oxygen Consumption mL/min/kg 20 15 10 5 0 Walk ACW ECW Weightbearing short Non-weight bearing cast long leg cast Lee J Orthop Trauma 1987 ©️ Iris Zieler 3.Energydeficitreduces rateofMPS FSR (%/h) Mixed Muscle Protein Synthesis 0.08 Reduced energy intake impairs collagen synthesis, tissue granulation, matrix protein deposition, 0.04 etc. for wound healing 0 WM ED Pasiakosetal. J Nutr2010 ©️ Iris Zieler Positiveenergybalanceaccelerates muscle lossduringinactivity Plasma CRP % change 60 40 20 0 HIGH LOW -20 -40 -60 Bioloetal. AJCN 2008 ©️ Iris Zieler KeyPoint Both positiveand negativeenergy balance have detrimentaleffectsonrecoveryfrom injury So, careful assessmentofenergybalanceis critical to optimiserecoveryfrominjury ©️ Iris Zieler Targetedinterventions toovercomeanabolic resistancein immobilisedathletes 1 ProteinRecommendations 2 AminoAcidSupplementation ©️ Iris Zieler EAA+ CHOsupplementation duringbedrest preservesmusclemass Paddon-Joneset al. JCEM 2004 ©️ Iris Zieler Optimisingproteinnutrition ismorecomplexthan simplyrecommendingdailytotalprotein intake Witard etal. Nutrients2016 ©️ Iris Zieler ~0.3g/kgbodymass proteinissufficientto maximallystimulateMPSinuninjuredyoung adults Moore,Churchward-Venne, Witard J Gerontology 2015 ©️ Iris Zieler Abalancedproteinmealpattern stimulatesgreater daytimeresponseofMPSinyoung adults Mixed muscle protein synthesis (%/h) 0.10 0.08 0.06 0.04 0.02 0.00 Unbalanced Balanced Macnaughton &WitardThe Sp. and ExScientist 2014 Mamerow etal.J Nutr 2014 ©️ Iris Zieler EssentialAminoAcidsupplementation reduces muscleloss following kneesurgery Muscle Volume % change 0 Op Nonop -5 -10 -15 -20 PLA EAA Dreyer et al. ClinMed 2014 ©️ Iris Zieler Leucineamelioratestheearlyloss of musclemass with bedrest 7 days 14 days ) 14 days ) 0.0 N 0 k e s q -5 a -0.5 t m r d Alnine s-10 * b -10 Leucine t n e l e-15 i * n g -1.5 i n e-20 h n C -20 h-25 C Change in lean body mass (kg) Change in knee extensor torque (Nm) AJCN 2016t al. ©️ Iris Zieler Leucine+ EAA supplementationcan reverseattenuated MPSinelderly Potential for application in immobilization-induced anabolic resistance Katsanosetal. AJ Phys 2006 ©️ Iris Zieler Theroleofothernutrients ©️ Iris Zieler Creatine Muscle Power after 12 wks of Rehabilitation e Following ACL Surgery Muscle Size after 10 wks of Rehabilitation i e Following 2 weeks of Casting e i x 80 r b 70 x 25 h e r 60 a 20 t 50 h w r 15 e 40 t a 30 w 10 c e i 20 a 5 % 10 r c 0 0 i Immob Non-Immob Knee Ext Knee Flex % Cr Pl Cr Pl Hespel etal. AJSM 2001 Tyler et al. AJSM 2002 ©️ Iris Zieler Positiveeffectof Omega-3supplementationon overallbodymusclemass andstrength Bidet al. ClinNut ESPN 2021 ©️ Iris Zieler Butisthistranslatabletoathletes? Study populations: 1 Disease populations:cancerorCOPD Causesofmuscular atrophy: insufficient energyintake (nausea/vomiting),inability toperformMPS-stimulating boutsof exercise Were they previouslytrained? 2 Healthyindividuals afterfatiguingexercise bout No reason to expect (&thustrytomitigate) muscle loss: not immobilised Havejustactivated MPSmachinery ➢ Post-exercisefatigue canbeconsidered‘physiological’ ©️ Iris Zieler Omega-3 fattyacidsupplementation attenuatesskeletalmuscledisuseatrophy McGlory etal.2019 ©️ Iris Zieler Incorporation ofEPA/DHAintomusclephospholipid membraneupregulatesanaboliccellsignaling s ) Focal adhesion i A d BKinase (FAK) activity a 10.0 c 14.0 y a 4.00 a 8.0 t 12.0 l l 10.0 o 6.0 c t 3.00 c * Fishoilsupplementationincreases omega-3 compositionofskeletal muscle, whichprimesthemto b o 4.0 b o 6.0 a,b ( a a,b respondto anabolic%timulation 2.00 A ( 4.0 H 2.0 F 2.0 1.00 + U A 0.0 3 0.0 P n 0.00 E 0 1 2 4 0 1 2 4 Week -1.00 Week 0 1 2 4 Week McGlory etal.2014 ©️ Iris Zieler Alcoholconsumptionimpairs MPS responseto protein ingestionduringexerciserecovery • Physically-activeyoung adults Myofibrillar-MPS • REx+ EE+ HIT 0.08 • 25g wheyproteinOR 25gwhey +1.5g/kg BM alcohol 0.06 b • Restingand post-exercisemeasurements ofMPS c 0.04 a 0.02 0.00 Rest PRO ALC+PRO PlosOne 2014 ©️ Iris Zieler Recommendationstominimisemuscleloss duringinjury-associatedimmobilisation • Avoiding deficiencies (including energy) • Ample Protein (+ Leucine) • Timed protein intakemay beadvisable • Omega-3 supplementation • Potential benefitsof Creatine • Limit alcoholintake ©️ Iris Zieler Questions? ©️ Iris Zieler