肌肉萎縮

圓肩的原因可能是肩部的肌肉萎縮，正常肩部是隆起，肌肉萎縮以后，會出現(xiàn)肩膀變圓像下沉一樣，是肌肉的外形變小，應(yīng)該還是與直接的神經(jīng)損傷有關(guān)系。還有一種原因叫肌肉萎縮性頸椎病。臨床上有時候會遇到，一般頸椎病引起的圓肩是單側(cè)性，一側(cè)的肩膀變小變圓，另一側(cè)還是正常。如果兩側(cè)同時發(fā)生一般與頸椎關(guān)系不大，可能是神經(jīng)內(nèi)科方面的問題，神經(jīng)發(fā)育出現(xiàn)問題，或者是肌肉的營養(yǎng)系統(tǒng)出問題。不管是頸椎還是腰椎壓迫神經(jīng)造成，大多數(shù)是單側(cè)的，而不會雙側(cè)對稱發(fā)生。

肌少癥不但要有肌肉質(zhì)量（musclemass）減少，同時還要存在肌肉力量(mesclestrength)和/或軀體功能（phisicalperformance）的下降。糖尿病、冠心病、慢阻肺等多種疾病容易合并肌少癥，導致患者生存質(zhì)量下降，原發(fā)病治療困難。發(fā)現(xiàn)和治療肌少癥對于老年人尤為重要。

我們一直說腹橫肌好比腰椎保護的金腰帶，360°保護著人體腹部的組織，維護著腰椎的穩(wěn)定。那么，多裂肌是不是很重要呢？多裂肌是唯一從腰骶部跨越至背部的肌肉，其位于脊柱最內(nèi)側(cè)，覆蓋全脊柱，是附著面積最大的椎旁肌。因為多裂肌的力線位于腰部曲線的后部，可以起到“弓弦”的作用，使脊柱保持伸展并且增加腰椎的前凸。斜行的肌纖維可以使上部身體產(chǎn)生旋轉(zhuǎn)，如果沒有多裂肌的作用，腰椎的屈曲將會被強制約束，防止腰椎過度屈曲出現(xiàn)損傷。同時在脊柱單純旋轉(zhuǎn)時保持直立（而不出現(xiàn)前屈）。多裂肌纖維是位于腰骶結(jié)合部(L5-S1)后方的唯一肌肉纖維，由于該部位前傾明顯，多裂肌必須產(chǎn)生足夠的拉力保證L5椎體不向前滑移超過骶骨的前緣（脊椎滑脫）。慶幸的是，多裂肌大量精確地聚集在脊椎這個部位，但是不幸的是，它經(jīng)常得不到鍛煉出現(xiàn)廢用性萎縮，而被脂肪組織滲透替代。多裂肌作為腰椎穩(wěn)定性的重要來源，其萎縮與腰椎椎間盤突出癥、腰椎椎管狹窄癥、腰椎滑脫癥等腰椎退行性疾病關(guān)系密切。TeichtahlAJ，UrquhartDM，WangY，etal.Fatinfiltrationofparaspinalmusclesisassociatedwithlowbackpain，disability，andstructuralabnormalitiesincommunity-basedadults［J］.SpineJ，2015，15（7）：1593-1601.1腰椎椎間盤突出癥在腰椎椎間盤突出癥患者中，患側(cè)多裂肌的脂肪浸潤程度高于健側(cè)、CSA小于健側(cè)；和健康組相比，患側(cè)多裂肌CSA也明顯減小、脂肪浸潤程度增加。表明椎間盤突出引起神經(jīng)根癥狀持續(xù)時間越長，肌肉神經(jīng)源性改變的風險增加。故腰椎椎間盤突出對神經(jīng)造成的壓迫損傷，會導致神經(jīng)所支配的多裂肌發(fā)生萎縮。haoWP，KawaguchiY，MatsuiH，etal.Histochemistryandmorphologyofthemultifidusmuscleinlumbardischerniation：comparativestudybetweendiseasedandnormalsides［J］.Spine（PhilaPa1976），2000，25（17）：2191-2199.2腰椎滑脫癥在不同節(jié)段滑脫節(jié)段多裂肌的脂肪浸潤程度明顯增高，滑脫層面的多裂肌脂肪浸潤程度顯著高于其他非滑脫層面，II度滑脫的多裂肌脂肪浸潤程度明顯高于I度滑脫。腰椎滑脫患者進行l(wèi)ogistic回歸分析，發(fā)現(xiàn)多裂肌脂肪浸潤是促進腰椎滑脫的一個重要因素，認為多裂肌萎縮是退行性腰椎滑脫的一個重要原因。表明多裂肌萎縮與退行性腰椎滑脫可能互為影響。WangG，KarkiSB，XuS，etal.QuantitativeMRIandX-rayanalysisofdiscdegenerationandparaspinalmusclechangesindegenerativespondylolisthesis［J］.JBackMusculoskeletRehabil，2015，28（2）：277-285.3腰椎椎管狹窄癥腰椎椎管狹窄癥患者多裂肌脂肪浸潤的增加、腰大肌RCSA的降低與患者的機體功能降低有關(guān)（更高的疼痛評分），但多裂肌的脂肪浸潤程度與腰椎椎管狹窄程度和下腰痛持續(xù)時間無關(guān)。腰椎椎管狹窄癥患者多裂肌萎縮可降低患者的功能狀態(tài)。FortinM，Lazáryà，VargaPP，etal.Associationbetweenparaspinalmusclemorphology，clinicalsymptomsandfunctionalstatusinpatientswithlumbarspinalstenosis［J］.EurSpineJ，2017，26（10）：2543-2551.4脊柱后凸腰椎后凸患者的多裂肌萎縮程度顯著高于慢性下腰痛患者，logistic回歸分析發(fā)現(xiàn)，多裂肌CSA比其他椎旁肌CSA下降的更多，表明多裂肌的萎縮在腰椎后凸患者中更具有特異性。退行性脊柱后凸患者L2以上的多裂肌可能主要維持腰椎的曲度，L2以下的多裂肌可能主要控制腰椎的旋轉(zhuǎn)，多裂肌萎縮可能會加重胸腰椎后凸和矢狀面失衡，從而擾亂腰椎矢狀面平衡，揭示了多裂肌萎縮可能是促進脊柱后凸發(fā)生、發(fā)展的重要因素。XiaW，F(xiàn)uH，ZhuZ，etal.Associationbetweenbackmuscledegenerationandspinal-pelvicparametersinpatientswithdegenerativespinalkyphosis［J］.BMCMusculoskeletDisord，2019，20（1）：454.因此，腰椎退行性疾病會對多裂肌形態(tài)和功能造成影響，而多裂肌萎縮也會加重腰椎退行性變。由于多裂肌與腰椎穩(wěn)定性密切相關(guān)，多裂肌良好的生理功能是減緩腰椎退行性變和獲得滿意預后的重要條件。

肌肉減少癥的病因、治療及康復鍛煉：最新研究進展陶可（北京大學人民醫(yī)院骨關(guān)節(jié)科）什么是肌肉減少癥？肌肉減少癥這個詞的意思是“缺乏肌肉”，一旦你了解了這種情況，它就明白了。肌肉減少癥是一種與年齡相關(guān)的肌肉退化有關(guān)的疾病。它在50歲以上的人群中更相關(guān)也更常見。30歲以后，人開始失去肌肉力量。根據(jù)2004年發(fā)表在CurrentOpinioninClinicalNutritionandMetabolicCare上的一篇評論，人們往往每十年失去3%到8%的肌肉力量(1)。失去肌肉力量會降低您進行日?；顒雍腿粘Ｈ蝿?wù)的能力。它可能會增加患殘疾、失去獨立性和需要護理的風險。它可能會增加跌倒、事故、受傷、骨折、住院、手術(shù)和術(shù)后并發(fā)癥的風險?？紤]到住院和家庭護理的費用，肌肉減少癥也會變得非常昂貴。根據(jù)WorldviewsonEvidence-BasedNursing發(fā)表的2016年評論，肌肉減少癥還可能縮短您的壽命(2)。根據(jù)2015年發(fā)表在《營養(yǎng)學會會刊》上的一篇評論，肌肉減少癥的發(fā)生可能是由于肌肉細胞生長（合成代謝）信號和分解信號（分解代謝）信號之間的不平衡(3)。在一個健康的身體里，你的生長激素與蛋白質(zhì)破壞酶一起工作，在肌肉生長、壓力、損傷、分解、破壞、修復和恢復的持續(xù)循環(huán)中保持你的肌肉健康和肌肉質(zhì)量穩(wěn)定。在衰老的身體中，信號之間的不平衡和對生長信號的抵抗可能會發(fā)展，這會導致比合成代謝和肌肉生長更多的分解代謝和肌肉損失。圖1?agingmuscle:衰老的肌肉肌肉減少癥的癥狀肌肉減少癥的癥狀可能包括：?肌肉無力，?（容易）摔倒，?步行速度減緩慢?自我報告的肌肉萎縮?難以執(zhí)行或參與正常的日常任務(wù)和活動?運動時容易感到疲勞肌肉減少癥的根本原因如果您有任何健康問題，請務(wù)必查看問題的根本原因。如果我們著眼于問題的根本原因，我們就可以制定治療策略來解決這些問題，而不是僅僅在癥狀上貼上創(chuàng)可貼（即大家經(jīng)常說的：治標不治本）。肌肉減少癥的根本原因可能包括：圖2?肌肉減少癥的影響與危害：25%的65歲及以上人群受到影響，60%的80歲以上人群受到影響，以肌肉萎縮和活動減少為主要特征。（1）炎癥反應(yīng)：可導致的肌肉減少癥術(shù)語炎癥，也稱為炎癥老化，是指隨著年齡的增長而出現(xiàn)的炎癥反應(yīng)上調(diào)和全身低度炎癥。炎癥會加速衰老過程，并可能使一些與年齡相關(guān)的癥狀和疾病惡化。根據(jù)2013年發(fā)表在Longevity&Healthspan上的一項研究，炎癥可能是先天和后天免疫系統(tǒng)的結(jié)果，它可以增加體內(nèi)炎性細胞因子的產(chǎn)生(4)。這會促進炎癥并導致與年齡相關(guān)的健康問題，包括肌肉衰退。2013年發(fā)表在Thorax上的一項研究發(fā)現(xiàn)，患有慢性阻塞性肺病(COPD)和相關(guān)慢性炎癥的患者的肌肉質(zhì)量也有所下降(5)。還有許多其他以長期慢性炎癥為特征的疾病，包括慢性感染、炎癥性腸病和自身免疫性疾病，可能會增加肌肉減少和肌肉減少癥的風險。根據(jù)2016年發(fā)表在Maturitas上的系統(tǒng)回顧和薈萃分析，較高水平的C反應(yīng)蛋白可能與慢性炎癥和肌肉減少癥有關(guān)(6)。圖3?炎癥可通過一系列復雜的機制和病理過程，影響我們身體的各個重要器官：腦心肝腎肺、肌骨皮膚、腸道和甲狀腺等。（2）蛋白質(zhì)攝入不足：可導致的肌肉減少癥遵循低營養(yǎng)素和高精制糖、精制油、人工成分和過度加工食品的不健康飲食會增加慢性炎癥。注意您的常量營養(yǎng)素也很重要。熱量和蛋白質(zhì)含量過低的飲食不僅會導致體重減輕，還會導致肌肉質(zhì)量下降。蛋白質(zhì)對肌肉健康、肌肉質(zhì)量和肌肉力量至關(guān)重要。蛋白質(zhì)攝入不足可能導致肌肉減少癥。隨著年齡的增長，許多人的牙齒和牙齦出現(xiàn)問題，吞咽困難，口味和食欲發(fā)生變化，購物和烹飪的挑戰(zhàn)也越來越大。這會增加他們無法滿足蛋白質(zhì)和熱量需求的風險。根據(jù)2015年發(fā)表在《臨床醫(yī)學研究雜志》上的一篇評論，每餐攝入25至30克蛋白質(zhì)可能有助于降低肌肉減少癥的風險(7)。圖4?蛋白質(zhì)攝入對人體的8點益處：①維持穩(wěn)定的血糖；②改善脂肪利用效率；③促進肌肉重建；④提高記憶與學習能力；⑤保持積極的心態(tài)；⑥心臟正常的功能所必須；⑦減緩衰老進程并有可能長壽；⑧改善骨密度（3）胃酸水平低：所致的肌肉減少癥胃酸是一種水狀無色液體，由胃壁形成，可促進消化。顧名思義，胃酸是非常酸性的，它支持食物的分解以進行適當?shù)南?。胃酸還有助于營養(yǎng)物質(zhì)的適當吸收。胃酸水平低下顯然會導致消化問題。如果您的胃酸水平較低，您的身體可能無法分解和吸收食物中的蛋白質(zhì)和其他營養(yǎng)物質(zhì)。這不僅會導致消化問題，還會導致慢性炎癥和健康并發(fā)癥。根據(jù)2022年發(fā)表在《營養(yǎng)學》雜志上的一項研究，胃動力差可能與老年人的肌肉減少癥有關(guān)(8)。2019年發(fā)表在《科學報告》(ScienceReports)上的一項研究將與低胃酸水平相關(guān)的胃食管反流病與骨骼肌衰減不良和肌肉減少癥聯(lián)系起來(9)。圖5?胃酸的7大主要功能：①殺滅食物中的病菌，達到無菌化處理；②蛋白質(zhì)分解；③激活胃蛋白酶（胃內(nèi)最重要的消化酶）；④活化內(nèi)源性因子；⑤促進膽汁和膽酶轉(zhuǎn)運（至十二指腸）；⑥關(guān)閉食管括約?。ㄎ傅娜肟?，以便胃酸不易反流至食管，造成胃食管反流病，避免食管胃酸液的化學性腐蝕、損傷）；⑦打開幽門括約肌（胃的排出口，以便經(jīng)胃酸消化的食物，進入小腸內(nèi)，便于吸收）（4）腸道菌群失調(diào)：可致肌肉減少癥您的腸道是數(shù)萬億細菌和微生物的家園。其中一些微生物對您的健康有益，而另一些則對您的健康有害。關(guān)鍵是腸道微生物失衡，有益細菌多于有害細菌。不幸的是，炎癥性飲食、不良的生活方式選擇、營養(yǎng)失衡、壓力、環(huán)境毒素和其他因素都會破壞平衡。腸道菌群失調(diào)意味著腸道微生物群失衡，有害細菌過多而有益細菌過少。腸道菌群失調(diào)會導致慢性炎癥和慢性嚴重健康問題的風險。它還可能增加患肌肉減少癥的風險。2018年發(fā)表在MediatorsofInflammation上的一項研究發(fā)現(xiàn)，腸道菌群失調(diào)可能在與年齡相關(guān)的炎癥、炎癥、肌肉老化和肌肉減少癥中發(fā)揮作用(10)。研究人員發(fā)現(xiàn)，在解決肌肉減少癥時，針對腸道菌群失調(diào)可能很重要。發(fā)表在惡病質(zhì)、肌肉減少癥和肌肉雜志（Cachexia,Sarcopenia,andMuscle）上的2021年系統(tǒng)綜述支持了這些發(fā)現(xiàn)，并發(fā)現(xiàn)腸道生態(tài)失調(diào)可能在肌肉減少癥的發(fā)展中發(fā)揮關(guān)鍵作用(11)。圖6?腸道菌群失調(diào)是腸道內(nèi)菌群的失平衡，即有益菌（益生菌，goodbacteria）減少的同時，機會致病菌（有害菌，opportunisticbacteria）大量繁殖（5）慢性壓力和睡眠質(zhì)量差：可致肌肉減少癥慢性壓力和睡眠不佳是慢性炎癥、炎癥和與年齡相關(guān)的健康問題（包括肌肉減少癥）背后的主要潛在因素。根據(jù)2018年發(fā)表在激素雜志上的一項研究，慢性壓力可能在身體成分失調(diào)中發(fā)揮作用，包括肌肉減少癥(12)。與健康問題相關(guān)的慢性和嚴重壓力也可能導致肌肉減少癥。根據(jù)2015年發(fā)表在《營養(yǎng)學會會刊》上的評論、2016年發(fā)表在《當前胃腸病學報告》上的評論、2016年發(fā)表在《腎泌尿?qū)W月刊》上的評論和2016年發(fā)表在《營養(yǎng)學會會刊》上的評論，與慢性壓力相關(guān)的壓力肝病、慢性心力衰竭、慢性腎病和癌癥治療可能會導致肌肉減少和肌肉減少癥(13,14,15,16)。慢性壓力會導致睡眠不佳。然而，睡眠不足也會導致慢性壓力。睡眠不佳和慢性壓力都會增加慢性炎癥。而慢性炎癥會導致睡眠不佳和慢性壓力。慢性壓力、睡眠不佳和慢性壓力的循環(huán)會增加肌肉流失的風險。2017年發(fā)表在《醫(yī)學》（巴爾的摩）雜志上的一項橫斷面研究發(fā)現(xiàn)睡眠持續(xù)時間與肌肉減少癥之間存在聯(lián)系(17)。根據(jù)發(fā)表在《臨床醫(yī)學雜志》上的2019年系統(tǒng)評價和薈萃分析，睡眠質(zhì)量差會對肌肉減少癥產(chǎn)生負面影響(18)。圖7?慢性壓力的主要癥狀（磨牙、冷漠、注意力不能集中、易憤怒、焦慮、頭痛、肌肉緊張、胃腸道病、皮膚刺激、性欲下降、易疲勞）及其對身體的影響巨大teethgrinding,apathy,troubleconcentrating,anger,anxiety,headaches,muscletension,stomachproblems,skinirritations,decreasedsexdrive,fatigue肌肉減少癥的自然支持防治策略幸運的是，在一些簡單的飲食、生活方式和營養(yǎng)補充策略的幫助下，您可以自然地改善健康。我推薦以下針對肌肉減少癥的自然支持策略：（1）抗炎營養(yǎng)計劃慢性炎癥反應(yīng)是肌肉減少癥的一些主要原因(4,5,6)。炎癥性飲食是慢性炎癥和炎癥的主要驅(qū)動因素之一。食用精制糖和精制油會加劇炎癥并加速炎癥，這可能會導致肌肉減少癥。根據(jù)2020年發(fā)表在《營養(yǎng)雜志》上的一項研究，飲食的炎癥潛力與患肌肉減少癥的風險之間存在聯(lián)系(19)。我建議去除所有精制糖和碳水化合物、精制油、人造成分、油炸食品、垃圾食品和過度加工食品。食用富含營養(yǎng)和抗炎天然食物的飲食。多吃綠色蔬菜、香草、香料、豆芽、發(fā)酵食品、低升糖指數(shù)水果（如蘋果、香蕉、番茄、橙子等）、草飼牛肉、內(nèi)臟肉、牧場飼養(yǎng)的家禽和雞蛋、草飼動物的黃油和酥油、野生魚和野生動物（禁止吃國家野生動物保護法明文保護的動物）。盡可能吃有機食品。圖8?抑制炎癥反應(yīng)的食物（anti-inflammatoryfoods）與促進炎癥反應(yīng)的食物（pro-inflammatoryfoods）圖8-1?精煉油Refinedoil只不過是普通油的“精煉”版本。精煉過程涉及化學物質(zhì)，這些化學物質(zhì)在一定數(shù)量上對我們的健康有害。油的“凈化”是通過用酸、堿或漂白處理來完成的。精制油也經(jīng)過中和、過濾或除臭。所有這些過程都涉及己烷等化學品Refinedoilisnothingbutthe'refined'versionofthenormaloil.Theprocessofrefininginvolveschemicals,whichincertainquantities,areharmfultoourhealth.The'purification'oftheoilisdonebytreatingitwithacid,alkaliorbybleaching.Refinedoilisalsoneutralized,filteredordeodorized.Alloftheseprocessesinvolvechemicalssuchashexane（2）優(yōu)質(zhì)蛋白質(zhì)的攝入蛋白質(zhì)攝入不足會導致肌肉流失并增加患肌肉減少癥的風險(7)。確保在營養(yǎng)豐富、抗炎的飲食中攝入足夠的蛋白質(zhì)。目標是每磅體重攝入0.5至1克蛋白質(zhì)。我建議您主要關(guān)注健康的動物性蛋白質(zhì)，包括草飼牛肉、內(nèi)臟肉、牧場飼養(yǎng)的家禽和雞蛋、野生魚類和海鮮（痛風患者需注意選擇不易影響血尿酸的食物）。如果您難以通過食物滿足蛋白質(zhì)需求，可以使用蛋白粉來幫助獲取足夠的蛋白質(zhì)。堅果和種子可以添加額外的植物性蛋白質(zhì)。我不推薦豆類和小扁豆，尤其是不要大量食用，因為它們的碳水化合物含量很高，可能會導致消化不適。我建議避免食用谷物，因為它們含有麩質(zhì)和碳水化合物。圖9?決定蛋白質(zhì)攝入的目標：①體重控制減少，每日攝入蛋白量1-1.5g/kg體重，如果您的體重是70kg，那么每天蛋白質(zhì)需要70-105g即可；②重塑肌肉，每日攝入蛋白量1.5-2.0g/kg體重，如果您的體重是70kg，那么每天蛋白質(zhì)需要105-140g即可；③運動員，每日攝入蛋白量1.8-2.5g/kg體重，如果您的體重是70kg，那么每天蛋白質(zhì)需要126-175g即可；④久坐不動的朋友，每日攝入蛋白量1.0-1.2g/kg體重，如果您的體重是70kg，那么每天蛋白質(zhì)需要70-84g即可sedentaryindividuals（3）抗阻力訓練缺乏運動和久坐不動的生活方式會增加肌肉無力、肌肉流失和肌肉減少癥的風險。根據(jù)2015年發(fā)表在《臨床密度測定雜志》上的一篇評論，沒有充分使用肌肉是肌肉減少癥的主要驅(qū)動因素之一(20)。根據(jù)2016年發(fā)表在《脆弱與衰老雜志》上的一篇評論，生病或受傷后臥床休息和不活動會導致老年人肌肉快速流失(21)。由于不活動和久坐不動的生活方式導致的肌肉力量下降會導致疲勞、虛弱和力量不佳，這可能會使鍛煉變得更加困難，運動的動力也會降低。這會導致不活動、肌肉損失和疲勞的惡性循環(huán)。定期移動身體，更重要的是，進行阻力和力量訓練對于提高肌肉力量、質(zhì)量和健康以及降低肌肉減少癥的風險至關(guān)重要。我建議每周至少進行3到4天的阻力訓練。嘗試復合運動，例如深蹲、硬拉、推舉、劃船等。與物理治療師或教練一起工作可以幫助您學習正確的形式，安全地嘗試新的練習，并有效地提高您的力量。如果您正從一段時間的受傷、疾病或不活動中恢復過來，這可能尤為重要。如果您對阻力訓練和鍛煉完全陌生，這也是一個不錯的選擇。圖10?高強度間歇和阻力訓練的對于肌肉減少癥明顯有益（選擇適合自己的日常鍛煉方式，量力而行）highintensityintervalandresistancetrainingbenefits（4）限時飲食或間歇性禁食限時進食或間歇性禁食也可能有助于降低肌肉減少癥的風險。根據(jù)2014年發(fā)表在《國際健康科學雜志》(Qassim)上的一項研究，間歇性禁食可以減少炎癥和相關(guān)疾病的風險(22)。1988年發(fā)表在《臨床研究雜志》上的一項研究發(fā)現(xiàn)，間歇性禁食還可以改善人類生長激素(HGH)的分泌和水平，從而有助于改善肌肉質(zhì)量(23)。根據(jù)2019年發(fā)表在《營養(yǎng)學》雜志上的一項研究，間歇性禁食還可以提高支持關(guān)節(jié)和皮膚健康的膠原蛋白水平24)。我建議實行限時進食。理想情況下，我建議在6到10小時的進食窗口和14-18小時的禁食窗口期間進食。如果您不熟悉限時喂食，請從12小時的隔夜禁食開始。晚餐后停止進食，直到12小時后的第二天早餐才進食。逐漸延長禁食時間，直到找到適合自己的方法。記住不要在進食窗口期間限制自己。食用含有大量健康脂肪、足夠蛋白質(zhì)和大量微量營養(yǎng)素的抗炎全食，以滿足您的熱量和營養(yǎng)需求。圖11?7步法輕松搞定間歇性禁食（每位朋友，可以根據(jù)自己情況量力而行，而非推薦必須執(zhí)行上述禁食）：①simplefast:12hours，簡單常規(guī)的禁食12小時；②brunchfast:14hours，早午餐一起吃，禁食14小時，③crescendofast:16hours，漸進式禁食16小時，每周2天，④cyclefast:16hours，循環(huán)禁食16小時，每周3次，⑤strongfast:18hours，增強禁食18小時，每天一次，⑥warriorfast:19-21hours，激進禁食19-21小時，每天一次，⑦1dayfast:18hoursfasteachweek，徹底禁食24小時，每周一天（5）減輕壓力和改善睡眠質(zhì)量慢性壓力和睡眠不足可能會增加肌肉減少癥的風險(12,13,14,15,16,17,18)。減輕壓力水平和改善睡眠質(zhì)量可能會有所幫助。我建議練習冥想、呼吸、引導式放松技巧、祈禱和感恩，以降低壓力水平并更好地應(yīng)對壓力。寫日記可能有助于釋放情緒壓力并發(fā)現(xiàn)消極的心理漏洞。練習心態(tài)轉(zhuǎn)變和積極肯定?；〞r間在大自然中。花時間與支持你的朋友、家人和社區(qū)成員在一起。目標是每晚睡7到9個小時。大約在同一時間睡覺和起床，以支持您的晝夜節(jié)律。睡前至少兩小時避免：①糖、②咖啡因、③過量飲食（最好是所有食物）、④酒精、⑤電子產(chǎn)品和⑥壓力過大。參加放松的活動，例如拼圖、寫日記、閱讀、冥想、治療浴、喝涼茶，以及在晚上平靜地交談。買一張有支撐力的床、有支撐力且舒適的床墊、枕頭和床上用品、遮光窗簾和眼罩，以獲得更好的睡眠。圖12?良好夜間睡眠的方法：①床要舒適、②臥室盡量黑、③可以戴眼罩、④睡前8小時避免咖啡、⑤3小時前避免吃東西、⑥白天多曬太陽、⑦規(guī)律鍛煉，而非睡前鍛煉、⑧夜晚避免強亮燈環(huán)境、⑨九點入睡（6）改善胃酸水平胃酸水平低下也會導致肌肉減少癥(8,9)。改善胃酸水平至關(guān)重要。?①全天使用液體營養(yǎng)：盡量確保至少一半的膳食是液體形式，例如蛋白質(zhì)奶昔或綠色奶昔（廣東人講究的喝湯是很有道理的）。蛋白質(zhì)奶昔是預代謝的，非常容易消化，不依賴于胃酸HCL的產(chǎn)生。如果您的胃酸HCL含量較低，每天喝一到兩杯蛋白質(zhì)奶昔可能會有所幫助，以支持氨基酸的吸收，減少對消化的額外壓力，并支持健康的胃酸水平。?②使用生姜：生姜是改善消化液的最佳物質(zhì)之一。我建議每天喝2至3杯姜茶，您可以將姜精油放入水中（2至3滴放入8盎司水中）(1盎司=31g=31ml)，每天將1/2英寸的新鮮姜根放入綠汁中(1英寸=2.54厘米)，然后使用在你的食物上磨碎生姜。您還可以在飲食中加入發(fā)酵生姜，這在泡菜等亞洲菜肴中很常見。由于辛辣食物可能會引發(fā)反流問題，因此請確保它不會為您引發(fā)。如果是，請專注于其他步驟。?③進餐時間以外的超級水合物：良好的水合作用可以幫助激活腸蠕動并推動內(nèi)容物通過消化系統(tǒng)，從而減少體內(nèi)的微生物發(fā)酵和毒性。這有助于維持胃酸水平。?④吃肉時少喝水：當您吃肉或任何較重的食物時，您應(yīng)該至少在餐前30分鐘停止飲用水或其他液體，除非您需要補充2盎司的水，在這些進餐期間不喝水將減少胃液的任何潛在稀釋并允許更好的消化（飯前不建議大量飲水、吃水果、冷飲或果汁等稀釋胃液的物品）。?⑤飯后不要喝水：為了實現(xiàn)最佳消化，我還建議至少在飯后30分鐘后再喝水或其他液體。這允許適當?shù)奈杆峄顒?、殺菌和蛋白質(zhì)代謝。?⑥使用檸檬和蘋果醋：擠壓新鮮檸檬或在肉類和蔬菜上使用檸檬汁或蘋果醋有助于預先代謝食物并支持更好的消化和營養(yǎng)吸收（這可能是為何西方餐食，開胃配水，都會加上檸檬的原因）。您可以用檸檬或蘋果醋腌制食物，也可以在食用前將它們作為調(diào)料添加。再次確保蘋果醋不會引發(fā)任何反流癥狀，關(guān)注我的其他建議。?⑦開餐時吃蛋白質(zhì)食物：當您開始進食時，特別是當您攝入蛋白質(zhì)時，胃會開始攪動胃酸。雖然在他們的蛋白質(zhì)菜肴之前吃沙拉在文化上很常見，但這對您的胃酸HCL生產(chǎn)來說并不好。將蛋白質(zhì)與沙拉或蔬菜一起吃而不是之后吃是一個更好的主意。?⑧使用發(fā)酵蔬菜：酸菜、泡菜、泡菜、腌姜和其他發(fā)酵蔬菜等發(fā)酵食品都含有有機酸、酶和益生菌，有助于改善消化液分泌（韓國泡菜？但腌制的蔬菜可能會含有較多的細菌，且煙硝酸鹽含量往往過高，不建議多吃或經(jīng)常吃）。我建議您在所有較重的膳食中使用其中一種尤其是任何含蛋白質(zhì)的食物。?⑨使用發(fā)酵飲料：發(fā)酵飲料，如蘋果醋、椰子開菲爾和康普茶，具有抗菌功效，有助于減少細菌負荷，尤其是胃中的細菌，如幽門螺桿菌。保持幽門螺桿菌水平下降對于身體能夠產(chǎn)生足夠的胃酸至關(guān)重要。?⑩在最放松的時候吃最大的一餐：您的身體需要激活副交感神經(jīng)系統(tǒng)以產(chǎn)生足夠的胃酸。如果您很忙并且在旅途中，您將處于戰(zhàn)斗或逃跑的同情模式。如果您與低胃酸作斗爭，這種戰(zhàn)斗或逃跑狀態(tài)不會讓您的身體產(chǎn)生足夠的能量。飯前放松對改善胃酸分泌很重要。（心情愉快、精神壓力小時，是享用美味的大餐絕佳時機）圖13?10種改善胃酸的好方法（如上面①-⑩所述）（7）支持整體腸道健康和消化腸道菌群失調(diào)和腸道健康狀況不佳也可能增加患肌肉減少癥的風險(10,11)。我建議支持您的整體腸道健康和消化。2021年發(fā)表在《營養(yǎng)前沿》(FrontiersinNutrition)上的一項研究發(fā)現(xiàn)，用益生菌和消化酶靶向腸道微生物群可能有助于肌肉減少癥(25)。2022年發(fā)表在惡病質(zhì)、肌肉減少癥和肌肉雜志上的一項研究發(fā)現(xiàn)，補充益生菌可能支持腸道肌肉軸，并可能減少與年齡相關(guān)的肌肉減少癥(26)。根據(jù)2018年發(fā)表在《臨床營養(yǎng)和代謝護理當前觀點》上的一篇評論，支持蛋白質(zhì)消化可能有助于減少與年齡相關(guān)的肌肉減少癥(27)。多吃富含益生菌的食物富含益生菌的食物包括酸菜、發(fā)酵香草、泡菜、開菲爾、康普茶和酸奶。然而，吃富含益生菌的食物不足以支持您的腸道菌群，尤其是當您正在應(yīng)對腸道微生物失衡和各種慢性腸道健康問題時。益生菌可能有助于改善腸道微生物失衡和消化。我推薦使用Probiocharge1000億（藥店有一點商品化的非處方益生菌可以選擇：雙歧桿菌，培菲康等。在使用前請咨詢你的藥師或醫(yī)生。溫馨提示：益生菌不可以與抗生素等藥物同時服用，且最好用溫水送服）。為了進一步支持您的消化，我還建議使用消化酶（乳酶生片等）。消化酶可能有助于減輕腹瀉和腸易激綜合征IBS的癥狀，這些癥狀通常與膽汁酸吸收不良有關(guān)。我推薦ProteoEnzymes來支持蛋白質(zhì)和整體消化。ProteoEnzymes?影響細胞因子和類花生酸的平衡，促進關(guān)節(jié)舒適度并支持身體維持組織完整性的能力。它還有助于平衡免疫系統(tǒng)，降低自身免疫活性并分解體內(nèi)的致病性生物膜。ProteoEnzymes中的蛋白水解酶可以分解因受傷和組織損傷而產(chǎn)生的蛋白質(zhì)和復合物。據(jù)信，這項活動有助于營養(yǎng)和氧氣的輸送，并可能有助于加快身體恢復和愈合的能力。耐酸膠囊促進酶的全身遞送。每餐服用或根據(jù)需要服用。圖14?建議使用益生菌（必要時添加消化酶）（8）補充必需氨基酸獲得足夠的蛋白質(zhì)并滿足您的氨基酸需求對于減少肌肉減少癥至關(guān)重要(7)（推薦每天1-2個雞蛋）。補充必需氨基酸可能會有幫助。我推薦AminoStrongEssentialAminoAcids。AminoStrong?代表了使用氨基酸合成肌肉蛋白質(zhì)的突破。已經(jīng)進行了20多項人體試驗，以得出這種特定的、正在申請專利的氨基酸組合，具有最有效的合成代謝比例。無論您是想增強肌肉力量和功能，還是想防止因缺乏運動或衰老而導致的肌肉流失，AminoStrong都能以正確的比例提供正確的氨基酸，幫助您實現(xiàn)目標并保持健康。包含AminoStrong的氨基酸(AA)配方由國際公認的肌肉代謝和衰老以及長壽領(lǐng)域的研究人員精心開發(fā)和研究。AminoStrong專為尋求刺激肌肉蛋白質(zhì)合成、加速肌肉恢復以及促進肌肉力量和功能的年輕人和老年人而設(shè)計。圖15?建議攝入優(yōu)質(zhì)必須氨基酸（多推薦：雞蛋、各種魚肉、牛肉）（9）考慮使用乳清蛋白獲得足夠的蛋白質(zhì)對于減少肌肉減少癥至關(guān)重要(7)。使用乳清蛋白可能會有所幫助（主要來源于雞蛋清）。我推薦乳清濃香草。強乳清粉是一種美味、高蛋白、低碳水化合物的功能性食品粉。它采用品質(zhì)卓越的乳清蛋白制成，這些乳清蛋白來自新西蘭無農(nóng)藥、非轉(zhuǎn)基因草場上放牧的奶牛，這里被認為是世界上污染最少的環(huán)境之一。奶牛從不喂谷物，也沒有接受激素或抗生素治療。與其他速溶乳清配方不同，WheyStrong不含大豆。乳清蛋白由稱為氨基酸的單個“構(gòu)件”組成，用于制造酶、激素和抗體。乳清蛋白被認為是一種完整的蛋白質(zhì)，因為它含有足夠比例的所有必需氨基酸，這些氨基酸是人體無法制造的，必須通過飲食獲得。它還富含半胱氨酸，有助于在體內(nèi)產(chǎn)生一種重要的抗氧化劑，即谷胱甘肽。乳清蛋白還含有大量支鏈氨基酸(BCAA)，尤其是亮氨酸。亮氨酸的重要作用是鍛煉肌肉。已發(fā)現(xiàn)乳清蛋白支持健康的身體成分。每天將30克（約一勺）混合在8盎司水或任何其他飲料中，或遵照保健醫(yī)生的指示。圖16?建議攝入乳清蛋白（主要來源于雞蛋清）小結(jié)肌肉減少癥是指與年齡相關(guān)的肌肉退化。肌肉質(zhì)量下降和肌肉減少癥可能會降低您參與日常任務(wù)和活動的能力。它可能導致跌倒、受傷、住院、殘疾、喪失獨立性、護理和壽命縮短。幸運的是，借助一些簡單的自然策略，您可以自然地改善肌肉健康。建議您遵循我針對肌肉減少癥的自然支持策略，以隨著年齡的增長保持肌肉質(zhì)量。（文中所涉及優(yōu)質(zhì)蛋白、氨基酸、乳清蛋白等，都可以在日常生活中食材中獲得，不推薦選擇進口商品替代）WhatisSarcopeniaThewordsarcopeniameans“l(fā)ackofflesh”,whichmakessenseonceyouunderstandthecondition.Sarcopeniaisaconditionrelatedtoage-associatedmuscledegeneration.Itismorerelevantandmorecommoninthoseover50yearsofage.Aftertheageof30,peoplestartlosingtheirmusclestrength.Accordingtoa2004reviewpublishedinCurrentOpinioninClinicalNutritionandMetabolicCare,peopletendtolosebetween3to8percentoftheirmusclestrengtheachdecade(1).Losingmusclestrengthcanreduceyourabilitytoperformregulardailyactivitiesandroutinetasks.Itmayincreasetheriskofdevelopingadisability,losingindependence,andneedingcare.Itmayincreasetheriskoffalls,accidents,injuries,fractures,hospitalization,surgeries,andpost-surgerycomplications.Consideringthecostofhospitalizationandhomecare,sarcopeniacanalsobecomeverycostly.Accordingtoa2016reviewpublishedinWorldviewsonEvidence-BasedNursing,sarcopeniamayalsoshortenyourlifespan(2).Accordingtoa2015reviewpublishedinTheProceedingsoftheNutritionalSociety,sarcopeniamaydevelopbecauseoftheimbalancebetweenthesignalsformusclecellgrowth(anabolism)andsignalsforbreakdown(catabolism)(3).Inahealthybody,yourgrowthhormonesworktogetherwithprotein-destroyingenzymestokeepyourmuscleshealthyandmusclemasssteadythroughouttheongoingcycleofmusclegrowth,stress,injury,breakdown,destruction,repair,andrecovery.Inanagingbody,animbalancebetweensignalsandaresistancetogrowthsignalsmaydevelop,whichcancausemorecatabolismandmusclelossoveranabolismandmusclegrowth.SymptomsofSarcopeniaSymptomsofsarcopeniamayinclude:MuscleweaknessFallingSlowwalkingspeedSelf-reportedmusclewastingDifficultyperformingorpartakinginnormaldailytasksandactivitiesFatigueeasilyduringexertionRootCausesofSarcopeniaIfyouhaveanyhealthissues,it’simportanttolookattherootcausesoftheproblem.Ifwelookattherootcauseoftheproblem,wecandeveloptreatmentstrategiestoaddresstheminsteadofonlyputtingabandaidonthesymptoms.Therootcausesofsarcopeniamayinclude:InflammagingTheterminflammaging,alsoknownasinflamm-agingorinflamm-ageing,referstoanupregulatedinflammatoryresponseandalow-gradeinflammationthroughoutthebodythatdevelopswithadvancedage.Inflammagingcanacceleratetheagingprocessandmayworsensomeage-relatedsymptomsanddiseases.Accordingtoa2013studypublishedinLongevity&Healthspan,inflammagingmaybeaconsequenceoftheinnateandacquiredimmunesystemthatcanincreaseinflammatorycytokineproductioninthebody(4).Thiscanpromoteinflammationandcontributetoage-relatedhealthissues,includingmuscledecline.A2013studypublishedinThoraxhasfoundthatpatientswithchronicobstructivepulmonarydisease(COPD)andrelatedchronicinflammationalsohadadeclineinmusclemass(5).Therearemanyotherdiseasesthatarecharacterizedbylong-termchronicinflammation,includingchronicinfections,inflammatoryboweldiseases,andautoimmuneconditions,thatmayincreasetheriskofmusclelossandsarcopenia.Accordingtoa2016systematicreviewandmeta-analysispublishedinMaturitas,higherlevelsofC-reactiveproteinmaybeassociatedwithchronicinflammationandsarcopenia(6).InadequateProteinIntakeFollowinganunhealthydietlowinnutrientsandhighinrefinedsugar,refinedoil,artificialingredients,andoverlyprocessedfoodscanincreasechronicinflammation.Payingattentiontoyourmacronutrientsiscriticalaswell.Adiettoolowincaloriesandtoolowinproteincannotonlyresultinweightloss,butalsoinalossofmusclemass.Proteiniscriticalformusclehealth,musclemass,andmusclestrength.Aninadequateproteinintakemayleadtosarcopenia.Withaging,manypeopledevelopproblemswiththeirteethandgums,haveissuesswallowing,experiencechangesintheirtasteandappetite,andhaveincreasedchallengesshoppingandcooking.Thiscanincreasetheirriskofnotmeetingtheirproteinandcaloricneeds.Accordingtoa2015reviewpublishedintheJournalofClinicalMedicineResearch,consuming25to30gramsofproteinateachmealmayhelptolowertheriskofsarcopenia(7).PoorStomachAcidLevelsStomachacidisalsoknownasgastricacid.Itisawatery,colorlessfluidmadebyyourstomachliningtosupportdigestion.Asitsnamesuggests,stomachacidisveryacidic,whichsupportsthebreakdownoffoodforproperdigestion.Stomachacidalsohelpstheproperabsorptionofnutrients.?Poorstomachacidlevelscanclearlycauseproblemswhenitcomestodigestion.Ifyouhavepoorstomachacidlevels,yourbodymaynotbeabletobreakdownandabsorbproteinandothernutrientsfromfood.Thiscannotonlyleadtodigestiveissuesbutchronicinflammationandhealthcomplications.Accordingtoa2022studypublishedinNutrients,poorgastricmotilitymaybeassociatedwithsarcopeniainolderadults(8).A2019studypublishedinScienceReportshaslinkedgastroesophagealrefluxdisease,associatedwithlowstomachacidlevels,topoorskeletalmuscleattenuationandsarcopenia(9).GutDysbiosisYourgutishometotrillionsofbacteriaandmicrobes.Someofthesemicrobesarebeneficial,othersareharmfultoyourhealth.Thekeyistohaveagutmicrobiomeimbalance,whereyouhavemorebeneficialbacteriathanharmfulones.Unfortunately,aninflammatorydiet,poorlifestylechoices,nutrientimbalances,stress,environmentaltoxins,andotherfactorscandisruptthebalance.?Gutdysbiosismeansthatthereisanimbalanceinyourgutmicrobiome,andtherearetoomanyharmfulbacteriaandtoofewbeneficialones.Gutdysbiosiscancreatechronicinflammationandtheriskofchronicandserioushealthissues.Itmayalsoincreaseyourriskofsarcopenia.A2018studypublishedinMediatorsofInflammationhasfoundthatgutdysbiosismayplayaroleinage-relatedinflammation,inflammaging,muscleaging,andsarcopenia(10).Researchersfoundthattargetinggutdysbiosismaybeimportantwhenaddressingsarcopenia.A2021systematicreviewpublishedintheJournalofCachexia,Sarcopenia,andMusclehassupportedthesefindingsandhasfoundthatgutdysbiosismayplayacriticalroleinthedevelopmentofsarcopenia(11).ChronicStress&PoorSleepQualityChronicstressandpoorsleeparemajorunderlyingfactorsbehindchronicinflammation,inflammaging,andage-relatedhealthissues,includingsarcopenia.Accordingtoa2018studypublishedintheHormones,chronicstressmayplayaroleinbodycompositiondisorders,includingsarcopenia(12).Chronicandseriousstressrelatedtohealthissuesmayalsocontributetosarcopenia.Accordingtoa2015reviewpublishedintheProceedingsoftheNutritionalSociety,a2016reviewpublishedinCurrentGastroenterologyReports,a2016reviewpublishedinNephro-UrologyMonthly,anda2016reviewpublishedintheProceedingsoftheNutritionalSociety,stressrelatedtochronicliverdisease,chronicheartfailure,chronickidneydisease,andcancertreatmentmaycausemusclelossandsarcopenia(13,14,15,16).Chronicstresscancontributetopoorsleep.However,poorsleepcanalsocontributetochronicstress.Bothpoorsleepandchronicstresscanincreasechronicinflammation.AndchronicinflammationcancausepoorsleepandchronicstressThecycleofchronicstress,poorsleep,andchronicstresscanincreasetheriskofmuscleloss.?A2017cross-sectionalstudypublishedinMedicine(Baltimore)hasfoundalinkbetweensleepdurationandsarcopenia(17).Accordingtoa2019systematicreviewandmeta-analysispublishedintheJournalofClinicalMedicine,poorsleepqualitycannegativelyaffectsarcopenia(18).NaturalSupportStrategiesFortunately,withthehelpofsomesimpledietary,lifestyle,andsupplementstrategies,youcanimproveyourhealthnaturally.Irecommendthefollowingnaturalsupportstrategiesforsarcopenia:Anti-InflammatoryNutritionPlanChronicinflammationandinflammagingaresomeofthemainrootcausesofsarcopenia(4,5,6).Aninflammatorydietisoneofthemaindrivingfactorsofchronicinflammationandinflammaging.Consumingrefinedsugarandrefinedoilsdriveupinflammationandaccelerateinflammaging,whichmaycontributetosarcopenia.Accordingtoa2020studypublishedinNutritionJournal,thereisalinkbetweentheinflammatorypotentialofyourdietandtheriskofdevelopingsarcopenia(19).Irecommendremovingallrefinedsugarandcarbs,refinedoils,artificialingredients,deep-friedfoods,junkfoods,andoverlyprocessedfoods.Consumeadiethighinnutrientsandanti-inflammatorywholefoods.Eatplentyofgreens,vegetables,herbs,spices,sprouts,fermentedfood,lowglycemicindexfruits,grass-fedbeef,organmeat,pasture-raisedpoultryandeggs,grass-fedbutterandghee,wild-caughtfish,andwildgame.Eatorganicwheneverpossibleandavailable.OptimizeProteinIntakeInadequateproteinintakecancausemusclelossandincreaseyourriskofsarcopenia(7).Makesurethatwithinyournutrient-dense,anti-inflammatorydiet,yougetenoughproteinin.Aimfor0.5to1gramofproteinperpoundofbodyweight.Irecommendthatyoumainlyfocusonhealthyanimal-basedproteins,includinggrass-fedbeef,organmeat,pasture-raisedpoultryandeggs,wild-caughtfishandseafood,andwildgame.Ifyouhavedifficultymeetingyourproteinneedsthroughfood,youcanuseproteinpowderstohelpgetenoughprotein.Nutsandseedscanaddadditionalplant-basedproteintothemix.Idon’trecommendbeansandlentils,especiallynotinhigheramounts,astheycanbehighincarbohydratesandmaycausedigestivediscomfort.Irecommendavoidinggrainsduetotheirglutenandcarbohydratecontent.DoResistanceTraining?Inactivityandasedentarylifestylecanincreaseyourriskofmuscleweakness,muscleloss,andsarcopenia.Accordingtoa2015reviewpublishedintheJournalofClinicalDensitometry,notusingyourmusclesenoughisoneofthemaindrivingfactorsofsarcopenia(20).Accordingtoa2016reviewpublishedintheJournalofFrailtyandAging,bedrestandinactivityafteranillnessorinjurycancauserapidmusclelossinolderadults(21).?Decreasedmusclestrengthduetoinactivityandasedentarylifestylecanleadtofatigue,weakness,andpoorstrength,whichmaymakeexercisemoredifficultandmotivationtomovelow.Thiscanleadtoaviciouscycleofinactivity,muscleloss,andfatigue.Movingyourbodyregularlyand,moreimportantly,doingresistanceandstrengthtrainingworkoutsiscriticalforimprovingyourmusclestrength,mass,andhealthandreducingtheriskofsarcopenia.?Irecommendresistancetrainingatleast3to4daysaweek.Trycompoundmovementssuchassquats,deadlifts,pushpresses,rows,andsoon.Workingwithaphysicaltherapistortrainercanhelpyoulearntheproperform,trynewexercisessafely,andimproveyourstrengtheffectively.Thismaybeparticularlyimportantifyouarecomingbackfromaperiodofinjury,illness,orinactivity.It’salsoagreatoptionifyouarecompletelynewtoresistancetrainingandexercise.Time-RestrictedFeedingTime-restrictedfeedingorintermittentfastingmayalsohelpreducetheriskofsarcopenia.Accordingtoa2014studypublishedintheInternationalJournalofHealthSciences(Qassim),intermittentfastingmayreduceinflammationandtheriskofassociateddiseases(22).?A1988studypublishedintheJournalofClinicalInvestigationhasfoundthatintermittentfastingmayalsoimprovehumangrowthhormone(HGH)secretionandlevelscontributingtoimprovedmusclemass(23).Accordingtoa2019studypublishedinNutrients,intermittentfastingmayalsoimprovecollagenlevelssupportingjointandskinhealth(24).Irecommendpracticingtime-restrictedfeeding.Ideally,Irecommendeatingduringa6to10-houreatingwindowwitha14-18hourfastingwindow.Ifyouarenewtotime-restrictedfeeding,beginwitha12-hourovernightfast.Stopeatingafterdinneranddon’teatuntilbreakfastthenextday,12hourslater.Extendyourfastingwindowgraduallyuntilyoufindwhatworksforyou.Remembernottorestrictyourselfduringyoureatingwindow.Consumeanti-inflammatorywholefoodswithplentyofhealthyfats,enoughprotein,andlotsofmicronutrientstomeetyourcaloricandnutritionalneeds.ReduceStress&ImproveSleepQualityChronicstressandpoorsleepmayincreasetheriskofsarcopenia?(12,13,14,15,16,17,18).Reducingyourstresslevelsandimprovingyoursleepqualitymayhelp.Irecommendpracticingmeditation,breathwork,guidedrelaxationtechniques,prayer,andgratitudetoreduceyourstresslevelsandrespondtostressbetter.Journalingmayhelptoreleaseemotionalstressandspotnegativementalloopholes.Practicemindsetshiftsandpositiveaffirmation.Spendtimeinnature.Spendtimewithsupportivefriends,family,andcommunitymembers.Aimtoget7to9hoursofsleepanight.Gotobedandwakeuparoundthesametimetosupportyourcircadianrhythm.Avoidsugar,caffeine,heavyfood,ideallyallfood,alcohol,electronics,andstressatleasttwohoursbeforegoingtobed.Engageinrelaxingactivities,suchaspuzzles,journaling,reading,meditation,healingbaths,sippingonherbaltea,andcalmconversationsintheevening.Investinasupportivebed,supportiveandcomfortablemattress,pillows,andbedding,blackoutcurtains,andaneyemaskforbettersleep.ImproveStomachAcidLevelsPoorstomachacidlevelscanalsocontributetosarcopenia(8,9).Improvingyourstomachacidlevelsiscritical.UseLiquidNutritionThroughouttheDay:Trytomakesurethatatleasthalfofyourmealsareinaliquidform,suchasaproteinshakeorgreensmoothie.Proteinshakesarepre-metabolizedandveryeasytodigestanddonotdependuponHCLproduction.IfyouhavelowHCL,itmaybehelpfultodrinkonetotwoproteinshakesdailytosupportaminoacidabsorption,reduceextrastressonyourdigestion,andsupporthealthystomachacidlevels.UseGinger:Gingerisoneofthebestthingsforimprovingdigestivejuices.Irecommenddrinking2to3cupsofgingerteaeachday,youcanputgingeressentialoilinwater(2to3dropsin8ozofwater),?juicea?inchoffreshgingerrootinagreenjuiceeachday,andusegroundgingeronyourfoods.Youcanalsoaddfermentedgingertoyourdiet,whichiscommoninAsiandishessuchaskimchi.Sincespicyfoodscanbetriggeringforrefluxissues,makesurethatitisnottriggeringforyou.Ifitis,focusontheothersteps.SuperHydrateOutsideofMealTimes:Goodhydrationcanhelpactivatebowelmotilityandpushcontentsthroughthedigestivesystemwhichwillreducemicrobialfermentationandtoxicityinthebody.Thiscanhelptosupportyourstomachacidlevels.DrinkVeryLittleWithMeatContainingMeals:Whenyouareeatingmeatoranysortofheavierfood,youshouldstopdrinkingwaterorotherliquidsatleast30minutesbeforethemeal,exceptifyouneedtotakeasupplementwith2ouncesofwater.Holdingoffwaterduringthesemealswillreduceanypotentialdilutionofthegastricjuicesandallowforbetterdigestion.HoldOffOnWaterAfteraMeal:Toallowforoptimaldigestion,Ialsorecommendnotdrinkingwaterorotherliquidsuntilatleast30minutesafterameal.Thisallowsforproperstomachacidactivity,sterilization,andproteinmetabolism.UseLemonandAppleCiderVinegar:Squeezingfreshlemonorusinglemonjuiceorapplecidervinegaronyourmeatandvegetableshelpstopre-metabolizethefoodandsupportbetterdigestionandnutrientabsorption.YoucaneithermarinatefoodsinalemonorACVbaseorjustaddthemasadressingrightbeforeyouconsumethem.Again,makesurethatapplecidervinegarisnottriggeringanyrefluxsymptoms,focusonmyotherrecommendations.EatProteinFoodsattheBeginningoftheMeal:Thestomachwillbeginchurningoutitsstomachacidwhenyoubegineating,especiallywhenyouareconsumingprotein.Whileit’sculturallycommontoasaladbeforetheirproteindish,thisisnotgreatforyourHCLproduction.Itisamuchbetterideatoeatyourproteinwiththesaladorvegetablesinsteadofafter.UseFermentedVeggies:Fermentedfoodssuchassauerkraut,kimchi,pickles,pickledginger,andotherfermentedvegetablesallcontainorganicacids,enzymes,andprobioticswhichhelptoimprovedigestivejuicesecretions?Irecommendusingoneofthesewithallofyourheaviermealsandespeciallyanymealwithprotein.UseFermentedDrinks:Fermenteddrinkssuchasapplecidervinegar,coconutkefir,andkombuchaofferantimicrobialbenefitsandhelptoreducethebacterialload,especiallythebacteriainthestomachsuchasHPylori.KeepingHPylorilevelsdowniscriticalforthebodytobeabletoproduceenoughstomachacid.EatYourLargestMealWhenYouAreMostRelaxed:Yourbodyneedstoactivatetheparasympatheticnervoussystemtoproduceenoughstomachacids.Ifyouarebusyandonthego,youwillbeinfightorflightsympatheticmode.Ifyoustrugglewithlowstomachacid,thisfightorflightstateisnotgoingtoallowyourbodytoproduceanywherenearenough.Relaxingbeforethemealisimportanttoimprovestomachacidproduction.SupportOverallGutHealthandDigestion?Gutdysbiosisandpoorguthealthmayalsoincreaseyourriskofsarcopenia(10,11).Irecommendsupportingyouroverallguthealthanddigestion.A2021studypublishedintheFrontiersinNutritionhasfoundthattargetingagutmicrobiomewithprobioticsanddigestiveenzymesmaybehelpfulforsarcopenia(25).A2022studypublishedintheJournalofCachexia,Sarcopenia,andMusclehasfoundthatprobioticsupplementationmaysupportthegut-muscleaxisandmayreduceage-relatedsarcopenia(26).Accordingtoa2018reviewpublishedinCurrentOpinionsinClinicalNutritionandMetabolicCare,supportingproteindigestionmayhelptoreduceage-relatedsarcopenia(27).Eatplentyofprobiotic-richfoodsprobiotic-richfoodsincludingsauerkrauts,fermentedherbs,kimchi,kefir,kombucha,andyogurt.However,eatingprobiotic-richfoodsisnotenoughtosupportyourgutflora,especiallyifyouaredealingwithgutmicrobiomeimbalanceandallkindsofchronicguthealthissues.Probioticsmayhelptoimprovegutmicrobiomeimbalanceanddigestion.IrecommendusingProbiocharge100Billion.Tofurthersupportyourdigestion,Ialsorecommendtheuseofdigestiveenzymes.DigestiveenzymesmayhelptoreducesymptomsofdiarrheaandIBS,whichareoftenconnectedtobileacidmalabsorption.?IrecommendProteoEnzymestosupportproteinandoveralldigestion.ProteoEnzymes?affectcytokineandeicosanoidbalance,promotejointcomfortandsupportthebody’sabilitytomaintaintissueintegrity.?Italsohelpsbalancetheimmunesystem,reduceautoimmuneactivityandbreakdownpathogenicbiofilmsinthebody.ProteolyticenzymesinProteoEnzymesmaybreakdownproteinsandcomplexesthatcanbeproducedasaresultofinjuryandtissuedamage.Thisactivityisbelievedtoaidnutrientandoxygendeliveryandmayhelpspeedthebody’sabilitytorecoverandheal.Acid-resistantcapsulesfacilitatethesystemicdeliveryofenzymes.Takeitwitheachmealorasneeded.SupplementwithEssentialAminoAcids?Gettingadequateproteinandmeetingyouraminoacidneedsiscriticalforreducingsarcopenia(7).Supplementingwithessentialaminoacidsmayhelp.IrecommendAminoStrongEssentialAminoAcids.AminoStrong?representsabreakthroughintheuseofaminoacidsformuscleproteinsynthesis.Over20humantrialshavebeenconductedtoarriveatthisspecific,patent-pendingcombinationofaminoacidsinthemosteffectiveanabolicratios.Whetheryouwanttosupportmusclestrengthandfunctionorpreventmusclelossassociatedwithinactivityoraging,AminoStrongprovidestherightaminoacidsintherightratiostohelpyoumeetyourgoalsandstayhealthy.?Theaminoacid(AA)formulathatcomprisesAminoStrongwasmeticulouslydevelopedandstudiedbyinternationallyrecognizedresearchersinthefieldsofmusclemetabolismandaging,andlongevity.AminoStrongisdesignedforbothyoungandelderlyindividualswhoareseekingtostimulatemuscleproteinsynthesis,hastenmusclerecovery,andpromotemusclestrengthandfunction.ConsiderUsingWheyProtein?Gettingadequateproteiniscriticalforreducingsarcopenia(7).Usingwheyproteinmayhelp.IrecommendWheyStrongVanilla.WheyStrongisagreat-tasting,highprotein,lowcarbohydrate,functionalfoodpowder.Itismadewithanexceptionalqualitywheyproteinmadefromthemilkofcowsthatgrazeonpesticide-free,non-GMOgrasspasturesinNewZealand,whichareknowntobeoneoftheleastpollutedenvironmentsintheworld.Themilkingcowsareneverfedgrainandarenotsubjectedtohormoneorantibiotictreatments.Unlikeotherinstantizedwheyformulations,WheyStrongissoy-free.?Wheyproteinismadeupofindividual“buildingblocks”calledaminoacids,whichareusedtomanufactureenzymes,hormones,andantibodies.Wheyproteinisconsideredacompleteprotein,asitcontainsanadequateproportionofalltheessentialaminoacids,whicharethosethatcannotbemadebythebodyandmustbeobtainedthroughthediet.Itisalsorichincysteine,andithelpscreateanimportantantioxidantinthebody,whichisglutathione.Wheyproteinalsocontainsahighamountofbranched-chainaminoacids(BCAAs),especiallyleucine.Theimportantroleofleucineistobuildmuscles.Wheyproteinhasbeenfoundtosupporthealthybodycomposition.?Mix30grams(approximatelyonescoop)in8ouncesofwateroranyotherbeverageperdayorasdirectedbyyourhealthcarepractitioner.FinalThoughtsSarcopeniareferstoage-associatedmuscledegeneration.Losingmusclemassanddevelopingsarcopeniamaydecreaseyourabilitytoparticipateindailytasksandactivities.Itmayleadtofalls,injuries,hospitalization,disability,lossofindependence,care,andashorterlifespan.Fortunately,youcanimproveyourmusclehealthnaturallywiththehelpofsomesimplenaturalstrategies.Irecommendthatyoufollowmynaturalsupportstrategiesforsarcopeniatokeepyourmusclemassasyouage.Ifyouwanttoworkwithafunctionalhealthcoach,Irecommend?thisarticle?withtipsonhowtofindagreatcoach.?Ourwebsiteteamoffers?long-distance?functionalhealthcoachingprograms.Forfurthersupportwithyourbrainhealthandotherhealthgoals,justreachoutandourfantasticcoachesareheretosupportyourjourney.參考文獻SourcesinThisArticleInclude:1.VolpiE,NazemiR,FujitaS.Muscletissuechangeswithaging.CurrOpinClinNutrMetabCare.2004Jul;7(4):405-10.doi:10.1097/01.mco.0000134362.76653.b2.PMID:151924432.ChangSF,LinPL.SystematicLiteratureReviewandMeta-AnalysisoftheAssociationofSarcopeniaWithMortality.WorldviewsEvidBasedNurs.2016Apr;13(2):153-62.doi:10.1111/wvn.12147.Epub2016Feb4.PMID:268445383.MurtonAJ.Muscleproteinturnoverintheelderlyanditspotentialcontributiontothedevelopmentofsarcopenia.ProcNutrSoc.2015Nov;74(4):387-96.doi:10.1017/S0029665115000130.Epub2015Mar31.PMID:258266834.BaylisD,BartlettDB,PatelHP,RobertsHC.Understandinghowweage:insightsintoinflammaging.LongevHealthspan.2013May2;2(1):8.doi:10.1186/2046-2395-2-8.PMID:244720985.ConstantinD,MenonMK,Houchen-WolloffL,etalSkeletalmusclemolecularresponsestoresistancetraininganddietarysupplementationinCOPDThorax2013;68:625-633.LinkHere6.BanoG,TrevisanC,CarraroS,SolmiM,LuchiniC,StubbsB,ManzatoE,SergiG,VeroneseN.Inflammationandsarcopenia:Asystematicreviewandmeta-analysis.Maturitas.2017Feb;96:10-15.doi:10.1016/j.maturitas.2016.11.006.Epub2016Nov13.PMID:280415877.YanaiH.NutritionforSarcopenia.JClinMedRes.2015Dec;7(12):926-31.doi:10.14740/jocmr2361w.Epub2015Oct23.PMID:265664058.HuangHH,WangTY,YaoSF,LinPY,ChangJC,PengLN,ChenLK,YenDH.GastricMobilityandGastrointestinalHormonesinOlderPatientswithSarcopenia.Nutrients.2022Apr30;14(9):1897.doi:10.3390/nu14091897.PMID:355658649.Kim,Y.M.,Kim,JH.,Baik,S.J.etal.Associationbetweenskeletalmuscleattenuationandgastroesophagealrefluxdisease:Ahealthcheck-upcohortstudy.SciRep9,20102(2019).LinkHere10.PiccaA,FanelliF,CalvaniR,MulèG,PesceV,SistoA,PantanelliC,BernabeiR,LandiF,MarzettiE.GutDysbiosisandMuscleAging:SearchingforNovelTargetsagainstSarcopenia.MediatorsInflamm.2018Jan30;2018:7026198.doi:10.1155/2018/7026198.PMID:2968653311.LiuC,CheungWH,LiJ,ChowSK,YuJ,WongSH,IpM,SungJJY,WongRMY.Understandingthegutmicrobiotaandsarcopenia:asystematicreview.JCachexiaSarcopeniaMuscle.2021Dec;12(6):1393-1407.doi:10.1002/jcsm.12784.Epub2021Sep14.PMID:3452325012.Stefanaki,C.,Pervanidou,P.,Boschiero,D.etal.Chronicstressandbodycompositiondisorders:implicationsforhealthanddisease.Hormones17,33–43(2018).LinkHere13.vonHaehlingS.Thewastingcontinuuminheartfailure:fromsarcopeniatocachexia.ProcNutrSoc.2015Nov;74(4):367-77.doi:10.1017/S0029665115002438.Epub2015Aug12.PMID:2626458114.KappusMR,MendozaMS,NguyenD,MediciV,McClaveSA.SarcopeniainPatientswithChronicLiverDisease:CanItBeAlteredbyDietandExercise?CurrGastroenterolRep.2016Aug;18(8):43.doi:10.1007/s11894-016-0516-y.Erratumin:CurrGastroenterolRep.2016Nov;18(11):57.PMID:2737229115.HiraiK,OokawaraS,MorishitaY.SarcopeniaandPhysicalInactivityinPatientsWithChronicKidneyDisease.NephrourolMon.2016Apr26;8(3):e37443.doi:10.5812/numonthly.37443.PMID:2757075516.PradoCM,CushenSJ,OrssoCE,RyanAM.Sarcopeniaandcachexiaintheeraofobesity:clinicalandnutritionalimpact.ProcNutrSoc.2016May;75(2):188-98.doi:10.1017/S0029665115004279.Epub2016Jan8.PMID:2674321017.HuX,JiangJ,WangH,ZhangL,DongB,YangM.Associationbetweensleepdurationandsarcopeniaamongcommunity-dwellingolderadults:Across-sectionalstudy.Medicine(Baltimore).2017Mar;96(10):e6268.doi:10.1097/MD.0000000000006268.PMID:2827223818.Rubio-AriasJá,Rodríguez-FernándezR,AndreuL,Martínez-ArandaLM,Martínez-RodriguezA,Ramos-CampoDJ.EffectofSleepQualityonthePrevalenceofSarcopeniainOlderAdults:ASystematicReviewwithMeta-Analysis.JClinMed.2019Dec6;8(12):2156.doi:10.3390/jcm8122156.PMID:3181760319.Bagheri,A.,Soltani,S.,Hashemi,R.etal.Inflammatorypotentialofthedietandriskofsarcopeniaanditscomponents.NutrJ19,129(2020).LinkHere20.DoddsRM,RobertsHC,CooperC,SayerAA.TheEpidemiologyofSarcopenia.JClinDensitom.2015Oct-Dec;18(4):461-6.doi:10.1016/j.jocd.2015.04.012.Epub2015Jun12.PMID:2607342321.BellKE,vonAllmenMT,DevriesMC,PhillipsSM.MuscleDisuseasaPivotalProbleminSarcopenia-relatedMuscleLossandDysfunction.JFrailtyAging.2016;5(1):33-41.doi:10.14283/jfa.2016.78.PMID:2698036722.AlySM.Roleofintermittentfastingonimprovinghealthandreducingdiseases.IntJHealthSci(Qassim).2014Jul;8(3):V-VI.doi:10.12816/0023985.PMID:2550586823.HoKY,Veldhuis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不只是瘦、弱：重視肌肉減少癥(Sarcopenia)陶可（北京大學人民醫(yī)院骨關(guān)節(jié)科）圖125歲和65歲是的上臂肌肉大體結(jié)構(gòu)、核磁共振MRI檢查結(jié)果：可見25歲時肌肉較為豐富、發(fā)達；而65歲時，肌肉已經(jīng)發(fā)生明顯萎縮，質(zhì)量變差，且MRI上可見較多量的脂肪組織細胞的浸潤，替代了原來肌肉組織。從而，會導致人體肌肉力量衰退，活動量減少，平衡控制力降低，這可能也是跌倒已發(fā)生在老年人群的重要原因之一。圖230歲、50歲和80歲的肌肉（大腿前方股四頭?。┍容^：可見30歲時肌肉較為豐富、發(fā)達，圍繞在骨骼周圍；而50歲時，肌肉已經(jīng)發(fā)生較為明顯的萎縮，取而代之的是脂肪組織的浸潤，同時可見骨骼組織也出現(xiàn)了部分萎縮；80歲的肌肉組織發(fā)生了非常顯著的進一步萎縮，脂肪組織浸潤較為明顯，骨骼組織相應(yīng)的也出現(xiàn)廣泛萎縮，而肢體周經(jīng)也出現(xiàn)一定的縮小。圖3肌肉萎縮癥的主要病因包括：①lowtestosteronelevels，低睪酮水平（雄性激素降低）；②physicallyinactive，身體活動量低，缺乏有效體育鍛煉；③nutritionaldeficiencies，營養(yǎng)缺乏或不良；④rheumatoidarthritis，類風濕關(guān)節(jié)炎等某些影響全身各系統(tǒng)器官與代謝的慢性疾?。虎輊lder年齡增長衰老。圖4(A)蘇木精和曙紅染色，以突出年輕、健康的Wistar大鼠肌肉組織中可能發(fā)生的結(jié)構(gòu)改變。年輕健康大鼠的肌纖維組織結(jié)構(gòu)未見任何損傷。(B)年輕健康Wistar大鼠肌肉纖維周(μm)（平均值±標準差）的形態(tài)分析。在肌纖維周長(μm)(平均值±標準差)的形態(tài)分析中，年輕的健康大鼠顯示出正常的肌肉營養(yǎng)。鏡頭倍率：20×。比例尺：50μm；(C)蘇木精和伊紅染色以突出老年Wistar大鼠肌肉組織中可能發(fā)生的結(jié)構(gòu)改變。老年大鼠肌纖維組織結(jié)構(gòu)受損，表現(xiàn)為局灶性纖維化。(D)老年Wistar大鼠肌肉纖維周長(μm)(平均值±標準差)的形態(tài)學分析。在肌纖維周長(μm)（平均值±標準偏差）的形態(tài)分析中，老年大鼠表現(xiàn)出高度顯著的肌纖維萎縮，并表現(xiàn)出顯著的纖維尺寸異質(zhì)性。使用圖像采集軟件（AxioVisionRelease4.8.2-SP2Software，CarlZeissMicroscopyGmbH，Jena，Germany）考慮和計算肌肉纖維的周長。鏡頭倍率：20×。比例尺：50μm。肌肉減少癥是一個重要的健康問題，涉及肌肉體積、質(zhì)量和力量的逐漸下降。研究表明，它僅限于與年齡相關(guān)的肌肉質(zhì)量和功能的改變。文獻中的證據(jù)表明，低度慢性炎癥易導致老年人肌肉減少癥的進展。炎癥標志物的測量可能表明老年人在多種疾病/健康狀況下的功能限制。炎癥是干預的潛在目標，以避免與衰老相關(guān)的肌肉無力。然而，鍛煉仍然是預防肌肉減少癥的關(guān)鍵策略。結(jié)果表明，有氧運動訓練(aerobicexercisetraining,AET)或高強度間歇訓練可以增強抗阻力訓練RE對骨骼肌的影響。由于在某些情況下老年人不能或不愿意執(zhí)行運動訓練計劃，因此正在開發(fā)替代性潛在治療方法來對抗肌肉減少癥。最近的臨床證據(jù)表明，全身振動(WBV)和全身肌電刺激(WB-EMS)可以提高功能受損老年人的肌肉運動能力。后一種治療方法對于那些有單調(diào)慢性病的患者也可以在家中進行。目前的科學貢獻想向科學界強調(diào)適應(yīng)老年人身體活動的積極作用，作為預防或治療肌肉萎縮的一種可能的非藥物治療。即使這項科學貢獻表明了運動對預防和治療老年人肌肉減少癥的有益作用，仍需要進一步研究以改善晚年的肌肉功能表現(xiàn)。肌肉減少癥定義肌肉減少癥是一種隨著衰老和/或不動而發(fā)生的肌肉損失（肌肉萎縮）。它的特征是骨骼肌體積、質(zhì)量和強度的退行性喪失。肌肉損失的速度取決于運動水平、合并癥、營養(yǎng)和其他因素。肌肉損失與肌肉合成信號通路的變化有關(guān)。它不同于惡病質(zhì)，在惡病質(zhì)（腫瘤或感染等消耗性疾?。┲屑∪馔ㄟ^細胞因子介導的降解，盡管這兩種情況可能并存。肌肉減少癥被認為是虛弱綜合征的一個組成部分。[1]肌肉減少癥可導致生活質(zhì)量下降、跌倒、骨折和殘疾。[2][3]肌肉減少癥是改變與人口老齡化相關(guān)的身體成分的一個因素；某些肌肉區(qū)域預計會首先受到影響，特別是大腿前部和腹部肌肉。[2][4]在人口研究中，體重指數(shù)(BMI)被認為在老齡人口中下降，而生物電阻抗分析(BIA)顯示體脂比例上升。[5]肌肉減少癥sarcopenia一詞來自希臘語σìρξsarx，“肉體”和πεν?αpenia，“貧窮”。這是羅森伯格于1989年首次提出的，他寫道：“可能沒有任何一種與年齡相關(guān)的衰退特征能夠更顯著地影響步行、活動能力、熱量卡路里攝入量以及整體營養(yǎng)攝入量和狀態(tài)、獨立性、呼吸等?！斌w征和癥狀肌肉減少癥的標志是瘦肌肉量減少或肌肉萎縮。由于肥胖、脂肪量變化或水腫，身體成分的變化可能難以檢測。體重、肢體或腰圍的變化并不是肌肉質(zhì)量變化的可靠指標。肌肉減少癥還可能導致力量下降、功能下降和跌倒風險增加。肌肉減少癥也可能沒有任何癥狀，直到它很嚴重并且經(jīng)常未被識別。[1]然而，研究表明，身體上部可能會發(fā)生肥大以補償這種瘦肌肉質(zhì)量的損失[2][6]因此，肌肉減少癥發(fā)作的一個早期指標可能是大腿前部和腹部肌肉質(zhì)量的顯著損失。[2]病因肌肉減少癥的病因有很多，很可能是多種相互作用因素的結(jié)果。對肌肉減少癥病因的了解尚不完整，但體內(nèi)激素水平變化、行動不便、與年齡相關(guān)的肌肉變化、營養(yǎng)和神經(jīng)退行性變化都被認為是潛在的致病因素。[7]肌肉減少癥的程度由兩個因素決定：肌肉質(zhì)量的初始量和肌肉質(zhì)量下降的速度。由于這些因素在人群中存在差異，進展速度和肌肉損失變得明顯的閾值是可變的。[8]不動會顯著增加肌肉流失的速度，即使在年輕人中也是如此。其他可能增加肌肉減少癥進展速度的因素包括營養(yǎng)攝入減少、體力活動不足或慢性疾病。[1]此外，流行病學研究表明，早期環(huán)境（兒童及青少年時期肌肉儲備量）影響可能對肌肉健康產(chǎn)生長期影響。例如，低出生體重是早期環(huán)境不佳的標志，與成年后肌肉質(zhì)量和力量下降有關(guān)。[9][10][11]病理生理學機制已經(jīng)提出了多種理論來解釋肌肉減少癥的肌肉變化機制，包括衛(wèi)星細胞募集的變化、合成代謝信號的變化、蛋白質(zhì)氧化、炎癥和發(fā)育因素。肌肉減少癥的病理變化包括肌肉組織質(zhì)量下降，反映在肌肉纖維被脂肪替代、纖維化增加、肌肉代謝變化、氧化應(yīng)激和神經(jīng)肌肉接頭退化[12]。肌纖維類型的分布在肌肉減少癥肌肉中也會發(fā)生變化，導致II型肌纖維或“快肌”減少，而I型肌纖維或“慢肌”肌纖維幾乎沒有減少。去神經(jīng)支配的II型纖維通常通過慢速I型纖維運動神經(jīng)的神經(jīng)再支配轉(zhuǎn)化為I型纖維。[13]在受傷或運動時未能激活衛(wèi)星細胞也被認為是肌肉減少癥的病理生理學原因之一。[12]此外，氧化的蛋白質(zhì)會導致脂褐素和交聯(lián)蛋白的積累，從而導致骨骼肌中非收縮性物質(zhì)的積累，并導致肌肉減少癥。[8]一個明顯的保護因素是足夠水平的蛋白質(zhì)BNIP3，它可以防止細胞累積受損的線粒體。BNIP3的缺乏會導致肌肉發(fā)炎和萎縮。[14]診斷多個專家組提出了多種診斷標準，并且仍然是研究和爭論的領(lǐng)域。盡管缺乏廣泛接受的定義，肌肉減少癥在2016年被指定為ICD-10代碼(M62.84)，將其識別為一種疾病狀態(tài)。[15]當患者的肌肉質(zhì)量至少低于相關(guān)人群平均值的兩個標準差并且行走速度較慢時，可以診斷為肌肉減少癥。[16]歐洲老年人肌肉減少癥工作組(EWGSOP)為肌肉減少癥制定了廣泛的臨床定義，指定為存在低肌肉質(zhì)量和低肌肉力量或低身體表現(xiàn)。[7]其他國際團體提出的標準包括步行速度、6分鐘步行距離或握力等指標。[15]單獨的握力也被提倡作為肌肉減少癥的臨床標志物，該標志物簡單且具有成本效益并且具有良好的預測能力，盡管它沒有提供全面的信息。[17]有一些肌肉減少癥篩查工具可以評估患者報告的日常活動困難，例如步行、爬樓梯或從椅子上站起來，并已被證明可以預測肌肉減少癥和不良功能結(jié)果。[18]肌肉減少癥治療鍛煉運動仍然是肌肉減少癥的首選干預措施，但將研究結(jié)果轉(zhuǎn)化為臨床實踐具有挑戰(zhàn)性。運動的類型、持續(xù)時間和強度在研究之間是可變的，防止肌肉減少癥的標準化運動處方。[19]缺乏鍛煉是肌肉減少癥的一個重要危險因素，鍛煉可以顯著減緩肌肉流失的速度。[20]運動可以成為一種有效的干預措施，因為老化的骨骼肌保留了合成蛋白質(zhì)的能力以響應(yīng)短期阻力運動。[21]老年人的漸進式阻力訓練可以改善身體表現(xiàn)（步態(tài)速度）和肌肉力量。[22]（鍛煉方式，大家可參考：下肢、膝關(guān)節(jié)疼痛、腫脹：說說膝關(guān)節(jié)核心肌群——股四頭肌鍛煉https://station.haodf.com/health/article?healthId=8618339876＆articleId=9391847461）藥物目前，尚無批準用于治療肌肉減少癥的藥物。[23]睪酮或其他合成代謝類固醇也被研究用于治療肌肉減少癥，似乎對肌肉力量和質(zhì)量有一些積極影響，但會引起一些副作用，并引起人們對男性前列腺癌和女性男性化的擔憂。[24][25]此外，最近的研究表明，睪酮治療可能會誘發(fā)不良心血管事件。[26][27][28]DHEA和人類生長激素已被證明在這種情況下幾乎沒有影響。生長激素增加肌肉蛋白質(zhì)合成并增加肌肉質(zhì)量，但在大多數(shù)研究中不會導致力量和功能的增加。[24]這一點，以及其效應(yīng)胰島素樣生長因子1(IGF-1)類似缺乏功效，可能是由于炎癥和其他年齡變化導致衰老肌肉對IGF-1的局部抵抗。[24]正在研究的其他可能用于治療肌肉減少癥的藥物包括生長素釋放肽、維生素D、血管緊張素轉(zhuǎn)換酶抑制劑和二十碳五烯酸。[24][25]營養(yǎng)熱量卡路里和蛋白質(zhì)的攝入是肌肉蛋白質(zhì)合成的重要刺激物。[29]老年人可能不像年輕人那樣有效地利用蛋白質(zhì)，并且可能需要更多的蛋白質(zhì)來防止肌肉萎縮。[16]許多專家組建議將老年人的膳食蛋白質(zhì)建議增加到每天1.0-1.2克/千克體重。[30][31]確保老年人有足夠的營養(yǎng)有助于預防肌肉減少癥和虛弱，因為這是一種簡單、低成本的治療方法，沒有重大副作用。[32]額外補充物肌肉減少癥的一個組成部分是老化骨骼肌喪失對合成代謝刺激（如氨基酸）作出反應(yīng)的能力，尤其是在較低濃度時。然而，老化的肌肉保留了對較大劑量的蛋白質(zhì)或氨基酸的合成代謝反應(yīng)的能力。據(jù)報道，補充較大劑量的氨基酸，特別是亮氨酸可以抵消因衰老而導致的肌肉損失。[33]運動可以與補充氨基酸協(xié)同作用。[23]β-羥基β-甲基丁酸(HMB)是亮氨酸的代謝物，可作為刺激蛋白質(zhì)合成的信號分子。[16][23]據(jù)報道，它具有多個目標，包括刺激mTOR和降低蛋白酶體表達。臨床試驗始終支持使用它來防止瘦的老年人失去體重。[34][35][36]需要更多的研究來確定HMB對該年齡組肌肉力量和功能的精確影響。[35]流行病學肌肉減少癥的患病率取決于每項流行病學研究中使用的定義。60-70歲人群的估計患病率為5-13%，80歲以上人群的患病率增加到11-50%。這相當于超過5000萬人，預計在未來40年內(nèi)將影響超過2億人，因為老年人口不斷增加。[7]公共衛(wèi)生影響鑒于工業(yè)化人口的壽命延長和老年人口的增加，肌肉減少癥正在成為一個主要的公共衛(wèi)生問題。肌肉減少癥是許多不良后果的預兆，包括增加殘疾、跌倒和死亡率。易患肌肉減少癥的人群不動或臥床休息會對功能結(jié)果產(chǎn)生巨大影響。在老年人中，這通常會導致生物儲備減少和對壓力源的脆弱性增加，稱為“虛弱綜合癥”。瘦體重的減少還與感染風險增加、免疫力下降和傷口愈合不良有關(guān)。伴隨肌肉萎縮的虛弱會導致跌倒、骨折、身體殘疾、需要機構(gòu)護理、生活質(zhì)量下降、死亡率增加和醫(yī)療費用增加的風險增加。[16]這代表了重大的個人和社會負擔，其公共衛(wèi)生影響越來越受到認可。[7]研究方向有很多機會可以更好地了解肌肉減少癥的原因和后果，并幫助指導臨床護理。這包括闡明肌肉減少癥的分子和細胞機制，按種族進一步細化參考人群，驗證診斷標準和臨床工具，以及跟蹤住院率、發(fā)病率和死亡率。還需要確定和研究潛在的治療方法和干預時機。[37]臨床開發(fā)中的新藥物療法包括肌肉生長抑制素和選擇性雄激素受體調(diào)節(jié)劑(SARM)。[38]非甾體選擇性雄激素受體調(diào)節(jié)劑SARM特別令人感興趣，因為它們在睪酮對肌肉的合成代謝作用之間表現(xiàn)出顯著的選擇性，但幾乎沒有雄激素作用的證據(jù)（例如男性前列腺刺激）。[38]SarcopeniaSarcopeniaisanimportanthealthprobleminvolvingaprogressivedeclineofmusclemass,qualityandstrength.Ithasbeenshownthatitislimitedtotheage-relatedalterationofmusclemassandfunction.Evidenceinliteraturesuggeststhatlow-gradechronicinflammationpredisposestotheprogressofsarcopeniaintheelderly.Themeasurementofinflammatorymarkersmaybeindicativeoffunctionallimitationsinolderpeopleacrossseveraldiseases/healthconditions.Inflammationisapotentialtargetforinterventionstoavoidmuscularweaknessassociatedwithageing.However,exercisecontinuetobethekeystrategytopreventsarcopenia.ItwasshownthataerobicexercisetrainingAETorhigh-intensityintervaltrainingmayenhancetheeffectsofresistanceexercise(RE)onskeletalmuscle.Sinceolderadultsareunableorunwillingtoperformexercisetrainingprogramsinsomecases,alternativepotentialtreatmentapproachesarebeingdevelopedtocounterthesarcopenia.Recentclinicalevidencehasshownthatwhole-bodyvibration(WBV)andwhole-bodyelectromyostimulation(WB-EMS)canimprovemuscleexercisecapacityinfunctionallyimpairedolderpeople.Thelatterkindoftherapeutictreatmentcouldalsobecarriedoutathomeforthosepatientswhohavemonotonouschronicproblems.Thepresentscientificcontributionwouldliketoemphasizetothescientificcommunitythepositiveeffectsoftheadaptedphysicalactivityintheelderlyasapossiblenon-pharmacologictreatmenttopreventortreatmuscleatrophy.Evenifthisscientificcontributionhassuggestedthebeneficialeffectsofexerciseforthepreventionandtreatmentofsarcopeniainelderlypeople,furtherstudiesarerequiredtoimprovemuscleperformanceinlaterlife.Sarcopeniaisatypeofmuscleloss(muscleatrophy)thatoccurswithagingand/orimmobility.Itischaracterizedbythedegenerativelossofskeletalmusclemass,quality,andstrength.Therateofmusclelossisdependentonexerciselevel,co-morbidities,nutritionandotherfactors.Themusclelossisrelatedtochangesinmusclesynthesissignallingpathways.Itisdistinctfromcachexia,inwhichmuscleisdegradedthroughcytokine-mediateddegradation,althoughbothconditionsmayco-exist.Sarcopeniaisconsideredacomponentoffrailtysyndrome.[1]Sarcopeniacanleadtoreducedqualityoflife,falls,fracture,anddisability.[2][3]Sarcopeniaisafactorinchangingbodycompositionassociatedwithagingpopulations;andcertainmuscleregionsareexpectedtobeaffectedfirst,specificallytheanteriorthighandabdominalmuscles.[2][4]Inpopulationstudies,bodymassindex(BMI)isseentodecreaseinagingpopulationswhilebioelectricalimpedanceanalysis(BIA)showsbodyfatproportionrising.[5]ThetermsarcopeniaisfromGreekσ?ρξsarx,“flesh“andπεν?αpenia,“poverty“.ThiswasfirstproposedbyRosenbergin1989,whowrotethat“theremaybenosinglefeatureofage-relateddeclinethatcouldmoredramaticallyaffectambulation,mobility,calorieintake,andoverallnutrientintakeandstatus,independence,breathing,etc.“SignsandsymptomsThehallmarksignofsarcopeniaislossofleanmusclemass,ormuscleatrophy.Thechangeinbodycompositionmaybedifficulttodetectduetoobesity,changesinfatmass,oredema.Changesinweight,limborwaistcircumferencearenotreliableindicatorsofmusclemasschanges.Sarcopeniamayalsocausereducedstrength,functionaldeclineandincreasedriskoffalling.Sarcopeniamayalsohavenosymptomsuntilitissevereandisoftenunrecognized.[1]Researchhasshown,however,thathypertrophymayoccurintheupperpartsofthebodytocompensateforthislossofleanmusclemass[2][6]Therefore,oneearlyindicatoroftheonsetofsarcopeniacanbesignificantlossofmusclemassintheanteriorthighandabdominalmuscles.[2]CausesTherearemanyproposedcausesofsarcopeniaanditislikelytheresultofmultipleinteractingfactors.Understandingofthecausesofsarcopeniaisincomplete,howeverchangesinhormones,immobility,age-relatedmusclechanges,nutritionandneurodegenerativechangeshaveallbeenrecognizedaspotentialcausativefactors.[7]Thedegreeofsarcopeniaisdeterminedbytwofactors:initialamountofmusclemassandrateatwhichmusclemassdeclines.Duetovariationsinthesefactorsacrossthepopulation,therateofprogressionandthethresholdatwhichmusclelossbecomesapparentisvariable.[8]Immobilitydramaticallyincreasestherateofmuscleloss,eveninyoungerpeople.Otherfactorsthatcanincreaserateofprogressionofsarcopeniaincludedecreasednutrientintake,lowphysicalactivity,orchronicdisease.[1]Additionally,epidemiologicalresearchhasindicatedthatearlyenvironmentalinfluencesmayhavelong-termeffectsonmusclehealth.Forexample,lowbirthweight,amarkerofapoorearlyenvironment,isassociatedwithreducedmusclemassandstrengthinadultlife.[9][10][11]PathophysiologyTherearemultipletheoriesproposedtoexplainthemechanismsofmusclechangesofsarcopeniaincludingchangesinsatellitecellrecruitment,changesinanabolicsignalling,proteinoxidation,inflammation,anddevelopmentalfactors.Thepathologicchangesofsarcopeniaincludeareductioninmuscletissuequalityasreflectedinthereplacementofmusclefiberswithfat,anincreaseinfibrosis,changesinmusclemetabolism,oxidativestress,anddegenerationoftheneuromuscularjunction.[12]ThedistributionofmusclefiberstypesalsochangesinsarcopenicmusclecausingadecreaseintypeIImusclefibers,or“fasttwitch,“withlittletonodecreaseintypeImusclefibers,or“slow-twitch“musclefibers.DeinervatedtypeIIfibersareoftenconvertedtotypeIfibersbyreinnervationbyslowtypeIfibermotornerves.[13]Thefailuretoactivatesatellitecellsuponinjuryorexerciseisalsothoughttocontributetothepathophysiologyofsarcopenia.[12]Additionally,oxidizedproteinscanleadtoabuildupoflipofuscinandcross-linkedproteinscausinganaccumulationofnon-contractilematerialintheskeletalmuscleandcontributetosarcopenicmuscle.[8]AnapparentprotectivefactorissufficientlevelsoftheproteinBNIP3,whichpreventscells‘buildupofdamagedmitochondria.DeficiencyofBNIP3leadstomuscleinflammationandatrophy.[14]DiagnosisMultiplediagnosticcriteriahavebeenproposedbyvariousexpertgroupsandcontinuestobeanareaofresearchanddebate.Despitethelackofawidelyaccepteddefinition,sarcopeniawasassignedanICD-10code(M62.84)in2016,recognizingitasadiseasestate.[15]Sarcopeniacanbediagnosedwhenapatienthasmusclemassthatisatleasttwostandarddeviationsbelowtherelevantpopulationmeanandhasaslowwalkingspeed.[16]TheEuropeanWorkingGrouponSarcopeniainOlderPeople(EWGSOP)developedabroadclinicaldefinitionforsarcopenia,designatedasthepresenceoflowmusclemassandeitherlowmuscularstrengthorlowphysicalperformance.[7]Otherinternationalgroupshaveproposedcriteriathatincludemetricsonwalkingspeed,distancewalkedin6?minutes,orgripstrength.[15]Handgripstrengthalonehasalsobeenadvocatedasaclinicalmarkerofsarcopeniathatissimpleandcosteffectiveandhasgoodpredictivepower,althoughitdoesnotprovidecomprehensiveinformation.[17]Therearescreeningtoolsforsarcopeniathatassesspatientreporteddifficultyindoingdailyactivitiessuchaswalking,climbingstairsorstandingfromachairandhavebeenshowntopredictsarcopeniaandpoorfunctionaloutcomes.[18]ManagementExerciseExerciseremainstheinterventionofchoiceforsarcopenia,buttranslationofresearchfindingsintoclinicalpracticeischallenging.Thetype,durationandintensityofexercisearevariablebetweenstudies,preventingastandardizedexerciseprescriptionforsarcopenia.[19]Lackofexerciseisasignificantriskfactorforsarcopeniaandexercisecandramaticallyslowtherateofmuscleloss.[20]Exercisecanbeaneffectiveinterventionbecauseagingskeletalmuscleretainsabilitytosynthesizeproteinsinresponsetoshort-termresistanceexercise.[21]Progressiveresistancetraininginolderadultscanimprovephysicalperformance(gaitspeed)andmuscularstrength.[22]MedicationTherearecurrentlynoapprovedmedicationsforthetreatmentofsarcopenia.[23]Testosteroneorotheranabolicsteroidshavealsobeeninvestigatedfortreatmentofsarcopenia,andseemtohavesomepositiveeffectsonmusclestrengthandmass,butcauseseveralsideeffectsandraiseconcernsofprostatecancerinmenandvirilizationinwomen.[24][25]Additionally,recentstudiessuggesttestosteronetreatmentsmayinduceadversecardiovascularevents.[26][27][28]DHEAandhumangrowthhormonehavebeenshowntohavelittletonoeffectinthissetting.Growthhormoneincreasesmuscleproteinsynthesisandincreasesmusclemass,butdoesnotleadtogainsinstrengthandfunctioninmoststudies.[24]This,andthesimilarlackofefficacyofitseffectorinsulin-likegrowthfactor1(IGF-1),maybeduetolocalresistancetoIGF-1inagingmuscle,resultingfrominflammationandotheragechanges.[24]Othermedicationsunderinvestigationaspossibletreatmentsforsarcopeniaincludeghrelin,vitaminD,angiotensinconvertingenzymeinhibitors,andeicosapentaenoicacid.[24][25]NutritionIntakeofcaloriesandproteinareimportantstimuliformuscleproteinsynthesis.[29]Olderadultsmaynotutilizeproteinsoefficientlyasyoungerpeopleandmayrequirehigheramountstopreventmuscleatrophy.[16]Anumberofexpertgroupshaveproposedanincreaseindietaryproteinrecommendationsforolderagegroupsto1.0-1.2g/kgbodyweightperday.[30][31]Ensuringadequatenutritioninolderadultsisofinterestinthepreventionofsarcopeniaandfrailty,sinceitisasimple,low-costtreatmentapproachwithoutmajorsideeffects.[32]SupplementsAcomponentofsarcopeniaisthelossofabilityforagingskeletalmuscletorespondtoanabolicstimulisuchasaminoacids,especiallyatlowerconcentrations.However,agingmuscleretainstheabilityofananabolicresponsetoproteinoraminoacidsatlargerdoses.Supplementationwithlargerdosesofaminoacids,particularlyleucinehasbeenreportedtocounteractmusclelosswithaging.[33]Exercisemayworksynergisticallywithaminoacidsupplementation.[23]β-hydroxyβ-methylbutyrate(HMB)isametaboliteofleucinethatactsasasignallingmoleculetostimulateproteinsynthesis.[16][23]Itisreportedtohavemultipletargets,includingstimulatingmTORanddecreasingproteasomeexpression.Itsusetopreventthelossofleanbodymassinolderadultsisconsistentlysupportedinclinicaltrials.[34][35][36]MoreresearchisneededtodeterminethepreciseeffectsofHMBonmusclestrengthandfunctioninthisagegroup.[35]EpidemiologyTheprevalenceofsarcopeniadependsonthedefinitionusedineachepidemiologicalstudy.Estimatedprevalenceinpeoplebetweentheagesof60-70is5-13%andincreasesto11-50%inpeoplemorethan80yearsofage.Thisequatesto＞50millionpeopleandisprojectedtoaffect＞200millioninthenext40yearsgiventherisingpopulationofolderadults.[7]PublichealthimpactSarcopeniaisemergingasamajorpublichealthconcerngiventheincreasedlongevityofindustrializedpopulationsandgrowinggeriatricpopulation.Sarcopeniaisapredictorofmanyadverseoutcomesincludingincreaseddisability,fallsandmortality[citationneeded].Immobilityorbedrestinpopulationspredisposedtosarcopeniacancausedramaticimpactonfunctionaloutcomes.Intheelderly,thisoftenleadstodecreasedbiologicalreserveandincreasedvulnerabilitytostressorsknownasthe“frailtysyndrome“.Lossofleanbodymassisalsoassociatedwithincreasedriskofinfection,decreasedimmunity,andpoorwoundhealing.Theweaknessthataccompaniesmuscleatrophyleadstohigherriskoffalls,fractures,physicaldisability,needforinstitutionalcare,reducedqualityoflife,increasedmortality,andincreasedhealthcarecosts.[16]Thisrepresentsasignificantpersonalandsocietalburdenanditspublichealthimpactisincreasinglyrecognized.[7]ResearchdirectionsTherearesignificantopportunitiestobetterunderstandthecausesandconsequencesofsarcopeniaandhelpguideclinicalcare.Thisincludeselucidationofthemolecularandcellularmechanismsofsarcopenia,furtherrefinementofreferencepopulationsbyethnicgroups,validationofdiagnosticcriteriaandclinicaltools,aswellastrackingofincidenceofhospitalizationadmissions,morbidity,andmortality.Identificationandresearchonpotentialtherapeuticapproachesandtimingofinterventionsisalsoneeded.[37]Newpharmaceuticaltherapiesinclinicaldevelopmentincludemyostatinandtheselectiveandrogenreceptormodulators(SARMs).[38]NonsteriodalSARMsareofparticularinterest,giventheyexhibitsignificantselectivitybetweentheanaboliceffectsoftestosteroneonmuscle,butwithlittletonoevidenceofandrogeniceffects(suchasprostatestimulationinmen).[38]Figure4.(A)Hematoxylin＆Eosinstaininginordertohighlightpossiblestructuralalterationsinmuscletissuefromyoung,healthyWistarRats.Musclefibersofyounghealthyratdidnotshowanydamagedhistologicalstructure.ThesampleswereexaminedwithaZeissAxioplanlightmicroscope(CarlZeiss,Oberkochen,Germany)andadigitalcamera(AxioCamMRc5,CarlZeiss)wasusedtotakethepictures.Lensmagnification:20×.Scalebars:50μm;(B)Morphometricanalysisoftheperimeter(μm)(mean±SD)ofthemusclefibersfromyounghealthyWistarRats.Inthemorphometricanalysisoftheperimeter(μm)(mean±SD)ofthemusclefibers,theyounghealthyratshowsnormalmuscletrophic.Theperimeterofmusclefiberswasconsideredandcalculatedusingsoftwareforimageacquisition(AxioVisionRelease4.8.2-SP2Software,CarlZeissMicroscopyGmbH,Jena,Germany).Lensmagnification:20×.Scalebars:50μm;(C)Hematoxylin＆EosinstaininginordertohighlightpossiblestructuralalterationsinmuscletissuefromelderlyWistarRats.Musclefibersofelderlyratshowdamagedhistologicalstructureasfocalperimisiofibrosis.ThesampleswereexaminedwithaZeissAxioplanlightmicroscope(CarlZeiss,Oberkochen,Germany)andadigitalcamera(AxioCamMRc5,CarlZeiss)wasusedtotakethepictures.Lensmagnification:20×.Scalebars:50μm;(D)Morphometricanalysisoftheperimeter(μm)(mean±SD)ofthemusclefibersfromelderlyWistarRats.Inthemorphometricanalysisoftheperimeter(μm)(mean±SD)ofthemusclefibers,theelderlyratshowsahighlysignificantmusclefiberhypotrophyandexhibitsremarkablefibersizeheterogeneity.Theperimeterofmusclefiberswasconsideredandcalculatedusingsoftwareforimageacquisition(AxioVisionRelease4.8.2-SP2Software,CarlZeissMicroscopyGmbH,Jena,Germany).Lensmagnification:20×.Scalebars:50μm.FromWikipedia,thefreeencyclopediahttps://amino-ther.com/clinical-evidence/sarcopenia-and-frailty/更多參考文獻ReferencesPetersonSJ,MozerM(February2017).“DifferentiatingSarcopeniaandCachexiaAmongPatientsWithCancer“.NutritioninClinicalPractice.32(1):30–39.doi:10.1177/0884533616680354.PMID28124947.S2CID206555460.AtaAM,KaraM,KaymakB,OzcakarL.SarcopeniaIsNot“Love“:YouHavetoLookWhereYouLostit!.AmJPhysMedRehabil.2020;99(10):e119-e120.doi:10.1097/PHM.0000000000001391.BeaudartC,ZaariaM,PasleauF,etal:Healthoutcomesofsarcopenia:asystematicreviewandmeta-analysis.PLoSOne2017;12:e0169548AtaAM,KaraM,KaymakB,etal:Regionalandtotalmusclemass,musclestrengthandphysicalperformance:thepotentialuseofultrasoundimagingforsarcopenia.ArchGerontolGeriatr2019;83:55–60Ranasinghe,Chathuranga;Gamage,Prasanna(2013).“RelationshipbetweenBodymassindex(BMI)andbodyfatpercentage,estimatedbybioelectricalimpedance,inagroupofSriLankanadults:acrosssectionalstudy“.BMCPublicHealth.13:797.doi:10.1186/1471-2458-13-797.PMC3766672.PMID24004464.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