Healthy Older People Everyday (HOPE) - Role of Healthy Diet on Muscle and Bone Health (HOPE-DIET)

Certain clinical syndromes eg frailty, sarcopenia, dementia, depression, cognitive impairment, vision impairment and falls in older adults carry an increased risk for poor health outcomes and if identified early, can be prevented, delayed or reversible. There is evidence to suggest that exercise and dietary intervention can help delay or prevent sarcopenia, frailty and dementia.

The current hypothesis is older adults do not consume enough protein in their diet. Local delicacies enhanced with protein content, in addition to physical activity will improve muscle strength, function, perceived health status and possibly may even reverse frailty and sarcopenia. Additionally, it is hypothesized that combination of multi component group exercise activities and high protein nutrition will be effective in improving participants' social, mental and physical status.

Study Overview

• Status: Unknown
• Conditions: Muscle Weakness; Cognitive Decline; Bone Health
• Intervention / Treatment: Other: Protein supplementation and regular physical activity

Detailed Description

From our own published local data, the prevalence of pre-frailty in North-West area is 37% and frailty 6.2%. Prevalence of frailty in individuals with diabetes is 12%, double that of general population.

Evidence suggest that multi-component intervention may delay the onset of disability, and in some cases reverse frailty with the potential to avert preventable adverse events such as falls, fractures and reduce overall healthcare utilisation and extend health-span. There is a similar multi-centre trial in progress in Europe called SPRINTT. As physical exercise and adequate protein and energy intake are to date the only strategies of proven efficacy to improve muscle health, it is important that we develop locally relevant protein enriched food prototypes that can deliver an effective dosage of protein to the older adult and compare them with available protein enriched supplements. High protein diet stimulates muscle protein synthesis and plays a role in delaying the onset of frailty and sarcopenia. An adequate intake of dietary proteins is vital to maintaining muscle mass and stimulating protein synthesis. Older adults are at high risk for insufficient protein intake and furthermore, the current recommended dietary allowance for protein (0.8 g/kg/day) might not be sufficient for preserving muscle mass and quality in old age. It appears therefore appropriate to promote a protein intake of 1.0-1.2 g/kg/day, while 1.2-1.5 g/kg/day of protein may be required in older adults with acute or chronic diseases. Finally, older people with severe illnesses or overt malnutrition may need as much as 2.0 g/kg/day of protein. In addition to protein, the PROVIDE study also showed that sufficient levels of vitamin D and protein is necessary to increase muscle mass and reduce sarcopenia. While most middle aged adults and older adults attempt to keep up with physical activity, very few actually are aware of importance of protein and Vitamin D enriched diet. Exercise and increased protein intake can also down-regulate systemic inflammation.

Locally, there's one small study (n=49 for nutrition and n=49 combined intervention) which documented reversal of frailty with multicomponent intervention, where the nutrition component was a commercial formula Fortisip (Nutricia Dublin). Up to now, there are no locally developed high protein supplements and we have no data on average protein content of local diet consumption in older adults. If locally produced, culturally-relevant high protein food prototype is widely accepted and is proven to improve function and quality of life, it will be an innovative solution to solving nutritional gaps and delivering an effective dose of protein to the elderly population in Singapore. This can especially help the elderly population receive protein supplementation not through commercially produced expensive supplements but through the foods and drinks that they consume everyday. These prototypes can also help the local food and beverage industry recognize the importance and value of investing resources into the continued development of these products to better address local public health needs and possibly export these products to the wider region's ageing population.

In addition, the results from this study will provide the basis and baseline for a review of the current recommended dietary allowance for protein, especially among older adults. The current recommendation of 0.8 g of protein/kg/day was based on the maintenance of a healthy adult's nitrogen balance. It would be important to formulate a set of recommendation to meet the functional and physiological needs of the elderly.

This programme will be the nutritional arm of a current study called 'HAPPY' Healthy Ageing Promotion Program For You, where participants are screened for frailty in the day care, senior activity centre's and community centre's. Participants with cognitive impairment and / or pre-frail are invited to participate in dual task exercise led by trainer from Japan. This locally produced high protein food will be trialled in these participants who have been identified during screening for "HAPPY". Informed consent will be obtained from participants to participate in the HAPPY and HOPE programmes.

• Study Type: Interventional
• Enrollment (Anticipated): 1000
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 65 years and older (OLDER_ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• At least pre-frail (Frail scale score of at least 1) but ambulant
• Grip strength not more than 25kg for males and 18kg for females

Exclusion Criteria:

• With kidney conditions

Study Plan

How is the study designed?

Design Details

• Primary Purpose: PREVENTION
• Allocation: RANDOMIZED
• Interventional Model: FACTORIAL
• Masking: SINGLE

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
NO_INTERVENTION: Control (No intervention); Participants will not undergo any treatment. Continue with usual daily activities and diet for 6 months.
EXPERIMENTAL: Nutrition group; Participants will receive protein enriched food to supplement the diet for 6 months.	Other: Protein supplementation and regular physical activity; To determine if high protein diet and/or regular physical activity improves muscle and bone health
EXPERIMENTAL: Exercise group; Participants will exercise 3 times a week for 60 minutes each time over 6 months.	Other: Protein supplementation and regular physical activity; To determine if high protein diet and/or regular physical activity improves muscle and bone health
EXPERIMENTAL: Nutrition + Exercise group; Participants will receive protein enriched food to supplement the diet and exercise 3 times a week for 60 minutes each time over 6 months.	Other: Protein supplementation and regular physical activity; To determine if high protein diet and/or regular physical activity improves muscle and bone health

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes in frailty status	Changes in frailty status by 5-item FRAIL scale Scale range from 0 to 5, the higher the value, the more frail.	2 years
Changes in lower extremity physical performance	Changes in short physical performance battery (SPPB) summary score 3 subscales (range from 0 to 4 for balance, gait speed and chair stand) summed to give total score range from 0 to 12. The higher the value, the better the performance of lower extremity.	2 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes in upper extremity muscle strength	Changes in handgrip strength test performance (kg)	2 years
Changes in skeletal muscle mass	Changes in skeletal muscle mass by bioelectrical impedance analysis	2 years
Changes in sarcopenic status	Changes in sarcopenic status by SARC-F scale Scale range from 0 to 10, the higher the value, the greater the likelihood of sarcopenic	2 years
Changes in mood	Changes in Geriatric Depression Scale (GDS) Scale range from 0 to 15, the higher the score, the greater the likelihood of depression.	2 years
Changes in mood	Changes in UCLA Loneliness Scale Scale range from 0 to 9, the higher the value, the greater the loneliness Scale from 0 to	2 years
Changes in cognitive function	Changes in Mini Mental State Examination (MMSE) score 5 subscales: Orientation (0 to 10), Registration (0 to 3), Attention and Calculation (0 to 5), Recall (0 to 3), Language and Praxis (0 to 9) Total scale range from 0 to 30, the higher the value, the less cognitive impairment.	2 years
Changes in cognitive function	Changes in Montreal Cognitive Assessment (MoCA)	2 years
Changes in nutritional status	Changes in Mini Nutritional Assessment (MNA) score 2 Subscales: Screening (0 to 14) and Assessment (0 to 16) Total scale range from 0 to 30, the higher the value, the more well nourished.	2 years
Changes in functional status (instrumental activities of daily living)	Changes in Instrumental Activities of Daily Living (IADL) score Scale range from 0 to 8, the higher the value, the greater the ability.	2 years
Changes in functional status (activities of daily living)	Changes in Activities of Daily Living (ADL) score Scale range from 0 to 6, the higher the value, the greater the ability.	2 years
Changes in fall risk	Changes in fall efficacy questionnaire	2 years
Incidence of self-reported falls	Number of falls assessed by questionnaires	2 years
Changes in quality of life	Changes in EuroQoL-5D (EQ5D) score 5 subscales (1 to 5): Mobility, self-care, usual activities, pain/discomfort, anxiety/depressed Each subscale assessed individually.	2 years
Changes in social engagement	Changes in Lubben Social Network Scale. Scale range from 0 to 30, the higher the value, the greater the social engagement	2 years
Changes in systemic inflammation	Changes in Tumour necrosis factor alpha (TNF-a)	2 years
Changes in systemic inflammation	Changes in Interleukin-10	2 years
Changes in systemic inflammation	Changes in Interleukin-6	2 years
Changes in phase angle by bioelectrical impedance analysis	Changes in phase angle by bioelectrical impedance analysis	2 years
Changes in protein mass	Changes in protein mass by bioelectrical impedance analysis	2 years
Changes in level of bone biomarkers	Changes in level of serum sclerotin	2 years
Changes in level of bone biomarkers	Changes in level of serum osteocalcin	2 years
Changes in level of bone biomarkers	Changes in level of free Vitamin D	2 years
Acceptance of protein enriched food by local seniors	Assessed by taste test questionnaire	2 years
Cost-effectiveness analysis	Cost effectiveness will be evaluated from the societal perspective. Cost of the program as well as healthcare utilization related to frailty and sarcopenia will be collected. An incremental cost effectiveness ratio will be computed by identifying the additional costs associated with the Intervention Group per additional unit of health outcome (QALYs).	2 years

Collaborators and Investigators

• Sponsor: National University Hospital, Singapore
• Collaborators: Health Promotion Board (HPB); Saw Swee Hock Shool of Public Health, National University of Singapore

Study record dates

Study Major Dates

• Study Start (ANTICIPATED): January 1, 2019
• Primary Completion (ANTICIPATED): December 1, 2020
• Study Completion (ANTICIPATED): December 1, 2020

Study Registration Dates

• First Submitted: December 11, 2018
• First Submitted That Met QC Criteria: December 20, 2018
• First Posted (ACTUAL): December 26, 2018

Study Record Updates

• Last Update Posted (ACTUAL): December 26, 2018
• Last Update Submitted That Met QC Criteria: December 20, 2018
• Last Verified: December 1, 2018

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Mental Disorders; Pathologic Processes; Nervous System Diseases; Neurologic Manifestations; Neurocognitive Disorders; Musculoskeletal Diseases; Muscular Diseases; Neuromuscular Manifestations; Cognition Disorders; Muscle Weakness; Cognitive Dysfunction
• Other Study ID Numbers: 2018/01183

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No