____________________________________________

ABSTRACT

Due to health problems and changes in the lifestyle, elderly people wake up a lot during their sleeping cycle. There is loss of skeletal muscle that is frequently reported in aged people. Sleep that is frequently disrupted has shown impaired secretion of hormone such as insulin-like growth factor-1 (IGF-1). The muscle strength is compromised due to inflammation. In addition, IGF-1 also influences the muscle mass and its activities. This highlights that the sleep quality is influenced by the state of the muscles and sleep status also affects the muscle functioning. Lot of studies have assessed the effect of muscle conditions (muscle strength, muscle mass) on the sleep quality but till date no research has demonstrated the role of massage therapies in the overall improvement of the sleeping process. A method for falling asleep quickly for productive and quality sleep, using special manual therapy with shaking and bimanual stretching of muscles has been devised. Our novel massage therapy consists of twitching, shaking and stretching of the muscles in order to relax these initiator fibers. Firstly, in this technique we raise the limbs by 20-30 centimeters, and head by 5-6 centimeters. Secondly, the limbs and head are gently dropped so that the limb or head falls in unison with the exhalation. This is carried out until the patient falls asleep. The feeling of falling into bottomless space helps to clear the mind and releases any stress from the body as well as the mind. As this method is repeated at the same time before the person falls asleep, it brings improvement in the sleeping cycle. This review article discusses the older and newer massage therapies that can improve the sleep pattern and sleeping duration among the people affected with insomnia.

Keywords: insomnia, massage therapy, sleep quality, sleep cycle, muscles, stretching.

1. INTRODUCTION 

Sound sleep is very important physiological process that helps to restore the essential functioning of the day to day activities. Lack of sufficient sleep impairs the overall performance and results in the impairment of the cognitive abilities (1, 2), organ dysfunction, health deterioration (3-5) and increases the mortality (6-8). As we age, a change in our sleep pattern occurs both qualitatively and quantitatively. For example, infants sleep for almost 12-16 hours in a day. However, sleep demand decreases as we approach adulthood, requiring only 7-8 hours to maintain healthy balance. In older people, the sleep duration is further decreased. Various factors play a role that causes less sleep especially at night. Elderly people tend to have more disturbed sleep at night as they commonly have a nap during daytime. Additionally, there are different health problems such as changes in the body’s physiology & biological processes and an altered circadian rhythm are the underlying factors that affect the sleep quality among elders. There has been an increasing reports of sleep-related disorders among older population that aggravates the problem of insomnia (9-11). 

It has been highlighted by National sleep foundation that more than 50% of the elderly with the age above 65 years have reported of sleep associated problems and complained of disruptions while sleeping and causing insomnia. In another study, it was mentioned that as people age they find it difficult to fall asleep, and tend to wake up early in the morning (12, 13). Due to health problems and changes in the lifestyle, elderly people wake up a lot during their sleeping cycle (14). When an individual wakes up in the morning feeling energized, demonstrates no disruptions in his sleep and reports of no body pain that is a sign of sound sleep quality. On the other hand, difficulty to sleep in a stretch, getting up too early in the morning, and inability to sleep after getting woken up are the frequent complaints that are reported by older people. These are a sign of poor sleep quality mainly caused due to the aging process which results in increased sleep latency, and affecting the sleep efficiency. Due to the aging process, the activity of the neurotransmitters is decreased affecting the distribution of norepinephrine. As a result, the circadian rhythm is also changed in such a way that it affects the non-rapid eye movement (NREM) sleep cycle. Therefore, the sleep quality is affected as there is no phase 4 or deep sleep (15). It is demonstrated below how the physiological changes that affect the muscle activity impacts the sleep quality. 

1. AGE ASSOCIATED ALTERATIONS IN THE MUSCLES THAT AFFECT SLEEP 

Sarcopenia is known as the loss of skeletal muscle that is frequently reported in aged people (16-19). Elderly people have an increased amount of fat mass as compared to the younger group even if they are not obese (BMI < 30 kg/m2). This can be attributed to several factors such as behavioral, environmental and lifestyle related that occur as the age progresses. Several research studies have mentioned decreased muscle mass among the elderly (20, 21). It is believed that decreased synthesis of muscle proteins causes loss of muscle mass (22, 23), although it is not consistently seen. A research study concluded that in healthy elderly individuals the muscle protein synthesis tends to be normal (24, 25). 

Protein catabolic activity is measured by the level of the essential amino acids mainly by the branched chain amino acids. Muscle protein synthesis depends on the availability of blood amino acids (26, 27), where the stimulus for the protein synthesis is controlled by the essential amino acids (28). The response to these amino acids is very less in elderly individual as compared to the younger people (29). Sarcopenia compromises not only the muscle mass but there is decreased muscle response to normal stimuli, and delayed functions. It also causes bone fragility as there is less bone mass and reduced strength in the bones and muscles. It is noteworthy to remember that the skeletal and muscular systems are dependent on each other. The impact of the mechanical forces of the muscular contractions are what defines the bone strength, architecture and density. Hence diminished muscular strength results in weakened bone density. There is frequent falls, muscle cramps, weakness and frequent fractures in elderly. All these result in severely altered sleep patterns and reduced sound quality (29). 

1. INACTIVITY AND AGING PHYSICAL 

Immobilization lead to muscular deterioration with age as there is decreased utilization of muscle glucose. Additionally, it induces changes in the body similar to that encountered during stress response. These factors lead to decreased energy consumption by the muscles. The excess energy is accumulated in the liver which promotes lipid production. The increased adipocytes become metabolically active due to the presence of excessive fat. This results in enhanced production of inflammatory molecules and there is decreased collection of anti-inflammatory adiponectin (30-32). Due to increased amount of proinflammatory cytokines and induced stress activity blood coagulation, inflammatory response and platelet aggregation is promoted. This is also the underlying cause of increased occurrence of cardiovascular disease, atherosclerosis commonly seen in elderly people (30). 

Lack of adequate physical activity directly impacts the levels of cytokines and chemokines that have anti-inflammatory properties. During regular muscular activity, the contracting muscle, adjacent tissues and circulating cells interact by transmitting signals through “myokines” such as IL-6, IL-8, and IL-15 produced by the contracting muscles. The anti-inflammatory property displayed by muscle’s contractions is due to the release of IL-1 receptor antagonist and sTNF-R molecules. Regular muscle relaxation techniques are very important to manage low-grade inflammation, relive the muscular cramps, pain and associated weakness with it. This will play an important role to improve the sleep as muscle strengthening therapies will effectively increase the blood flow and decrease the systemic inflammation (33). 

Sleep is crucial to maintain a balanced physical and mental state (34). Previous research has shown that whether it is lack or excess of sound sleep quality, both result in different types of problems. There is increased risk of hypertension (35, 36), diabetes (37), obesity (38), lack of concentration, and impaired cognitive abilities as a result of this (39-41). A study demonstrated that less sleep also causes increased inflammation among adults (42). Sleep that is frequently disrupted has shown impaired secretion of hormone such as insulin-like growth factor-1 (IGF-1) (43). The muscle strength is compromised due to inflammation. In addition, IGF-1 also influences the muscle mass and its activities (44). This highlights that the sleep quality is influenced by the state of the muscles and sleep status also affects the muscle functioning. 

Lot of studies have assessed the effect of muscle conditions (muscle strength, muscle mass) on the sleep quality but till date no research has demonstrated the role of massage therapies in the overall improvement of the sleeping process. This review article demonstrates an update regarding massage therapies that targets the muscle fibers and how they play a significant role in restoring sleep’s quality.

1. MASSAGE THERAPY AND CHANGES IN THE SLEEP QUALITY 

Massage therapy is an important therapeutic mode of relieving any muscular injuries, tension and improving the performance (45,46). Massage can be defined as the manipulation of the body’s tissues in such a way that the rhythmic pressure and strokes ensure well-being of an individual (45). The commonly used techniques are as follows (47): 

Effleurage: It involves smooth gliding movement over the target surface such that the motion follows the contours of the body. In this technique a light stroke is applied initially and later on deeper pressure is applied. It helps in relaxing the muscles, increases the vascular flow and raises tissue temperature. 

Petrissage: It involves a kneading motion where after the pressure application the tissue is compressed and lifted after each stroke. It involves the kneading, compression and lifting of the tissue. It helps in enhancing the muscular tone by loosening the muscular adhesions, decreases the muscular swelling and spasms. 

Tapotement: It involves rapid hand striking repeatedly on a particular tissue. In this the pressure is applied after cupping the hands or using the ulnar side at the target area. It stimulates the muscle spindles or Golgi tendon organs of the muscular system. 

Friction: It involves shorter strokes applied in a parallel or transverse direction across the muscular fibers. In this method either the thumb or index finger is used to apply circular strokes at the targeted site. It promotes blood circulation, breaks the adhesions, raises the cell activity by decreasing the inflammation and relieves the pain due to the muscular cramps. 

Vibration: It involves the shaking of the target site. As tremendous deeper pressure is applied it results in shaking of the tissues. Due to the rapid strokes, it results in enhancing muscular relaxation and circulation. 

All these massage techniques target the muscles so that the pain is relieved and the overall performance is enhanced. As a whole these techniques ensure that the blood flow is improved, sore muscles are relaxed (46, 48), adhesions get loosened, cramps and spasms are efficiently reduced, ensure that the muscle spindles get stimulated and circulation is improved (48). It has been observed that these methods when performed by a certified specialist enhance the flexibility, promote muscle recovery that directly helps the body to relax and get a better sleep. The muscles are essential component that affect our sleep quality and massage is a vital part to attain that (45). 

Previous research has shown that massage therapy can significantly improve the muscle recovery (45). It promotes blood flow and tissue alignment if the muscles are injured. In a study it was seen that 15-30 minutes of combination therapy including effleurage, petrissage, and tapotement helped in reducing the muscle soreness and promoted increased activity in the muscles (45, 48). Additionally, the relaxation therapy through massage clears the blood lactate from the muscles (48). It was also observed that not only physical improvement is seen after massage but also psychological benefits are detected (49). 

1. MANUAL THERAPY WITH SHAKING AND BIMANUAL STRETCHING OF MUSCLES - A NOVEL APPROACH

A method for falling asleep quickly for productive and quality sleep, using special manual therapy with shaking and bimanual stretching of muscles has been implemented at the Tyan Anmo Medical Massage School. There has been a lot of development of sleep therapies but majority do not pay attention to relieving the muscular tension. Muscular cramps and muscular pain is a major factor that causes insomnia, however no study has been conducted to elaborate its nature and reason. Additionally, due to aging the muscular system is unable to completely relax due to impairment in the functioning of actin-myosin mechanism of muscular system. This is a bigger problem than the irregularity in the circadian rhythm or inhibitory cycles of brain functions that control our sleep patterns. Hence to improve the flexibility, reduce stress levels and enhance the blood circulation we devised a new therapy that helps in improving the sleep quality. In this therapy our main target is the muscle fibers as these small bundles regulate the body’s movement. 

The main reflexes of falling asleep disappear with age. Therefore, it is fundamentally important to create new reflexes of falling asleep for productive and high-quality life. The therapy is performed at a fixed time and at patient's home on their beds, where they usually sleep. The therapy is carried out for 2-3 weeks. Performing therapy at the same time repeatedly (conducting same motions and manipulations over and over again) create new reflexes. The effect is seen to be persistent and long lasting. 

An external manual approach is indispensable in this technique, since the muscles are the key to attain complete relaxation. Though many different techniques focus on breathing and consciousness blackouts but if the muscular system is in a state of rapid response a disturbed sleep will be the outcome. Due to this, the sensitivity threshold of the muscle fibers group initiating movement in the muscle gets activated due to misalignment of fibers and hence the person wakes up in the second or third sleep cycle. Muscles, like other tissues of the body change with age and their ability to restore a zero state, that is, complete relaxation, is lost over time. 

When the massage therapy is initiated the muscles get relaxed as contracted muscle fibers return to a state of deactivation of actin-myosin system. Each movement of the body is performed by a group of muscles that is innervated by a certain nerve. In a normal situation, the movement is cascading, that is, at first, the small amount of muscle fibers get activated and contract. Then impulse fires further, transmitting to all the other fibers of the target muscle and thereby movement of joint or the body part takes place. Similarly, during relaxation the nerve impulse ceases, and firstly the small muscle fibers relax followed by all other fibers. 

With age, the process of muscle relaxation loses its original effectiveness. Therefore, we observe the jerky twitching of the limbs or body before a person falls asleep. This happens when the larger group of muscle fibers that are responsible for movement of the muscles relax before the smaller group of muscle fibers (these are responsible for initiating larger groups of muscle fibers for movement of the same muscle) are able to relax. The proper cycle of contraction and relaxation is interrupted such that the limbs or the body begins to twitch while a person is asleep.

 

Our novel massage therapy consists of twitching, shaking and stretching of the muscles in order to relax these initiator fibers. Firstly, in this technique we raise the limbs by 20-30 centimeters, and head by 5-6 centimeters. Secondly, the limbs and head are gently dropped so that the limb or head falls in unison with the exhalation. This is carried out until the patient falls asleep. The feeling of falling into bottomless space helps to clear the mind and releases any stress from the body as well as the mind. As this method is repeated at the same time before the person falls asleep, it brings improvement in the sleeping cycle. 

The purpose of this technique is to disengage muscular system and bring synchronization in the smaller and larger group of muscle fibers. The manual therapy will provide a balanced state where adequate relaxation is attained when a person tries to sleep. It will improve the sleep duration, pattern and overall body’s function. 

The manual approach of massage therapy involves different systems that help to relax the muscular system. The complex interplay of massage therapies affects the biochemical, physiological, neurological and psychological systems that improve the sleep quality (50). Here are the mechanism involving each system that affects the sleep: 

1. ROLE OF MASSAGE THERAPY 

6.1 Biomechanical Impact 

In a study conducted by Stanley et. al. it was observed that massage therapy reduced the passive stiffness. 10 minute effleurage did not show much improvement in reducing the stiffness of the gastrocnemius as compared to a 10-minute rest. As pressure applied during effleurage does not significantly produces a impactful response, such that the muscles remain in the contractile state (51,52). In another study performed by Chanawong and co-workers it was found that after conducting massage among soccer players, the blood flow was increased and muscular tension was decreased (53). 

Possibly due to stretching and shaking, the adhesions and spasms in the muscles were significantly reduced. Additionally, the proprioceptors of muscles were activated after massage. As the blood circulation was enhanced in the muscles, it led to an increased oxygen supply to the muscles and therefore, the nutrients level also improved (54). All these mechanism denote that massage can drastically relax the stiffened muscles, and help to improve the sleep pattern. 

6.2 Physiological Impact 

It is believed that the pressure applied during manual massage therapy helps to clear out the waste metabolites from the muscles as it improves the blood flow. Furthermore, the oxygen content is also enhanced due to the therapy (55-57). In a study performed by Hidetoshi et al. it was observed that after 5 minutes of massage therapy (lumbar region) the blood volume in the muscles was increased (55). Massage therapy lead to an increased activity of the parasympathetic nervous system. As a result, it reduces the blood pressure and heart rate, increases the heart rate variability, and also reduces the level of the stress hormone, cortisol (58,59). 

Surussawadi [59) reported that after performing massage sessions in patients the cortisol level were greatly reduced as compared to the baseline measurements. This brings out a significant finding that body is not only in a state of physical relaxation but also the stress and anxiety is reduced after massage therapy. This helps an individual to fall asleep faster as all the parameters are also in a state of equilibrium.

6.3  Neurological Impact 

It is believed that massage therapy enhances muscles relaxation and activates the sensory receptors by managing the excitability of the neuromuscular system. This response is detected by noticing a change in the amplitude of the Hoffman reflex (H-reflex) [60-63]. In a study it was reported that after each massage session the Hoffman reflex (H-reflex) amplitude was less as compared to the control group. This signifies that massage promoted relaxation of the deeper mechanoreceptors and therefore a decreased amplitude was seen (63). 

Massage therapy was found to be very effective in relieving pain (64,65). For example traditional Thai massage promotes the circulation of blood and lymph. It also activates the autonomic nervous system by applying sufficient pressure on the skin and muscles. Due to this the toxins and other harmful byproducts get removed promoting the release of nutrients to the target tissues. This further helps in reducing the swelling and pain in the muscles and joints. A study has shown that massage led to reduced headaches and other pain therefore, improving the sleep quality (65). 

Massage stimulates the specific myofascial trigger points (MTrPs). These trigger points consist of an accumulation of different chemical mediators such as bradykinin, serotonin and substance P. Massage helps in breaking down the MTrPs adhesions. It improves the blood circulation and removes all waste metabolites (lactic acid and substance P). An adequate amount of pressure applied during massage therapy also stimulates the proprioceptors located in the target muscles, such as the Golgi tendon organ and spindle cells. This combined effect results in the pain relief (65). It demonstrates that after massage therapy, due to

pain relief, breaking down of adhesions and improved stimulation of the proprioceptors, the sleep is also effectively improved. 

6.4 Psychological Impact 

Various research studies have demonstrated that massage therapy helps in reducing the stress and anxiety levels (66). In a study it was seen that after applying moderate pressure, dopamine levels were increased and norepinephrine level was reduced. This led to reduced anxiety and stress (66). As massage therapy promotes relaxation therefore the stress response is reduced. This further causes reduction in the response of sympathetic nervous system and vagal outflow [67]. After the massage therapy the feeling of relaxation can be attributed to a reduction in the defense arousal response (68). Another study highlighted that the decreased heart rate, and activity of automatic nervous system is due to an increased response of parasympathetic activity and decreased activity of the sympathetic nervous system (69). 

The effects of massage therapy:

Table 1:

Study	Intervention	Measurement	Results
Biochemical makers
Nordschow and Bierman (70)	30 minutes of massage	Finger to floor test	Improvement in the stretching capacity and range of motion.

Leivadi et al.  (71)	30 minutes  massage ,	Level of  anxiety and  mood states,  Pain (visual  analog scale), Neck  extension	Massage helped to increase the neck extension.  Better mood  Less muscular pain
Physiological makers
Hidetoshiet al. (72)	5 minutes  massage	Pain (visual  analog scale), Skin  Temperature,  Blood flow and blood volume in muscles	After massage therapy:  Rise in skin temperature,  Improved blood volume and flow, Less pain
Buttagat et  al. (73)	30 minutes  massage on  back  muscle	Body  flexibility;  Anxiety, pain threshold,  muscle tension	Massage resulted in:  Better flexibility, reduced muscle tension and cramps,  Less anxiety and muscular pain.
Neurological makers
Buttagat et al. (73)	30 minutes  Thai  massage	Anxiety,  muscle tension, pain	Overall improvement, relaxation of the muscles, less pain

Chatchawan et al. (74)	Massage  lasting for 25 minutes  followed by 5 minutes of  stretching	Range of  motion, pain  threshold  (Visual analog scale)	Increased movement of the neck muscles, less rigidity and pain.
Psychological makers
Buttagat et al. (73)	Massage  followed by breathing  exercise.	Body  flexibility,  muscular pain, anxiety	Results showed better muscular flexibility, and reduced pain in the muscle.
Chan et al.(74)	40 minutes  Massage  involving head and neck	Pressure pain thresholds and assessment of mood states;	Massage resulted in improved mood outcome and relaxation of muscles.

Sleep quality is affected by lot of factors that eventually impact the health. It involves factors such as age, lifestyle, anxiety, health problem and environment (76). Most of the elderly get a disturbed sleep at night and therefore they tend to fall asleep during the day (77). This is caused to age associated changes in the circadian rhythm that prevents deep sleep at night. With the massage therapy the body gets relaxed and stress as well anxiety is reduced that improves the sleep cycle. In a recent study it was observed that after the muscle relaxation therapy the sleep quality improved significantly (78). Similar findings were also seen in studies conducted by Sumiarsih and Ali where it was observed that after muscle relaxation therapy the sleep needs were adequately met (79, 80). 

Our massage therapy involving the twitching, shaking and stretching of the muscles results activation of the parasympathetic nerves. This result in suppression of the actions modulated by the sympathetic nervous system. As both of them work in the opposite way where activation of one leads to diminished effect of the other one (81). It has been observed that after the massage therapy there was an improvement in sleep duration, sleep quality and sleeping efficiency (82). 

Though there are lot of pharmacological methods and approaches to ensure enough sleep is attained among elderly population. But this method will manage the insomnia effectively. When performed repetitively it will improve the habitual sleeping process after few sessions. Further randomized clinical trials with larger population should be conducted so that it can be implemented for people dealing with insomnia. 

1. CONCLUSION 

World Health Organization has defined massage therapy as "green medicine". It demonstrates remarkable outcome, is cost-effective and does not have any side-effects. The new massage approach implemented by us that targets the muscular system has shown significant results in improving the sleep. The manual massage therapy involves a complex interplay where the physiological, physical and biochemical systems are approached. The massage therapy is an effective way to improve the sleep state as it controls the major part of our sleeping schedule. A targeted approach to the muscles will help in improving flexibility, blood flow and reduce the toxins, and other adhesions. The rigidity and stiffness associated with age will also be properly managed leading to a better relaxation state that will help anyone to enjoy a sound sleep. Future research should focus on RCT with larger sample size to demonstrate its effectiveness in the management of insomnia. 

REFERENCES 

1. Verstraeten E. Neurocognitive effects of obstructive sleep apnea syndrome. Curr Neurol Neurosci Rep. 2007; 7:161–166. [PubMed: 17324368] 
2. Ferrara M, De Gennaro L, Casagrande M, Bertini M. Selective slow-wave sleep depri- vation and time-of-night effects on cognitive performance upon awakening. Psychophy- siology. 2000; 37:440– 446. [PubMed: 10934902] 
3. Weissman MM, Greenwald S, Nino-Murcia G, Dement WC. The morbidity of insomnia uncomplicated by psychiatric disorders. Gen Hosp Psychiatry. 1997; 19:245–250. [PubMed: 9327253] 
4. Leproult R, Copinschi G, Buxton O, Van Cauter E. Sleep loss results in an elevation of cortisol levels the next evening. Sleep. 1997; 20:865–870. [PubMed: 9415946]
5. Scheen AJ, Byrne MM, Plat L, Leproult R, Van Cauter E. Relationships between sleep quality and glucose regulation in normal humans. Am J Physiol. 1996; 271(2 Pt 1): E261–E270. [PubMed: 8770019] 
6. Wingard DL, Berkman LF. Mortality risk associated with sleeping patterns among adults. Sleep. 1983; 6:102–107. [PubMed: 6878979] 
7. Lavie P, Herer P, Peled R, et al. Mortality in sleep apnea patients: a multivariate analysis of risk factors. Sleep. 1995; 18:149–157. [PubMed: 7610310] 
8. Punjabi NM, Caffo BS, Goodwin JL, et al. Sleepdisordered breathing and mortality: a prospective cohort study. PLoS Med. 2009; 6:e1000132. [PubMed: 19688045]
9. Feinberg I. Changes in sleep cycle patterns with age. J Psychiatr Res. 1974; 10:283–306. [PubMed: 4376564] 
10. Gillin JC, Duncan WC, Murphy DL, et al. Age-related changes in sleep in depressed and normal subjects. Psychiatry Res. 1981; 4:73–78. [PubMed: 6939001] Edwards et al. Page 12 
11. Redline S, Kirchner HL, Quan SF, Gottlieb DJ, Kapur V, Newman A. The effects of age, sex, ethnicity, and sleep-disordered breathing on sleep architecture. Arch Intern Med. 2004; 164:406– 418. [PubMed: 14980992] 
12. Sagayadevan V, Abdin E, Binte Shafie S, Jeyagurunathan A, Sambasivam R, Zhang Y, et al. Prevalence and correlates of sleep problems among elderly Singaporeans. Psychogeriatr. 2017;17(1):43-51. 
13. Lubis, Marliyani. Fulfilling the needs of sleep rest in the elderly at UPT elderly social services and toddler children in Binjai and Medan areas. Medan: Univer North Sumatra; 2011. 
14. Fitriyia, Rahmadona. The effect of progressive muscle relaxation on fulfilling sleep needs in the elderly in UPT elderly social services and toddler children in Binjai and Medan. Medan: Univer North Sumatra; 2012. 
15. Oktora, Dwi SP. the effect of al-qur'an murottal therapy on elderly sleep quality in cilacap dewanata's social rehabilitation unit. Purwokerto: Jenderal Soedirman Univer. 2013 
16. S. H. Cohn, D. Vartsky, S. Yasumura et al., “Compartmental body composition based on total-body nitrogen, potassium, and calcium,” The American Journal of Physiology, vol. 239, no. 6, pp. E524–E530, 1980. 
17. C. Dutta and E. C. Hadley, “The significance of sarcopenia in old age,” The Journals of Gerontology Series A Biological Sciences and Medical Sciences, vol. 50, pp. 1–4, 1995.
18. G. B. Forbes and J.C. Reina, “Adult lean bodymass declineswith age: some longitudinal observations,” Metabolism, vol. 19, no. 9, pp. 653–663, 1970. 
19. J. J. Kehayias, M. A. Fiatarone, H. Zhuang, and R. Roubenoff, “Total body potassium and body fat: relevance to aging,” The American Journal of Clinical Nutrition, vol. 66, no. 4, pp. 904– 910, 1997. 
20. W. J. Evans, “What is sarcopenia?” The Journals of Gerontology, vol. 50, pp. 5–8, 1995. 
21. G. B. Forbes, “The adult decline in lean body mass,” Human Biology, vol. 48, no. 1, pp. 161–173, 1976. 
22. P. Balagopal, O. E. Rooyackers, D. B. Adey, P. A. Ades, and K. S. Nair, “Effects of aging on in vivo synthesis of skeletal muscle myosin heavy-chain and sarcoplasmic protein in humans,” American Journal of Physiology: Endocrinology and Metabolism, vol. 273, no. 4, pp. E790–E800, 1997. 
23. S.Welle, C.Thornton, R. Jozefowicz, andM. Statt, “Myofibrillar protein synthesis in young and old men,” The American Journal of Physiology—Endocrinology and Metabolism, vol. 264, no. 5, pp. 693–698, 1993. 
24. E. Volpi, B. Mittendorfer, S. E. Wolf, and R. R. Wolfe, “Oral amino acids stimulate muscle protein anabolism in the elderly despite higher first-pass splanchnic extraction,” American Journal of Physiology— Endocrinology and Metabolism, vol. 277, no. 3, pp. E513–E520, 1999. 
25. E.Volpi, M. Sheffield-Moore, B. B. Rasmussen, andR.R.Wolfe, “Basal muscle amino acid kinetics and protein synthesis in healthy young and older men,” The Journal of the American Medical Association, vol. 286, no. 10, pp. 1206–1212, 2001. 
26. M. J. Rennie, J. Boh´e, and R. R. Wolfe, “Latency, duration and dose response relationships of amino acid effects on human muscle protein synthesis,” Journal of Nutrition, vol. 132, no. 10, pp. 3225–3227, 2002. 
27. R. R. Wolfe, “Regulation of muscle protein by amino acids,” Journal of Nutrition, vol. 132, no. 10, pp. 3219–3224, 2002. 
28. E. Volpi, H. Kobayashi, M. Sheffield-Moore, B. Mittendorfer, and R. R. Wolfe, “Essential amino acids are primarily responsible for the amino acid stimulation of muscle protein anabolism in healthy elderly adults,” The American Journal of Clinical Nutrition, vol. 78, no. 2, pp. 250–258, 2003.
29. C. S.Katsanos, H. Kobayashi, M. Sheffield- Moore, A. Aarsland, and R. R.Wolfe, “Aging is associated with diminished accretion ofmuscle proteins after the ingestion of a small bolus of essential amino acids,”The American Journal of ClinicalNutrition, vol. 82, no. 5, pp. 1065–1073, 2005. 
30. M. Morelli, M. Gaggini, G. G. Daniele, P. Marraccini, R. Sicari, and A. Gastaldelli, “Ectopic fat: the true culprit linking obesity and cardiovascular disease?”Thrombosis and Haemostasis, vol. 110, no. 4, pp. 651–660, 2013. 
31. D.Heber, “An integrative view of obesity,” The American Journal of Clinical Nutrition, vol. 91, no. 1, pp. 280–283, 2010. 
32. R. M. Maizels and J. E. Allen, “Eosinophils forestall obesity,” Science, vol. 332, no. 6026, pp. 186–187, 2011. 
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