Effect of Remotely Supervised Weight Loss and Exercise Training Versus Lifestyle Counseling on Cardiovascular Risk and Clinical Outcomes in Older Adults With Rheumatoid Arthritis: A Randomized Controlled Trial.

OBJECTIVE: To compare a remotely supervised weight loss and exercise intervention to lifestyle counseling for effects on cardiovascular disease risk, disease activity, and patient-reported outcomes in older patients with rheumatoid arthritis (RA) and overweight/obesity. METHODS: Twenty older (60-80 years), previously sedentary participants with seropositive RA and overweight/obesity were randomized to 16 weeks of either Supervised Weight loss and Exercise Training (SWET) or Counseling Health As Treatment (CHAT). The SWET group completed aerobic training (150 minutes/week moderate-to-vigorous intensity), resistance training (two days/week), and a hypocaloric diet (7% weight loss goal). The CHAT control group completed two lifestyle counseling sessions followed by monthly check-ins. The primary outcome was a composite metabolic syndrome z-score (MSSc) derived from fasting glucose, triglycerides, high density lipoprotein-cholesterol, minimal waist circumference, and mean arterial pressure. Secondary outcomes included RA disease activity and patient-reported outcomes. RESULTS: Both groups improved MSSc (absolute change -1.67 ± 0.64 in SWET; -1.34 ± 1.30 in CHAT; P < 0.01 for both groups) with no between-group difference. Compared with CHAT, SWET significantly improved body weight, fat mass, Disease Activity Score-28 C-reactive protein, and patient-reported physical health, physical function, mental health, and fatigue (P < 0.04 for all between-group comparisons). Based on canonical correlations for fat mass, cardiorespiratory fitness, and leg strength, component-specific effects were strongest for (1) weight loss improving MSSc, physical health, and mental health; (2) aerobic training improving physical function and fatigue; and (3) resistance training improving Disease Activity Score-28 C-reactive protein. CONCLUSION: In older patients with RA and overweight/obesity, 16 weeks of remotely supervised weight loss, aerobic training, and resistance training improve cardiometabolic health, patient-reported outcomes, and disease activity. Less intensive lifestyle counseling similarly improves cardiovascular disease risk profiles, suggesting an important role for integrative interventions in the routine clinical care of this at-risk RA population.

The effects of a 6-month weight loss intervention on physical function and serum biomarkers in older adults with and without osteoarthritis.

Objective: To examine the effects of a 6-month weight loss intervention on physical function, inflammatory biomarkers, and metabolic biomarkers in both those with and without osteoarthritis (OA). Design: 59 individuals ≥60 years old with obesity and a functional impairment were enrolled into this IRB approved clinical trial and randomized into one of two 6-month weight loss arms: a higher protein hypocaloric diet or a standard protein hypocaloric diet. All participants were prescribed individualized 500-kcal daily-deficit diets, with a goal of 10% weight loss. Additionally, participants participated in three, low-intensity, exercise sessions per week. Physical function, serum biomarkers and body composition data were assessed at the baseline and 6-month timepoints. Statistical analyses assessed the relationships between biomarkers, physical function, body composition, and OA status as a result of the intervention. Results: No group effects of dietary intervention were detected on any outcome measures (multiple p â€‹> â€‹0.05). During the 6-month trial, participants lost 6.2 â€‹± â€‹4.0% of their bodyweight (p â€‹< â€‹0.0001) and experienced improved physical function on the Short-Performance-Physical-Battery (p â€‹< â€‹0.0001), 8-foot-up-and-go (p â€‹< â€‹0.0001), and time to complete 10-chair-stands (p â€‹< â€‹0.0001). Adiponectin concentrations (p â€‹= â€‹0.0480) were elevated, and cartilage oligomeric matrix protein (COMP) concentrations (p â€‹< â€‹0.0001) were reduced; further analysis revealed that reductions in serum COMP concentrations were greater in OA-negative individuals. Conclusions: These results suggest that weight loss in older adults with and without OA may provide a protective effect to cartilage and OA. In particular, OA-negative individuals may be able to mitigate changes associated with OA through weight loss.

Effects of exercise amount and intensity versus a combined exercise and lifestyle intervention on metabolic syndrome in adults with prediabetes: a STRRIDE-PD randomized trial.

The purpose of this secondary analysis was to determine what portion of the effects of a Diabetes Prevention Program-like intervention on metabolic syndrome (MetS) could be achieved with exercise alone, as well as to determine the relative importance of exercise intensity and amount to the total exercise effect on MetS. Sedentary, overweight adults with prediabetes were randomly assigned to one of four 6-month interventions: 1) low-amount/moderate-intensity (10 kcal/kg/week at 50% peak V˙O2); 2) high-amount/moderate-intensity (16 kcal/kg/week at 50% peak V˙O2); 3) high-amount/vigorous-intensity (16 kcal/kg/week at 75% peak V˙O2); or 4) diet (7% weight loss) plus low-amount/moderate-intensity (10 kcal/kg/week at 50% peak V˙O2). The primary outcome of this secondary analysis was change in the MetS z-score. A total of 130 participants had complete data for all five Adult Treatment Panel (ATP) III MetS criteria. The diet-and-exercise group statistically outperformed the MetS z-score and the ATP III score compared to the exercise alone group. Aerobic exercise alone achieved 24%-50% of the total effect of the combined diet-and-exercise intervention on the MetS score. Low-amount moderate-intensity exercise quantitatively performed equal to or better than the interventions of high-amount moderate-intensity or high-amount vigorous-intensity exercise in improving the MetS score. The combined diet-and-exercise intervention remains more efficacious in improving the MetS z-score. However, all three exercise interventions alone showed improvements in the MetS z-score, suggesting that a modest amount of moderate-intensity exercise is all that is required to achieve approximately half the effect of a diet-and-exercise intervention on the MetS. Clinical Trial Registration: clinicaltrials.gov, identifier NCT00962962.

Remotely Supervised Weight Loss and Exercise Training to Improve Rheumatoid Arthritis Cardiovascular Risk: Rationale and Design of the Supervised Weight Loss Plus Exercise Training-Rheumatoid Arthritis Trial.

Patients with rheumatoid arthritis (RA) remain at an increased risk for cardiovascular disease (CVD) and mortality. RA CVD results from a combination of traditional risk factors and RA-related systemic inflammation. One hypothetical means of improving overall RA CVD risk is through reduction of excess body weight and increased physical activity. Together, weight loss and physical activity can improve traditional cardiometabolic health through fat mass loss, while also improving skeletal muscle health. Additionally, disease-related CVD risk may improve as both fat mass loss and exercise reduce systemic inflammation. To explore this hypothesis, 26 older persons with RA and overweight/obesity will be randomized to 16 weeks of a usual care control arm or to a remotely Supervised Weight Loss Plus Exercise Training (SWET) program. A caloric restriction diet (targeting 7% weight loss) will occur via a dietitian-led intervention, with weekly weigh-ins and group support sessions. Exercise training will consist of both aerobic training (150 minutes/week moderate-to-vigorous exercise) and resistance training (twice weekly). The SWET remote program will be delivered via a combination of video conference, the study YouTube channel, and study mobile applications. The primary cardiometabolic outcome is the metabolic syndrome Z score, calculated from blood pressure, waist circumference, high-density lipoprotein cholesterol, triglycerides, and glucose. RA-specific CVD risk will be assessed with measures of systemic inflammation, disease activity, patient-reported outcomes, and immune cell function. The SWET-RA trial will be the first to assess whether a remotely supervised, combined lifestyle intervention improves cardiometabolic health in an at-risk population of older individuals with RA and overweight/obesity.

Nutritional quality of calorie restricted diets in the CALERIE™ 1 trial.

OBJECTIVES: The aim was to determine the nutritional adequacy of calorie restricted (CR) diets during CR interventions up to 12 months. METHODS: The Comprehensive Assessment of Long-Term Effects of Reducing Intake of Energy (CALERIE™) phase 1 trial consisted of 3 single-site studies to test the feasibility and effectiveness of CR in adults without obesity. After baseline assessments, participants who were randomized to a CR intervention received education and training from registered dietitians on how to follow a healthful CR diet. Food diaries were completed at baseline and during the CR interventions (~6, 9, and 12 months) when participants were self-selecting CR diets. Diaries were analyzed for energy, macronutrients, fiber, 11 vitamins, and 9 minerals. Nutritional adequacy was defined by sex- and age-specific Estimated Average Requirement (EAR) or Adequate Intake (AI) criteria for each nutrient. Diet quality was evaluated using the PANDiet diet quality index. RESULTS: Eighty-eight CR participants (67% women, age 40 ± 9 y, BMI 27.7 ± 1.5 kg/m2) were included in the analysis. Dietary intake of fiber and most vitamins and minerals increased during CR. More than 90% of participants achieved 100% of EAR or AI during CR for 2 of 4 macronutrients (carbohydrate and protein), 6 of 11 vitamins (A, B1, B2, B3, B6, B12), and 6 of 9 minerals assessed (copper, iron, phosphorus, selenium, sodium, zinc). Nutrients for which <90% of participants achieved adequacy included fiber, omega-3 fatty acids, vitamins B5, B9, C, E, and K, and the minerals calcium, magnesium, and potassium. The PANDiet diet quality index improved from 72.9 ± 6.0% at baseline to 75.7 ± 5.2% during CR (p < 0.0001). CONCLUSION: Long-term, calorie-restricted diets were nutritionally equal or superior to baseline ad libitum diets among adults without obesity. Our results support modest calorie restriction as a safe strategy to promote healthy aging without compromising nutritional adequacy or diet quality.

Amount and intensity effects of exercise training alone versus a combined diet and exercise lifestyle intervention on health-related quality of life in the STRRIDE-PD randomized trial.

INTRODUCTION: To determine the relative contributions of various amounts and intensities of exercise alone to a combined lifestyle intervention on health-related quality of life (HrQoL) measures. RESEARCH DESIGN AND METHODS: Participants (n=162) were sedentary, overweight/obese, with pre-diabetes, and randomized to one of four 6-month interventions: (1) high amount/moderate intensity exercise-energy expenditure of 16 kcal/kg of body weight/week (KKW) at 50% oxygen consumption (V̇O2) reserve; (2) high/vigorous-16 KKW at 75% V̇O2 reserve; (3) low/moderate-10 KKW at 50% V̇O2 reserve; (4) low/moderate plus diet-10 KKW at 50% V̇O2 reserve plus a calorically restricted diet. The 36-Item Short-Form Survey (SF-36) and Satisfaction with Physical Function and Appearance (SPF/SPA) survey were assessed at baseline and post-intervention. Analyses of covariance determined differences in change scores among groups (p<0.05). Paired t-tests determined significant pre-intervention versus post-intervention scores within groups (p<0.05). RESULTS: Across the intervention, all groups (p<0.05) improved the physical component, SPF, and SPA scores. Only the low/moderate/diet group (p<0.001) significantly improved the mental component score. The high/vigorous group achieved 84.5% of the low/moderate/diet group effect for change in physical component score, and the low/moderate group achieved 83.7% of the low/moderate/diet group effect for change in mental component score. CONCLUSIONS: In general, a low amount of moderate intensity exercise combined with diet was the most effective intervention for improving HrQoL. Of the exercise-only interventions, vigorous intensity exercise provided the greatest impact on changes in physical function. On the other hand, low amounts of moderate intensity exercise provided the greatest impact on mental well-being, potentially being a more attainable exercise dose for previously sedentary individuals with pre-diabetes to achieve.

Mediterranean diet scoring systems: understanding the evolution and applications for Mediterranean and non-Mediterranean countries.

The Mediterranean diet (MedD) is a flexible dietary pattern which has such variability that has led to inconsistencies in definitions and assessment. The purpose of this narrative review is to evaluate scoring systems in a cultural and geographic context, from Mediterranean and non-Mediterranean countries, for comparison and application. The early MedD scoring systems (i.e. Trichopoulou's MedD Scale (T-MDS) and alternative MedD Scale (aMed)) are widely applied throughout the world but use population-specific median cut-offs which limit interpretation and cross-study comparisons. The T-MDS and aMed also do not account for non-traditional MedD foods which are consumed in greater quantities than when the scoring systems were developed. Scoring systems developed after the MedD pyramid publication in 2011 have generally used these recommendations as a basis for food group intake cut-offs, incorporating more foods/food groups as negative components, and some have included dietary and lifestyle behaviours. The different approaches to MedD assessment have created much variability in the foods/food group components included in scoring systems. Assessments that include dietary and lifestyle behaviours may reflect the nutrition transition occurring in Mediterranean countries and better guide clinical intervention approaches. While the new scoring systems are theorised to better capture MedD adherence and behaviours, comparisons are sparse in the literature and none exists outside of Europe. Consensus on food and dietary behaviours to include as well as the methodology for assigning points in MedD scoring systems is needed to advance our understanding of MedD and health relationships to promote public health messaging and clinical application.

Diet quality and exercise in older veterans with PTSD: a pilot study.

Older veterans with posttraumatic stress disorder (PTSD) are at increased risk of obesity and cardiometabolic disease. Physical activity and healthy eating are two behaviors that impact health, functional independence, and disease risk in later life, yet few studies have examined the relationship between PTSD and diet quality. This secondary analysis aimed to: (a) characterize the diet quality of older veterans with PTSD in comparison to U.S. dietary guidelines and (b) explore if participation in a supervised exercise intervention spurred simultaneous changes in dietary behavior. Diet quality was assessed with the Dietary Screener Questionnaire (DSQ), which measures daily intake of fiber, calcium, added sugar, whole grain, dairy, and fruits/vegetables/legumes. The sample included 54 military veterans ≥ 60 years old with PTSD who participated in a randomized controlled pilot trial comparing 12 weeks of supervised exercise (n = 36) to wait-list usual care (n = 18). The DSQ was administered at baseline and 12 weeks. Consumption of added sugar exceeded U.S. dietary guideline recommendations and consumption of whole grains, fruits/vegetables/legumes, fiber, calcium, and dairy fell short. Participation in the supervised exercise intervention was not associated with changes in diet quality. Results revealed that the diet quality of older veterans with PTSD is poor, and while the exercise intervention improved health through exercise, it did not make veterans any more likely to adopt a more healthful diet. Interventions targeting diet, or diet + exercise, are needed to manage the increased risk of obesity and cardiometabolic disease present in older veterans with PTSD.

Older veterans with posttraumatic stress disorder (PTSD) are at risk for several physical health conditions that reduce their quality of life. Physical activity and healthy eating are important behaviors for promoting good health and physical function in later life. The purpose of this study was to examine the diet quality of older veterans with PTSD and explore whether a program designed to increase exercise also improved diet. Diet quality was measured with a self-report survey, the Dietary Screener Questionnaire (DSQ), which measures daily intake of fiber, calcium, added sugar, whole grain, dairy, and fruits/vegetables/legumes. Study participants were 54 military veterans age 60 years and older with PTSD who participated in a randomized controlled pilot trial comparing 12 weeks of supervised exercise to wait-list usual care. The DSQ was administered at baseline and 12 weeks post intervention. Results show that older veterans with PTSD have overall poor diet quality that included consuming too much added sugar and not enough whole grains, fruits/vegetables/legumes, fiber, calcium, and dairy. Participation in the supervised exercise did not lead to simultaneous diet quality changes over 12 weeks. This study shows that diet quality is poor in older veterans with PTSD and future programs are needed to target this health behavior.

Rationale and Design for a Higher (Dairy) Protein Weight Loss Intervention That Promotes Muscle Quality and Bone Health in Older Adults with Obesity: A Randomized, Controlled Pilot Study.

In contrast to recommendations for young and middle-aged adults, intentional weight loss among older adults remains controversial and is inconsistently advised. Recent research suggests that a higher protein diet can mitigate loss of lean mass during periods of intentional weight loss among older adults with obesity; however, the effects of intentional weight loss on skeletal muscle and bone are not fully understood. The Dairy in the Diet Yields New Approaches for Muscle Optimization (DDYNAMO) trial is a 6-month, randomized, controlled pilot study assessing the effects of combining regular, generous intakes of high quality protein (30 g/meal; primarily from dairy) with caloric restriction (-500kcal/d) and low-intensity resistance exercise (30 min/3 times per week) on muscle quality, muscle composition, bone mineral density in men and women aged ≥60 years with obesity and mild to moderate functional impairment (Short Physical Performance Battery [SPPB] score ≥4 to ≤10). Participants will be re-assessed at 18 months to evaluate weight maintenance, bone mineral density, physical function, and other secondary measures. ClinicalTrials.gov Identifier: NCT02437643.

Effects of Amount, Intensity, and Mode of Exercise Training on Insulin Resistance and Type 2 Diabetes Risk in the STRRIDE Randomized Trials.

BACKGROUND: Lipoprotein Insulin Resistance Index (LP-IR) and Diabetes Risk Index are novel spectroscopic multimarkers of insulin resistance and type 2 diabetes risk. As the Studies of a Targeted Risk Reduction Intervention through Defined Exercise (STRRIDE) randomized trials have previously demonstrated the ability of exercise training to improve traditional markers of insulin action, the aim of this study was to examine the effects of exercise amount, intensity, and mode on LP-IR and the Diabetes Risk Index. METHODS: A total of 503 adults with dyslipidemia [STRRIDE I (n = 194), STRRIDE AT/RT (n = 139)] or prediabetes [STRRIDE-PD (n = 170)] were randomized to control or one of 10 exercise interventions, ranging from doses of 8-23 kcal/kg/week; intensities of 50-75% V̇O2peak; and durations of 6-8 months. Two groups included resistance training and one included dietary intervention (7% weight loss goal). Fasting plasma samples were obtained at baseline and 16-24 h after the final exercise bout. LP-IR, the Diabetes Risk Index, and concentrations of the branched chain amino acids valine and leucine were determined using nuclear magnetic resonance spectroscopy. LP-IR and the Diabetes Risk Index scores range from 0-100 and 1-100, respectively (greater scores indicate greater risk). Paired t-tests determined significance within groups (p < 0.05). RESULTS: After training, six exercise groups significantly improved LP-IR (ranging from -4.4 ± 8.2 to -12.4 ± 14.1), and four exercise groups significantly improved the Diabetes Risk Index (ranging from -2.8 ± 8.2 to -8.3 ± 10.4). The most beneficial interventions for both LP-IR and the Diabetes Risk Index were low amount/moderate intensity aerobic, aerobic plus resistance, and aerobic plus diet. SUMMARY: Multiple exercise interventions improved LP-IR and the Diabetes Risk Index. In those with dyslipidemia, adding resistance to aerobic training elicited a synergistic effect on insulin resistance and type 2 diabetes risk. In individuals with prediabetes, combining a dietary intervention and weight loss with aerobic training resulted in the most robust type 2 diabetes risk improvement.

Protein Recommendation to Increase Muscle (PRIMe): Study protocol for a randomized controlled pilot trial investigating the feasibility of a high protein diet to halt loss of muscle mass in patients with colorectal cancer.

BACKGROUND: Severe muscle mass (MM) loss is a defining feature of cancer observed across all types and stages of disease and is an independent predictor of poor clinical outcomes including higher incidences of chemotherapy toxicity and decreased survival. Protein is essential to build MM, yet the optimal amount for preventing or treating muscle loss in patients with cancer remains undefined. METHODS: The Protein Recommendation to Increase Muscle (PRIMe) study is a single-center, two-armed, parallel, randomized, controlled pilot trial that assesses the feasibility of utilizing a high protein (HP) diet to positively impact clinical outcomes in people undergoing chemotherapy to treat colorectal cancer. Forty patients with newly diagnosed stage II-IV colorectal cancer who are scheduled to receive chemotherapy will be included. Participants are randomly assigned to a HP or normal protein (NP) diet for twelve weeks. The HP and NP groups receive nutrition recommendations to achieve 2.0 g of protein per kilogram of body weight per day (g∙kg-1∙d-1) and 1.0 g⋅kg-1⋅d-1, respectively. These values refer to the upper and lower recommended range of protein intake for people with cancer. Energy recommendations are based on measured energy expenditure. Assessments are completed within two weeks of starting chemotherapy (baseline), at week 6, and at week 12. Changes to skeletal MM, physical function, anthropometrics, body composition, muscle strength, physical activity, energy metabolism, metabolic markers, nutritional status, quality of life, readiness to change and psychosocial determinants of behavioural change are assessed between the HP and NP groups. Feasibility of the nutritional intervention is assessed by change in MM as a surrogate marker. CONCLUSIONS: This evidence-based study investigates the feasibility of increasing protein intake following a diagnosis of cancer on clinical outcomes during treatment for colorectal cancer. This study will inform larger trials assessing the impact of increasing protein intake in cancer to determine their importance and integration into standard clinical care for people with cancer.

Impact on cardiometabolic risk of a weight loss intervention with higher protein from lean red meat: Combined results of 2 randomized controlled trials in obese middle-aged and older adults.

BACKGROUND: The recognized benefits of a higher protein diet on muscle mass and strength in older adults are tempered by concerns of the potentially negative cardiometabolic impact of dietary sources of animal protein. OBJECTIVE: The aim of this study was to explore the cardiometabolic impact of 2 weight reduction diets: a higher protein diet, providing balanced portions of lean beef and pork throughout the day, vs. a diet following the Recommended Daily Allowance level of protein in obese middle-aged and older adults. METHODS: Data from Measuring Eating, Activity and Strength: Understanding the Response-Using Protein and Protein Optimization in Women Enables Results-Using Protein were combined for the present analysis. Subjects were randomly assigned to a 6-month weight loss diet (500 kcal deficit) and prescribed a Recommended Daily Allowance level of protein (0.8 g protein/kg BW), control group, or a higher level of protein (1.2 g protein/kg BW), protein group. For the protein group, lean, high-quality protein was evenly distributed between meals or balanced throughout the day (30 g protein/meal). The following cardiometabolic markers were quantified by nuclear magnetic resonance spectroscopy: lipids, lipoproteins, GlycA, trimethylamine-N-oxide, betaine, branched-chain amino acids, and lipoprotein insulin resistance index scores. RESULTS: In both groups (control [n = 27] and protein [n = 53]), there were significant (P ≤ .05) changes from baseline in weight loss (-6.2% and -7.2%), distance walked (+53.1 and +75.0 meters), and fasting plasma glucose (-7.5 and -6.2 mg/dL), respectively. At endpoint, protein group had significantly (P ≤ .05) lower triglycerides (-17.3 mg/dL), large very-low-density lipoprotein particle concentration (VLDL-P; -1.2 nmol/L), total low-density lipoprotein particle concentration (LDL-P; -67.8 nmol/L), small LDL-P (-59.4 nmol/L) and lipoprotein insulin resistance index (-5.9), whereas control group had significantly (P ≤ .05) lower GlycA (-13.1 µmol/L), total VLDL-P (-7.9 nmol/L), and small VLDL-P (-7.0 nmol/L). Differences between groups were observed for small VLDL-P (P = .02) and protein intake (P < .0001). CONCLUSIONS: These findings suggest that a hypocaloric diet with either traditional (0.8 g/kg BW/d) or higher protein (1.2 g/kg BW/d; predominantly from lean red meat) content improves risk markers of cardiovascular disease and type II diabetes in obese middle-aged and older adults. Both diets were also associated with improved physical function, and neither had an adverse impact on cardiometabolic outcomes.

Influence of Weight Reduction and Enhanced Protein Intake on Biomarkers of Inflammation in Older Adults with Obesity.

Both aging and obesity are associated with increased levels of pro-inflammatory metabolites, while weight reduction is associated with improvements in inflammatory status. However, few studies have explored the response of key inflammatory markers to the combined settings of weight reduction in an aging population. There are also few studies that have investigated the potential impact of diet composition on inflammatory marker responses. In the MEASUR-UP trial, we evaluated changes in baseline levels of inflammatory markers with post-study levels for a traditional weight loss control group versus a group with generous, balanced protein intake. In this 6-month randomized controlled trial (RCT), older (≥60 years) adults with obesity (BMI ≥30 kg/m2) and Short Physical Performance Battery (SPPB) score of 4-10 were randomly assigned to either a traditional weight loss regimen, (Control, n = 14) or one with higher protein intake (≥30 g) at each meal (Protein, n = 25). All participants were prescribed a hypo-caloric diet and attended weekly support and education groups and weigh-ins. Protein participants consumed ≥30 g of high-quality protein/meal, including lean and extra lean beef provided to them for two of the three meals per day. Protein intakes were 0.8 and 1.2 g/kg/day for Control and Protein, respectively. Adiponectin, leptin, C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1), IL-6, IL-8, serum amyloid A (SAA), vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and glycated serum protein (GSP) levels were measured at 0 and 6-month time points. At the 6-month endpoint, there was significant weight loss and decrease in BMI in both the Control (-4.8 ± 8.2 kg; -2.3 ± 2.4 kg/m2; p = 0.05) and Protein (-8.7 ± 7.4 kg; -2.9 ± 2.3 kg/m2; p < 0.0001) groups. SPPB scores improved in both arms, with a superior functional response in Protein (p < 0.05). Body fat (%) at baseline was positively correlated with leptin, hs-CRP, VCAM-1, ICAM-1, and GSP. Several markers of inflammation responded to the Protein group: leptin (p < 0.001), hs-CRP (p < 0.01), and ICAM-1 (p < 0.01) were decreased and adiponectin increased (p < 0.01). There were no significant changes in any inflammatory markers in the Control arm. In the between group comparison, only adiponectin trended towards a group difference (more improvement in Protein; p < 0.07). Our findings in the MEASUR-UP trial show that a weight loss diet with enhanced protein intake is comparable to an adequate protein diet in terms of weight loss success and that it can lead to improvements in inflammatory status, specifically for adiponectin, leptin, hs-CRP, and ICAM-1. These findings are important given current recommendations for higher protein intakes in older adults and justify the additional study of the inflammatory impact of an enhanced protein diet. (ClinicalTrials.gov identifier: NCT01715753).

Markers of Renal Function in Older Adults Completing a Higher Protein Obesity Intervention and One Year Later: Findings from the MEASUR-UP Trial.

Increases in rates of obesity in the older population are hastening the development of chronic illnesses, including chronic kidney disease (CKD). However, obesity reduction in older adults is besought with concerns about the long-term benefit/risk, especially regarding loss of muscle mass and its impact on function. Higher protein intakes have been advocated to help offset the tendency for loss of muscle during weight reduction but this raises concerns about possible negative effects on older kidneys. We assessed markers of renal function in venous blood samples collected during a six-month randomized controlled weight loss trial of higher protein intake in obese (n = 67; BMI ≥ 30 kg/m2) older (≥60 years) adults with physical frailty and age-normal renal status (glomerular filtration rate [GFR] ≥ 45); the Control diet (0.8 g protein/kg body weight/day; n = 21) was compared to a protein-enhanced (1.2 g/g protein/kg body weight/day with 30 g protein/meal; n = 41; Protein) diet. Results showed no group effect of the Protein treatment on markers of renal function (estimated GFR, blood urea nitrogen, and creatinine), either upon intervention completion or one year later. Our findings align with literature support for the benefits of higher protein in the diets of older individuals during obesity reduction and help to confirm the safety of moderate increases in protein intake during weight loss in this population.

Obesity Interventions for Older Adults: Diet as a Determinant of Physical Function.

Throughout the world, a high prevalence of obesity in older populations has created a new phenotype of frailty: the obese, functionally frail older adult. The convergence of the obesity epidemic with global graying will undoubtedly increase the prevalence of this concern. Barriers to treatment include ambiguities about the appropriate level of obesity that should trigger an intervention, due to age-related physiologic changes and a lack of consensus on specific criteria and cutoffs. Moreover, obesity interventions for this population have been limited by concerns about negative effects on lean mass, bone mineral density, and even mortality. However, newly reported approaches for restoring physical function by obesity reduction have shown good short-term efficacy. Because the majority of these interventions have used exercise as part of the treatment, this review focuses specifically on current understanding of the discrete effects of dietary interventions for geriatric obesity with regards to functional outcomes on tests including the Short Physical Performance Battery, the Physical Performance Test, and the Western Ontario and McMaster Universities Osteoarthritis Index. The literature showed roughly equal benefits to function from a weight reduction diet or exercise regimen, although neither modality was as efficacious alone as the 2 combined. Only 1 of 3 studies of protein intake during weight loss showed a positive effect of protein on function, but findings to date are too limited to prove or disprove a protein benefit. We conclude that although diet and exercise should be combined whenever possible, it remains important to further investigate the beneficial and likely unique effects that calorie restriction and/or nutrient modification can provide, particularly for obese and functionally frail older populations.

Association of the Composite Inflammatory Biomarker GlycA, with Exercise-Induced Changes in Body Habitus in Men and Women with Prediabetes.

GlycA is a new composite measure of systemic inflammation and a predictor of many inflammatory diseases. GlycA is the nuclear magnetic resonance spectroscopy-derived signal arising from glucosamine residues on acute-phase proteins. This study aimed to evaluate how exercise-based lifestyle interventions modulate GlycA in persons at risk for type 2 diabetes. GlycA, fitness, and body habitus were measured in 169 sedentary adults (45-75 years) with prediabetes randomly assigned to one of four six-month exercise-based lifestyle interventions. Interventions included exercise prescription based on the amount (energy expenditure (kcal/kg weight/week (KKW)) and intensity (%VO2peak). The groups were (1) low-amount/moderate-intensity (10KKW/50%) exercise; (2) high-amount/moderate-intensity (16KKW/50%) exercise; (3) high-amount/vigorous-intensity (16KKW/75%) exercise; and (4) a Clinical Lifestyle (combined diet plus low-amount/moderate-intensity exercise) intervention. Six months of exercise training and/or diet-reduced GlycA (mean Δ: -6.8 ± 29.2 µmol/L; p = 0.006) and increased VO2peak (mean Δ: 1.98 ± 2.6 mL/kg/min; p < 0.001). Further, visceral (mean Δ: -21.1 ± 36.6 cm2) and subcutaneous fat (mean Δ: -24.3 ± 41.0 cm2) were reduced, while liver density (mean Δ: +2.3 ± 6.5HU) increased, all p < 0.001. When including individuals in all four interventions, GlycA reductions were associated with reductions in visceral adiposity (p < 0.03). Exercise-based lifestyle interventions reduced GlycA concentrations through mechanisms related to exercise-induced modulations of visceral adiposity. This trial is registered with Clinical Trial Registration Number NCT00962962.

Experimental Comparison of Efficacy for Three Handfeeding Techniques in Dementia.

BACKGROUND: Nursing home (NH) residents who require assistance during mealtimes are at risk for malnutrition. Supportive handfeeding is recommended, yet there is limited evidence supporting use of a specific handfeeding technique to increase meal intake. OBJECTIVES: To compare efficacy of three handfeeding techniques for assisting NH residents with dementia with meals: Direct Hand (DH), Over Hand (OH), and Under Hand (UH). DESIGN: A prospective pilot study using a within-subjects experimental Latin square design with randomization to one of three handfeeding technique sequences. SETTING AND PARTICIPANTS: 30 residents living with advanced dementia in 11 U.S. NHs. MEASUREMENTS: Time required for assistance; meal intake (% eaten); and feeding behaviors, measured by the Edinburgh Feeding Evaluation in Dementia (EdFED) scale. INTERVENTION: Research Assistants provided feeding assistance for 18 video-recorded meals per resident (N = 540 meals). Residents were assisted with one designated technique for 6 consecutive meals, changing technique every 2 days. RESULTS: Mean time spent providing meal assistance did not differ significantly between techniques. Mean meal intake was greater for DH (67 ± 15.2%) and UH (65 ± 15.0%) with both significantly greater than OH (60 ± 15.1%). Feeding behaviors were more frequent with OH (8.3 ± 1.8%), relative to DH (8.0 ± 1.8) and UH (7.7 ± 1.8). CONCLUSION: All three techniques are time neutral. UH and DH are viable options to increase meal intake among NH residents with advanced dementia and reduce feeding behaviors relative to OH feeding.

Influence of Protein Intake, Race, and Age on Responses to a Weight-Reduction Intervention in Obese Women.

BACKGROUND: Women have higher rates of obesity than men and develop more pronounced functional deficits as a result. Yet, little is known about how obesity reduction affects their functional status, including whether their responses differ when protein intake is enhanced. OBJECTIVE: The aim of this study was to confirm the feasibility of delivery of a higher-protein (balanced at each meal) calorie-restricted diet in obese women and determine its efficacy for influencing function and retention of lean mass. METHOD: Obese community-dwelling women [n = 80; body mass index (in kg/m2), in means ± SDs: 37.8 ± 5.9; aged 45-78 y; 58.8% white] were enrolled in a weight-loss (-500 kcal/d) study and randomly assigned to either a Control-Weight-Loss (C-WL; 0.8 g protein/kg body weight) group or a High-Protein-Weight-Loss (HP-WL; 1.2 g protein/kg body weight; 30 g protein 3 times/d) group in a 1:2 allocation. Primary outcomes were function by 6-min walk test (6MWT) and lean mass by using the BodPod (Life Measurement, Inc.) at 0, 4, and 6 mo. RESULTS: Both groups reduced calorie intakes and body weights (P < 0.001), and the feasibility of the HP-WL intervention was confirmed. The 6MWT results improved (P < 0.01) at 4 mo in the HP-WL group and at 6 mo in both groups (P < 0.001). Both groups improved function by several other measures while slightly decreasing (P < 0.01) lean mass (-1.0 kg, C-WL; -0.6 kg, HP-WL). Weight loss was greater in white than in black women at both 4 mo (6.0 ± 3.6 compared with 3.7 ± 3.4 kg; P < 0.02) and 6 mo (7.2 ± 4.8 compared with 4.0 ± 4.7 kg; P < 0.04) and tended to be positively related to age (P < 0.06). CONCLUSIONS: A clinically important functional benefit of obesity reduction was confirmed in both study groups, with no significant group effect. Our findings of racial differences in response to the intervention and a potential influence of participant age lend support for further studies sufficiently powered to explore the interaction of race and age with functional responses to obesity reduction in women. This trial was registered at clinicaltrials.gov as NCT02033655.

Effects of exercise training alone vs a combined exercise and nutritional lifestyle intervention on glucose homeostasis in prediabetic individuals: a randomised controlled trial.

AIMS/HYPOTHESIS: Although the Diabetes Prevention Program (DPP) established lifestyle changes (diet, exercise and weight loss) as the 'gold standard' preventive therapy for diabetes, the relative contribution of exercise alone to the overall utility of the combined diet and exercise effect of DPP is unknown; furthermore, the optimal intensity of exercise for preventing progression to diabetes remains very controversial. To establish clinical efficacy, we undertook a study (2009 to 2013) to determine: how much of the effect on measures of glucose homeostasis of a 6 month programme modelled after the first 6 months of the DPP is due to exercise alone; whether moderate- or vigorous-intensity exercise is better for improving glucose homeostasis; and to what extent amount of exercise is a contributor to improving glucose control. The primary outcome was improvement in fasting plasma glucose, with improvement in plasma glucose AUC response to an OGTT as the major secondary outcome. METHODS: The trial was a parallel clinical trial. Sedentary, non-smokers who were 45-75 year old adults (n = 237) with elevated fasting glucose (5.28-6.94 mmol/l) but without cardiovascular disease, uncontrolled hypertension, or diabetes, from the Durham area, were studied at Duke University. They were randomised into one of four 6 month interventions: (1) low amount (42 kJ kg body weight(-1) week(-1) [KKW])/moderate intensity: equivalent of expending 42 KKW (e.g. walking ∼16 km [8.6 miles] per week) with moderate-intensity (50% [Formula: see text]) exercise; (2) high amount (67 KKW)/moderate intensity: equivalent of expending 67 KKW (∼22.3 km [13.8 miles] per week) with moderate-intensity exercise; (3) high amount (67 KKW)/vigorous intensity: equivalent to group 2, but with vigorous-intensity exercise (75% [Formula: see text]); and (4) diet + 42 KKW moderate intensity: same as group 1 but with diet and weight loss (7%) to mimic the first 6 months of the DPP. Computer-generated randomisation lists were provided by our statistician (G. P. Samsa). The randomisation list was maintained by L. H. Willis and C. A. Slentz with no knowledge of or input into the scheduling, whereas all scheduling was done by L. A. Bateman, with no knowledge of the randomisation list. Subjects were automatically assigned to the next group listed on the randomisation sheet (with no ability to manipulate the list order) on the day that they came in for the OGTT, by L. H. Willis. All plasma analysis was done blinded by the individuals doing the measurements (i.e. lipids, glucose, insulin). Subjects and research staff (other than individuals analysing the blood) were not blinded to the group assignments. RESULTS: Number randomised, completers and number analysed with complete OGTT data for each group were: low-amount/moderate-intensity (61, 43, 35); high-amount/moderate-intensity (61, 44, 40); high-amount/vigorous-intensity (61, 43, 38); diet/exercise (54, 45, 37), respectively. Only the diet and exercise group experienced a decrease in fasting glucose (p < 0.001). The means and 95% CIs for changes in fasting glucose (mmol/l) for each group were: high-amount/moderate-intensity -0.07 (-0.20, 0.06); high-amount/vigorous 0.06 (-0.07, 0.19); low-amount/moderate 0.05 (-0.05, 0.15); and diet/exercise -0.32 (-0.46, -0.18). The effects sizes for each group (in the same order) were: 0.17, 0.15, 0.18 and 0.71, respecively. For glucose tolerance (glucose AUC of OGTT), similar improvements were observed for the diet and exercise (8.2% improvement, effect size 0.73) and the 67 KKW moderate-intensity exercise (6.4% improvement, effect size 0.60) groups; moderate-intensity exercise was significantly more effective than the same amount of vigorous-intensity exercise (p < 0.0207). The equivalent amount of vigorous-intensity exercise alone did not significantly improve glucose tolerance (1.2% improvement, effect size 0.21). Changes in insulin AUC, fasting plasma glucose and insulin did not differ among the exercise groups and were numerically inferior to the diet and exercise group. CONCLUSIONS/INTERPRETATION: In the present clinical efficacy trial we found that a high amount of moderate-intensity exercise alone was very effective at improving oral glucose tolerance despite a relatively modest 2 kg change in body fat mass. These data, combined with numerous published observations of the strong independent relation between postprandial glucose concentrations and prediction of future diabetes, suggest that walking ∼18.2 km (22.3 km prescribed with 81.6% adherence in the 67 KKW moderate-intensity group) per week may be nearly as effective as a more intensive multicomponent approach involving diet, exercise and weight loss for preventing the progression to diabetes in prediabetic individuals. These findings have important implications for the choice of clinical intervention to prevent progression to type 2 diabetes for those at high risk. TRIAL REGISTRATION: ClinicalTrials.gov NCT00962962 FUNDING: The study was funded by National Institutes for Health National Institute of Diabetes and Digestive and Kidney Diseases (NIH-NDDK) (R01DK081559).

Challenges in the Management of Geriatric Obesity in High Risk Populations.

The global prevalence of obesity in the older adult population is growing, an increasing concern in both the developed and developing countries of the world. The study of geriatric obesity and its management is a relatively new area of research, especially pertaining to those with elevated health risks. This review characterizes the state of science for this "fat and frail" population and identifies the many gaps in knowledge where future study is urgently needed. In community dwelling older adults, opportunities to improve both body weight and nutritional status are hampered by inadequate programs to identify and treat obesity, but where support programs exist, there are proven benefits. Nutritional status of the hospitalized older adult should be optimized to overcome the stressors of chronic disease, acute illness, and/or surgery. The least restrictive diets tailored to individual preferences while meeting each patient's nutritional needs will facilitate the energy required for mobility, respiratory sufficiency, immunocompentence, and wound healing. Complications of care due to obesity in the nursing home setting, especially in those with advanced physical and mental disabilities, are becoming more ubiquitous; in almost all of these situations, weight stability is advocated, as some evidence links weight loss with increased mortality. High quality interdisciplinary studies in a variety of settings are needed to identify standards of care and effective treatments for the most vulnerable obese older adults.