Changes in Self-Efficacy and Social Support after an Intervention to Increase Physical Activity Among Adults with Type 2 Diabetes in Oman: A 12-month follow-up of the MOVEdiabetes trial.

OBJECTIVES: This study aimed to describe changes in self-efficacy (SE) and social support (SS) 12 months after the MOVEdiabetes trial, an intervention designed to increase physical activity (PA) among adults with type 2 diabetes mellitus in Oman. METHODS: The original MOVEdiabetes trial was conducted between April 2016 and June 2017 in Muscat, Oman. The intervention group (IG) received personalised PA consultations, pedometers and monthly messages using a web-based application, while the comparison group received usual care. Self-reported SE and SS from family and friends were assessed using validated psychosocial scales. RESULTS: Of the 232 original participants in the trial, a total of 174 completed the 12 months follow-up study period (response rate: 75%). However, based on intention-to-treat analysis with several imputation procedures for missing data at 3 and/or 12 months, there was a significant increase in SE scores in the IG (+10.3, 95% confidence interval [CI]: 7.1-13.5; P <0.001); however, the correlation with PA levels was weak (+4.2, 95% CI: 2.7-5.7; P <0.001). Higher SE scores were noted in those without comorbidities (+12.2, 95% CI: 6.8-17.6; P <0.001) and with high income levels (+9.7, 95% CI: 5.2-14.2; P <0.001). Additionally, SS scores increased significantly among those in the IG who received support from friends (+2.3, 95% CI: 1.1-3.7; P <0.001), but not family (+1.2, 95% CI: -0.4-2.8; P = 0.110). The reliability of the scales was acceptable for SE and SS from family, but poor for SS from friends (Cronbach's alpha coefficients = 0.82, 0.82 and 0.40, respectively). CONCLUSION: The PA intervention was associated with positive changes in SE and SS from friends. However, further tools for assessing psychosocial influences on PA are needed in Arab countries.

Perceived Changes in General Well-being: Findings from the 'MOVEdiabetes' Physical Activity Randomized Control Trial.

OBJECTIVES: Studies have consistently reported the health benefits of physical activity (PA) in diabetes care. Our study aimed to explore perceptions of general well-being in participants of the 'MOVEdiabetes' intervention aimed at increasing PA in adults with type 2 diabetes in Oman. METHODS: 'MOVEdiabetes' is a cluster-randomized study where participants in the intervention group (IG) received PA consultations, pedometers, and WhatsApp messages versus the usual care in the control group (CG). At baseline and 12 months, perceptions on well-being were assessed using an English translated to Arabic 13-item questionnaire. Between groups differences in responses were compared using chi-squared tests. Spearman correlation analysis was utilized to explore associations between changes in responses and self-reported PA levels (metabolic equivalent of task.min/week). RESULTS: Of the 232 participants in the 'MOVEdiabetes' study, 75.0% completed the study. Overall, findings indicate a positive effect of the intervention on perceived general health, sleep, mental health, pain, and responses to quality of life. For the IG and CG, significant associations were shown between changes in self-reported PA and general health (r = 0.70 and 0.36, p < 0.001), feeling calm/peaceful (r = 0.86 and 0.93, p < 0.001), energetic (r = 0.86 and 0.82, p < 0.001), and depressed (r = -0.35 and -0.30, p < 0.001). However, the Cronbach's alpha value was 0.50, indicating insufficient internal consistency of the assessment tool. CONCLUSIONS: The intervention has a positive effect on many parameters of well-being. Further studies are needed to identify robust tools to measure associations between well-being and PA in culturally bounded Arabic speaking countries.

Acceptability of the "MOVEdiabetes" physical activity intervention in diabetes primary care settings in Oman: findings from participants and practitioners.

BACKGROUND: Adequate physical activity (PA) is considered essential in diabetes management. However, evidence on the best method of promoting PA within diabetes care is inconclusive. The current work identifies perceptions on the acceptability of Intervention Group Participants (IGP) and Project Officers (POs) about the "MOVEdiabetes" intervention programme aimed at increasing PA in adults with type 2 diabetes in Oman (a retrospectively registered trial). METHODS: The "MOVEdiabetes" programme (PA consultations, pedometers and WhatsApp messages) was delivered by the POs (primary health care practitioners) in four primary care centres within a one-year cluster randomised control trial. Recruitment and retention were measured from trial attendance records. Programme satisfaction, appropriateness, and content suitability were assessed using exit surveys for both the IGP (interview based) and POs (self-administered). Open text questions on perceptions to the study programme were also included. RESULTS: Participants were randomised to an intervention group (IG, n = 122) or comparison group (CG, n = 110). The overall retention rate at three and 12 months was 92.7% [110(90.2%) IG vs 105(95.5%) CG] and 75% [82(67.2%) IG vs 92(83.6%) CG] respectively. Most (n = 14, 87.5%) POs and more than half (n = 49, 59.8%) IGP perceived the programme as very appropriate and many reported that they were "quite/ very satisfied" with the programme (n = 16, 100% PO's and n = 71, 86.6% IGP). Two thirds (n = 55, 66.0%) of IGP were very/quite likely to recommend the programme to others. PA consultations, use of pedometers and Whatsapp messages were well perceived by all. Participants recommended the inclusion of dietary advice and PA promotion for the general public. Exploring PA facilities within the community was suggested by POs. CONCLUSIONS: The "MOVEdiabetes" programme achieved a high retention rate and was perceived as satisfactory and appropriate. Results from this study suggest that it is worthwhile exploring the use of the "MOVEdiabetes" programme in clinical practice and further community links. TRIAL REGISTRATION: International Standard Randomised Controlled Trials No: ISRCTN14425284. Registered retrospectively on 12th April 2016.

'MOVEdiabetes': a cluster randomized controlled trial to increase physical activity in adults with type 2 diabetes in primary health in Oman.

OBJECTIVE: This study examined the impact of a multicomponent intervention to increase physical activity (PA) in adults with type 2 diabetes (T2D) in Oman. RESEARCH DESIGN AND METHODS: This is a cluster randomized controlled trial in eight primary health centers. Participants were physically inactive, aged ≥18 years, and with no contraindication to PA. Patients attending intervention health centers (n=4) received the 'MOVEdiabetes' intervention, which consisted of personalized, individual face-to-face consultations by dietitians. Pedometers and monthly telephone WhatsApp messages were also used. Patients attending comparison health centers received usual care. The primary outcome was change in PA [Metabolic Equivalent(MET).min/week] after 12 months assessed by the Global Physical Activity Questionnaire. The secondary outcomes were changes in daily step counts, sitting time, weight, body mass index, glycated hemoglobin, blood pressure and lipids. RESULTS: Of the 232 participants (59.1% female, mean (SD) age 44.2 (8.1) years), 75% completed the study. At 12 months, the mean change in MET.min/week was +631.3 (95% CI 369.4 to 893.2) in the intervention group (IG) vs +183.2 (95% CI 83.3 to 283.0) in the comparison group, with a significant between-group difference of +447.4 (95% CI 150.7 to 744.1). The odds of meeting PA recommendations were 1.9 times higher in the IG (95% CI 1.2 to 3.3). Significant between-group differences in favor of IG were detected for mean steps/day (+757, 95% CI 18 to 1531) and sitting time hours/ per day (-1.5, 95% CI -2.4 to -0.7). Clinical measures of systolic and diastolic blood pressure and triglycerides also showed significant intervention effects. CONCLUSIONS: 'MOVEdiabetes' was effective in increasing PA, the likelihood of meeting PA recommendations, and providing cardioprotective benefits in adults with T2D attending primary care.

Perceived barriers to leisure time physical activity in adults with type 2 diabetes attending primary healthcare in Oman: a cross-sectional survey.

OBJECTIVES: Physical activity is fundamental in diabetes management for good metabolic control. This study aimed to identify barriers to performing leisure time physical activity and explore differences based on gender, age, marital status, employment, education, income and perceived stages of change in physical activity in adults with type 2 diabetes in Oman. DESIGN: Cross-sectional study using an Arabic version of the 'Barriers to Being Active' 27-item questionnaire. SETTING: Seventeen primary health centres randomly selected in Muscat. PARTICIPANTS: Individuals>18 years with type 2 diabetes, attending diabetes clinic for >2 years and with no contraindications to performing physical activity. PRIMARY AND SECONDARY OUTCOME MEASURES: Participants were asked to rate how far different factors influenced their physical activity under the following categories: fear of injury, lack of time, social support, energy, willpower, skills, resources, religion and environment. On a scale of 0-9, barriers were considered important if scored ≥5. RESULTS: A total of 305 questionnaires were collected. Most (96%) reported at least one barrier to performing leisure time physical activity. Lack of willpower (44.4%), lack of resources (30.5%) and lack of social support (29.2%) were the most frequently reported barriers. Using χ2 test, lack of willpower was significantly different in individuals with low versus high income (54.2%vs40%, P=0.002) and in those reporting inactive versus active stages of change for physical activity (50.7%vs34.7%, P=0.029), lack of resources was significantly different in those with low versus high income (40%vs24.3%, P=0.004) and married versus unmarried (33.8%vs18.5%, P=0.018). Lack of social support was significant in females versus males (35.4%vs20.8%, P=0.005). CONCLUSIONS: The findings can inform the design on physical activity intervention studies by testing the impact of strategies which incorporate ways to address reported barriers including approaches that enhance self-efficacy and social support.

Correlates of physical activity and sitting time in adults with type 2 diabetes attending primary health care in Oman.

BACKGROUND: Despite evidence of the benefits of physical activity in the management of type 2 diabetes, it is poorly addressed in diabetes care. This study aimed to identify the prevalence and correlates of meeting ≥600MET-min/wk. (150 min/wk) of physical activity and sitting time in adults with type 2 diabetes in Oman. Approaches to encourage physical activity in diabetes care were explored. METHODS: A cross-sectional study using the Global Physical Activity Questionnaire was conducted in 17 randomly selected primary health centres in Muscat. Clinical data including co-morbidities were extracted from the health information system. Questions on physical activity preferences and approaches were included. Patients were approached if they were ≥18 years, and had been registered in the diabetes clinic for >2 years. RESULTS: The questionnaire was completed by 305 people (females 57% and males 43%). Mean age (SD) was 57 (10.8) years and mean BMI (SD) was 31.0 (6.0) kg/m2. Duration of diabetes ranged from 2 to 25 (mean 7.6) years. Hypertension (71%) and dyslipidaemia (62%) were common comorbidities. Most (58.4%) had an HbA1c ≥7% indicating poor glycaemic control (55% in males vs 61% in females). Physical activity recommendations were met by 21.6% of the participants, mainly through leisure activities. Odds of meeting the recommendations were significantly higher in males (OR 4.8, 95% CI 2.5-9.1), individuals ≤57 years (OR 3.0, 95% CI 1.6-5.9), those at active self-reported stages of change for physical activity (OR 2.2, 95% CI 1.2-4.1) and those reporting no barriers to performing physical activity (OR 2.7, 95% CI 1.4-4.9). Median (25th, 75th percentiles) sitting time was 705 (600, 780) min/d. Older age (>57 years) was associated with longer sitting time (>705 min/d) (OR 2.8, 95% CI 1.7-4.6). Preferred methods to support physical activity in routine diabetes care were consultations (38%), structured physical activity sessions (13.4%) and referrals to physical activity facilities (5.6%) delivered by a variety of health care providers. CONCLUSIONS: The results suggest that intervention strategies should take account of gender, age, opportunities within daily life to promote active behaviour and readiness to change. Offering physical activity consultations is of interest to this study population, thus development and evaluation of interventions are warranted.

Effectiveness of nutritional and exercise interventions to improve body composition and muscle strength or function in sarcopenic obese older adults: A systematic review.

Although sarcopenic obesity (SO) poses a major public health concern, a robust approach for the optimization of body composition and strength/function in SO has not yet been established. The purpose of this systematic review was to assess the effectiveness of nutritional (focusing on energy and protein modulation) and exercise interventions, either individually or combined, on body composition and strength/function in older adults with SO. MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus were searched. Main inclusion criteria comprised sarcopenia as defined by the European Working Group on Sarcopenia in Older People (EWGSOP) and obesity defined as % body fat ≥40% (women) and ≥28% (men). Randomized controlled trials (RCTs), randomized controlled crossover trials and controlled clinical trials with older adults (mean age ≥65 years) following a nutritional regimen and/or an exercise training program were considered. Out of 109 full text articles identified, only two RCTs (61 participants) met the inclusion criteria. One study was a nutritional intervention adding 15 g protein·day-1 (via cheese consumption) to the participants' habitual diet. The second study was a high-speed circuit resistance training intervention. Body composition did not change significantly in either of the studies. However, the exercise intervention improved significantly muscle strength and physical function. Although this review was limited by the small number of eligible studies, it provides evidence for the potential benefits of exercise and highlights the necessity for future research to develop effective interventions including dietary and exercise regimens to combat sarcopenic obesity.

Health professionals' perceptions about physical activity promotion in diabetes care within primary health care settings in Oman.

BACKGROUND: As part of formative work to inform an interventional design to increase physical activity (PA) in patients with type 2 diabetes in Oman, this qualitative study aimed to determine health professionals' perception of barriers and opportunities, personnel responsibilities and plausible PA promotional approaches. METHODS: Four focus group discussions were carried out with groups of health care professionals (family physicians, dieticians and health educators, managers and general practitioners). All discussions were audio recorded and transcribed. Responses were analysed using a thematic analysis. RESULTS: Barriers to PA reported by participants (n = 29) were identified at three levels: health care system (e.g. deficient PA guidelines); individual (e.g. obstructive social norms) and community (e.g. lack of facilities). Participants felt that a multilevel approach is needed to address perceived barriers and to widen current opportunities. In the presence of various diabetes primary care providers, the potential for dieticians to include individualised PA consultations as part of their role was highlighted. Participants felt that consultations should be augmented by approaches within the community (volunteer support and/or appropriate facilities). However, despite lack of experience with technology supported approaches and motivational tools, the telephone application "WhatsApp" and use of pedometers were considered potentially suitable. The need for training in behaviour change techniques and clearly communicated intervention guidelines was emphasised. CONCLUSIONS: A multi-component approach including PA consultations, possibly led by trained dieticians, technological routes for providing support along with community mapping for resources appear to offer promising approaches for further PA intervention studies within diabetes primary health care.

Dietary intakes in geriatric orthopaedic rehabilitation patients: Need to look at food consumption not just provision.

BACKGROUND & AIMS: Elderly orthopaedic rehabilitation patients are potentially at high nutritional risk and thus nutrition provision is a fundamental component of the multidisciplinary care to optimise physical rehabilitation. Hospital food service (catering) is internationally recognised as a key component of good clinical care of patients and has the potential to provide a population approach to managing under-nutrition. Within Scotland, there have been significant developments with regards to food, fluid and nutritional care within clinical settings including the setting of clinical standards. However audits to date have focused on processes being in place and not patient outcomes. Therefore, this study aimed to evaluate food provision and consumption in elderly orthopaedic rehabilitation settings to determine whether nutrition standards are being met. METHODS: A service evaluation of food provision and consumption to inpatients 65 years and older in post-acute geriatric orthopaedic wards over 24 h in National Health Service (NHS) hospitals in Scotland, UK was conducted. Food provision from each meal, in-between meal snacks from the trolley service and also on ward provisions were measured by weighing all items prior to being served to the patient. Any leftover food items were also weighed to allow the amount of food consumed to be determined. Estimated energy and protein contents of foods provided and consumed were compared against nutrient standards for hospital foods. RESULTS: Food provision to n = 175 patients, across seven wards and three hospitals was significantly less than standards set for energy and protein provision for 'nutritionally well' patients; (Hospital B mean diff - 549 kcals, -19 g p < 0.01; and Hospital C mean diff -250 kcals, -12 g, p < 0.001). Patients consumed approximately three quarters (74%) of the food they were provided. Higher provision of both energy and protein was associated with higher levels of consumption (r = 0.77 and r = 0.79, p < 0.001), respectively. CONCLUSION: Significant work has been undertaken to improve the nutritional care of patients in hospitals. However, at a time where inefficiencies in clinical services must be reduced along side improvements in patient outcomes, there is a need for greater monitoring of patient food intakes to enable improvements in food production and food service systems to this end.

A randomised trial of the impact of energy density and texture of a meal on food and energy intake, satiation, satiety, appetite and palatability responses in healthy adults.

BACKGROUND & AIMS: Texture modified diets may be enriched to optimise the opportunity for individuals to meet their required energy intakes; however there is insufficient evidence supporting this strategy. Thus we sought to investigate the effect of texture and energy density on food (g) and energy intakes (kcal), appetite (satiation and satiety), and palatability in healthy adults. METHODS: A single blind within-subjects randomised crossover design, where 33 healthy adults consumed a test meal with either its texture and/or energy density altered, until satiation was reached whilst rating their appetite parameters. Subsequent intakes were recorded in a food diary to determine the effect of the treatments on satiety and identify any evidence of energy compensation. RESULTS: Test meal energy intakes (kcal) were significantly higher with energy enrichment of both meals (standard texture; 315 kcal and texture modified; 303 kcal (p = 0.001)) and remained higher over the day for both (260 kcal/d and, 225 kcal/d respectively (p < 0.05)). Area under the curve (AUC) did not differ between meals for hunger, fullness, or desire to eat however palatability was significantly reduced with texture modification. CONCLUSIONS: Enriching meals (standard texture and texture modified) is an effective method to increase short term energy intakes in healthy adults over a 24 h period and may have application to optimise energy intakes in a clinical setting.

The rising incidence of celiac disease in Scotland.

BACKGROUND AND OBJECTIVES: Although the incidence of pediatric celiac disease (CD) is increasing globally, it is uncertain whether this is attributed to improved case ascertainment or signifies a true rise. We aimed to identify all incident cases of childhood CD in southeast Scotland over the period 1990 to 2009 to assess trends in total incidence and cases diagnosed as a result of (1) a classic presentation, (2) a nonclassic presentation, or (3) targeted screening. METHODS: Twenty-year retrospective cohort study of case notes, pathology databases, endoscopy, and patient records for all children (<16 years of age) diagnosed with CD on biopsy in southeast Scotland (at-risk population of 225000-233000). Data were age-gender standardized and Poisson regression models used to calculate changes in incidence over time. RESULTS: A total of 266 children were diagnosed from 1990 to 2009 with an increase in incidence from 1.8/100000 (95% confidence interval [CI] 1.1-2.7) to 11.7/100000 (95% CI 9.8-13.9) between the epochs 1990 to 1994 and 2005 to 2009, respectively (P < .0001). The incidence of nonclassic presentation (children with a monosymptomatic presentation and those with extraintestinal symptoms) and actively screened cases increased by 1566% (P < .05) and 1170% (P < .001) from 1990 to 1999 to 2000 to 2009, respectively. However, a rise in the incidence of Oslo classic cases from 1.51/100000 (95% CI 0.91-2.38) in 1990 to 1994 to 5.22/100000 (95% CI 3.98-6.75) in 2005 to 2009 (P < .01) remained evident. CONCLUSIONS: The incidence of pediatric CD increased 6.4-fold over the 20 years. This study demonstrates that this rise is significant for classic CD, indicating a true rise in the incidence of pediatric CD.

Childhood coeliac disease diagnoses in Scotland 2009-2010: the SPSU project.

OBJECTIVES: To establish the incidence of childhood coeliac disease (CD) in Scotland between 1 September 2009 and 31 August 2010, to determine clinical features at presentation and reasons for diagnosis, and to identify any differences in incidence and practice between regions. DESIGN: Prospective data collection through the Scottish Paediatric Surveillance Unit (SPSU). Strategic contacts in each tertiary gastrointestinal region (East, West and North) were emailed monthly to report new cases of CD (<16 years). A clinical questionnaire was completed for each case. Additionally, regional laboratories were asked to report the number of diagnostic antibody tests for CD performed over the year. SETTING: This national study looked at the total cases within Scotland. Scotland has a population of 5.2 million, with the mid-year estimate in 2009 of 912 144 children under the age of 16. RESULTS: 91 new cases were reported, giving an overall adjusted incidence of 10.0/100 000/year. Incidence in the East was 16.3/100 000/year, West 8.1/100 000/year and North 7.7/100 000/year. Cases diagnosed due to active screening in the East (4.6/100 000/year) were more than twice the number observed in the West (2.0/100 000/year) and North (1.3/100 000/year), as was the incidence of classic cases. The most frequent symptoms reported were abdominal pain (50/91; 54.9%), failure to thrive (29/91; 31.9%), fatigue (29/91; 31.9%), diarrhoea (27/91; 29.7%) and bloating (19/91; 20.9%). Twenty-two children (24.2%) were diagnosed due to active screening, of which 14 had associated type 1 diabetes mellitus, one Down syndrome and seven had family history. Fifty-five per cent (12/22) of the patients diagnosed through active screening were asymptomatic. Significantly more CD diagnostic antibody tests were performed per head of population in the East compared with the West (OR 1.65, 95% CI 1.57 to 1.73) and North (OR 1.81, 95% CI 1.70 to 1.92). CONCLUSIONS: Approximately double the incidence of paediatric CD was observed in the East of Scotland. Evidence of more actively screened cases diagnosed and more antibody tests performed in the region suggests a lower threshold to test. An environmental influence cannot be dismissed since more classic cases were also captured. Further research is needed to highlight the role of any exogenous factors.

Dietary and fluid intakes of older adults in care homes requiring a texture modified diet: the role of snacks.

OBJECTIVE: To evaluate and compare energy, protein, non-starch polysaccharide, and fluid intakes of a care home population consuming a texture modified diet (TMD) with those on a standard diet and also to evaluate the role of snacks in individuals' diets. DESIGN: Cross-sectional study. SETTING: Care homes. PARTICIPANTS: Thirty residents (n = 15 requiring standard diet: n = 15 requiring TMD). MEASUREMENTS: Dietary intakes were assessed using a 3-day weighed plate-wastage method. All snacks and drinks consumed were observed and recorded. Weights of standard portions and volumes were used to determine actual amounts consumed of these items. Estimated intakes were converted to energy and nutrient intakes using WinDiets Dietary analysis software. RESULTS: Residents on a TMD had significantly lower intakes of energy (1312 [326] kcal versus 1569 [260] kcal, P < .024), non-starch polysaccharide (6.3 [1.7] g versus 8.3 [2.7] g, P < .02) and fluid (1196 [288] mL versus 1611 [362] mL, P < .002) when compared with residents on a standard texture diet. Snacks provided significantly less energy (13% or 173 kcal versus 22% or 343 kcal, P = .001) and non-starch polysaccharide (P < .001) in those requiring the TMD. CONCLUSIONS: These results suggest that dietary and fluid intakes of older adults in care homes requiring a TMD are significantly less than individuals on a standard texture diet. These are unlikely to be meeting individuals' dietary and nutritional needs. Strategies that maximize provision of appetizing energy and nutrient-dense foods (including snacks) and fluids of suitable textures require further investigation.

Relative validation of a short food frequency questionnaire to assess calcium intake in older adults.

OBJECTIVE: To develop and validate a food frequency questionnaire (FFQ) for estimating calcium intake in community-dwelling older adults using a food record as the reference method. METHOD: A validation study involving 102 subjects (67 females) aged > or =65 years and residing independently in Adelaide, Australia, between 2002-06 was performed. Estimates of calcium intake over the last year were calculated from two versions (35 and 15 items) of the FFQ and compared with average intake from four days of non-consecutive food records (4DFR). RESULTS: Mean calcium intake from the 4DFR was 987 mg/day (95% CI 922-1051). The 35 and 15-item questionnaires gave mean intakes of 992 mg/day (95% CI 913-1,071) and 1017 mg/day (95% CI 927-1,106) respectively. Mean difference (95% limits of agreement) between the food record and the 35 and 15-item questionnaires was 5 mg (-739-729) and 28 mg (-936-879) respectively. The 15-item questionnaire demonstrated 82% sensitivity for classifying subjects with calcium intake below the estimated average requirement (EAR, 840 mg for males 51-70 years; 1,100 mg for females >51 years and males >70 years of age) and 46% specificity for classifying subjects with intake above the EAR. CONCLUSION: The FFQ evaluated as part of this study is one of very few that has been tested across both genders and in older adults specifically. The 15-item version has demonstrated a level of sensitivity and specificity comparable with other FFQs for evaluating calcium intake. IMPLICATIONS: The 15-item FFQ can be confidently used for measuring group mean calcium intake in older Australians or as a screening tool to allow health professionals to identify those who are most at risk of inadequate dietary calcium intake.

Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial.

OBJECTIVE: To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture. DESIGN: Randomized controlled trial with 12-week masked outcome assessment. SETTING: Teaching hospital. PARTICIPANTS: One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture. INTERVENTION: Commenced seven days after injury. Consisted of daily multinutrient energy-dense oral supplement (6.3 kJ/mL) individually prescribed for six weeks (n = 25), tri-weekly resistance training for 12 weeks (n = 25), combined treatment (n = 24) or attention control plus usual care and general nutrition and exercise advice (n = 26). MEASUREMENTS: Weight change, quadriceps strength, gait speed, quality of life and health care utilization at completion of the 12-week intervention. RESULTS: At 12 weeks, all groups lost weight: nutrition -6.2% (-8.4, -4.0); resistance training -6.3% (-8.3, -4.3); nutrition and resistance training -4.7% (-7.4, -2.0); attention control -5.2% (-9.0, -1.5). Those receiving resistance training alone lost more weight than those receiving the combined treatment (P= 0.029). Significant weight loss was prevented if supplement was consumed for at least 35 days. Groups were no different at 12 weeks for any other outcome. CONCLUSION: Frail, undernourished older adults with a fall-related lower limb fracture experience clinically significant weight loss that is unable to be reversed with oral nutritional supplements. Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention. In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high.

Resting energy expenditure measured longitudinally following hip fracture compared to predictive equations: is an injury adjustment required?

The present study measuring resting energy expenditure (REE; kJ/d) longitudinally using indirect calorimetry in six elderly women aged > or =70 years following surgery for hip fracture, describes changes over time (days 10, 42 and 84 post-injury) and compares measured values to those calculated from routinely applied predictive equations. REE was compared to REE predicted using the Harris Benedict and Schofield equations, with and without accounting for the theoretical increase in energy expenditure of 35 % secondary to physiological stress of injury and surgery. Mean (95 % CI) measured REE (kJ/d) was 4704 (4354, 5054), 4090 (3719, 4461) and 4145 (3908, 4382) for days 10, 42 and 84, respectively. A time effect was observed for measured REE, P=0.003. Without adjusting for stress the mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Harris Benedict equation were 1 (-9, 12), 10 (2, 18) and 9 (1, 17) for days 10, 42 and 84, respectively. The mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Schofield equation without adjusting for stress were 8 (-3, 19), 16 (6, 26) and 16 (10, 22) for days 10, 42 and 84, respectively. After adjusting for stress, REE predicted from the Harris Benedict or Schofield equations overestimated measured REE by between 38 and 69 %. Energy expenditure following fracture is poorly understood. Our data suggest REE was relatively elevated early in recovery but declined during the first 6 weeks. Using the Harris Benedict or Schofield equations adjusted for stress may lead to overestimation of REE in the clinical setting. Further work is required to evaluate total energy expenditure before recommendations can be made to alter current practice for calculating theoretical total energy requirements of hip fracture patients.

Adherence to nutrition supplements among patients with a fall-related lower limb fracture.

BACKGROUND: The purpose of this study was to provide a detailed evaluation of adherence to nutrition supplements by patients with a lower limb fracture. METHODS: These descriptive data are from 49 nutritionally "at-risk" patients aged 70+ years admitted to the hospital after a fall-related lower limb fracture and allocated to receive supplementation as part of a randomized, controlled trial. Supplementation commenced on day 7 and continued for 42 days. Prescribed volumes aimed to meet 45% of individually estimated theoretical energy requirements to meet the shortfall between literature estimates of energy intake and requirements. The supplement was administered by nursing staff on medication rounds in the acute or residential care settings and supervised through thrice-weekly home visits postdischarge. RESULTS: Median daily percent of the prescribed volume of nutrition supplement consumed averaged over the 42 days was 67% (interquartile range [IQR], 31-89, n = 49). There was no difference in adherence for gender, accommodation, cognition, or whether the supplement was self-administered or supervised. Twenty-three participants took some supplement every day, and a further 12 missed <5 days. For these 35 "nonrefusers," adherence was 82% (IQR, 65-93), and they lost on average 0.7% (SD, 4.0%) of baseline weight over the 6 weeks of supplementation compared with a loss of 5.5% (SD, 5.4%) in the "refusers" (n = 14, 29%), p = .003. CONCLUSIONS: We achieved better volume and energy consumption than previous studies of hip fracture patients but still failed to meet target supplement volumes prescribed to meet 45% of theoretical energy requirements. Clinicians should consider alternative methods of feeding such as a nasogastric tube, particularly in those patients where adherence to oral nutrition supplements is poor and dietary intake alone is insufficient to meet estimated energy requirements.

Anthropometric indices predict physical function and mobility in older Australians: the Australian Longitudinal Study of Ageing.

OBJECTIVE: To evaluate, in terms of function and mobility, the predictive value of commonly adopted anthropometric 'definitions' used in the nutritional assessment of older adults, in a cohort of older Australians. DESIGN: Prospective cohort study - Australian Longitudinal Study of Ageing (ALSA). SETTING: Adelaide, South Australia (1992-1994). SUBJECTS: Data were analysed from 1272 non-institutionalised (685 males, 587 females) older adults > or =70 years old in South Australia. Seven 'definitions' commonly used in the anthropometric assessment of both under- and overnutrition (including four using body mass index (BMI), waist-to-hip ratio, waist circumference and percentage weight change) were evaluated at baseline, for their ability to predict functional and mobility limitation assessed (by self-report questionnaire) at two years follow-up. All questionnaires were administered and anthropometry performed by trained investigators. The associations between the definitions and decline in mobility and physical function were evaluated over two years using multiple logistic regression. RESULTS: A BMI >85th percentile or >30 kg m-2 or a waist circumference of >102 cm in males and >88 cm in females increased risk of functional and mobility limitations. Over two years, a loss of 10% body weight significantly increased the risk of functional and mobility limitations. CONCLUSION: Maintaining weight within older adults, irrespective of initial body weight, may be important in preventing functional and mobility limitations. Excessive weight is associated with an increased risk of limitation in function and mobility, both key components of health-related quality of life.

Corrected arm muscle area: an independent predictor of long-term mortality in community-dwelling older adults?

OBJECTIVES: Older people are at risk of undernutrition because of a number of physiological conditions and lifestyle factors. The purpose of this study was to explore the predictive relationship of corrected arm muscle area (CAMA) with 8-year mortality in a representative sample of older Australians. DESIGN: Prospective cohort study: The Australian Longitudinal Study of Ageing. SETTING: Community. PARTICIPANTS: One thousand three hundred ninety-six participants aged 70 and older. MEASUREMENTS: Trained observers measured baseline weight, height, mid upper arm circumference, and triceps skinfold thickness using standard techniques. Body mass index (BMI) and CAMA were calculated. Baseline BMI and CAMA measurements were categorized according to cutoff values proposed by Garrow et al. and Friedman et al., respectively. Subsequent analyses were undertaken using Cox proportional hazards regression. RESULTS: After adjustment for potential confounders (baseline age, gender, marital status, smoking, self-rated health, ability to conduct activities of daily living, comorbidity, cognition performance, and presence of depression), those older Australians with a low CAMA (