Effects and contextual factors of a diet and resistance exercise intervention vary across settings: an overview of three successive ProMuscle interventions.

BACKGROUND: Although many effective interventions have been developed, limited interventions have successfully been implemented. An intervention that was translated across settings is ProMuscle: a diet and resistance exercise intervention for older adults. However, varying contexts often lead to varying effects due to contextual factors (characteristics of individuals, organizations, communities or society). The current study aimed to gain insights into effects and contextual factors of ProMuscle in the controlled setting (ProMuscle: PM), real-life setting (ProMuscle in Practice: PiP), and real-life setting of the implementation pilots (ProMuscle Implementation Pilots: IP). METHODS: Data from the intervention arms of PM (N = 31) and PiP (N = 82), and from IP (N = 35) were used. Physical functioning (chair-rise test) and leg strength (1-10 repetition maximum) were measured at baseline and after 12-weeks intervention. Paired t-tests and General Linear Models were used to study changes after 12 weeks and differences between interventions. To explore contextual factors, researchers of PM and physiotherapists and dietitians of PiP and IP were interviewed. Factors were categorized according to the five domains and its underlying constructs of the Consolidated Framework for Implementation Research (CFIR). RESULTS: Improvements on chair-rise performance were found in PM (-2.0 ± 7.0 s, p = 0.186), PiP (-0.8 ± 2.9 s, p = 0.019) and IP (-3.3 ± 4.2 s, p = 0.001). Similar results were found for leg strength in PM (32.6 ± 24.8 kg, p < 0.001), PiP (17.0 ± 23.2 kg, p < 0.001), and IP (47.8 ± 46.8 kg, p < 0.001). Contextual factors that contribute to explaining the relatively high effects in IP included room for adapting and tailoring the intervention, involvement of experienced professionals, availability of and access to facilities, and participants characteristics. CONCLUSIONS: Effects of the intervention appeared to be strongest in the real-life setting of the implementation pilots. Specific contextual factors contributed to explaining the different findings across settings. Future studies should investigate crucial factors that determine successful implementation of interventions in the real-life setting, to ensure that effective interventions are put into action and reach a broad population. TRIAL REGISTRATION: The ProMuscle intervention was registered in the Trial Registration (clinicaltrials.gov identifier: NCT01110369 ) on February 12th, 2010. The ProMuscle in Practice intervention was registered in the Netherlands Trial Register (NTR6038) on August 30th, 2016. Trial registration was not needed for the ProMuscle Implementation Pilots as this research did not fall within the remit of the Dutch 'Medical Research Involving Human Subjects Act'.

Effect, process, and economic evaluation of a combined resistance exercise and diet intervention (ProMuscle in Practice) for community-dwelling older adults: design and methods of a randomised controlled trial.

BACKGROUND: Exercise and nutrition are important for older adults to maintain or to regain their muscle mass, function, strength, and ultimately quality of life. The effectiveness of combined resistance exercise and diet interventions is commonly evaluated in controlled clinical studies, but evidence from real-life settings is lacking. This article describes the effectiveness, process, and economic evaluation design of a combined nutrition and exercise intervention for community-dwelling older adults in a Dutch real-life setting. METHODS: The ProMuscle in Practice study is a randomised controlled multicentre intervention study, conducted in five municipalities in the Netherlands. Two hundred community-dwelling older adults (≥65 years) who are frail or pre-frail based on Fried frailty criteria or who experience strength loss are randomised over an intervention and control group by municipality. In the first 12-week intensive support intervention, participants in the intervention group perform resistance exercise training guided by a physiotherapist twice a week and increase protein intake by consuming protein-rich products under the supervision of a dietitian. Afterwards, they continue with a 12-week moderate support intervention. The control group receives only regular care during the two 12-week periods. Effect outcomes are measured at all locations at baseline, 12 weeks, 24 weeks, 36 weeks and only at three locations at 52 weeks. The primary outcome is physical functioning (Short Physical Performance Battery). Secondary outcomes include leg muscle strength, lean body mass, activities of daily living, social participation, food intake, and quality of life. Qualitative and quantitative implementation process data are collected during the intervention. Healthcare use and intervention costs are registered for the economic evaluation. DISCUSSION: Evaluating the effects, implementation, and costs of this combined intervention provides valuable insight into the feasibility of this intervention for community-dwelling older adults and into the intervention's ability to improve or to maintain physical functioning and quality of life. TRIAL REGISTRATION: Netherlands Trial Register ( NTR6038 ) since 30 August 2016.

Combined Protein-Rich Diet With Resistance Exercise Intervention to Counteract Sarcopenia: A Qualitative Study on Drivers and Barriers of Compliance.

Interventions combining protein-rich diets with resistance exercises seem a promising avenue in helping to prevent sarcopenia. However, compliance to health interventions is generally low. The aim of the present study was to provide qualitative insights into the drivers and barriers that older adults experience when trying to comply with a combined dietary and physical exercise intervention. Semi-structured interviews with 18 older adults participating in such an intervention were conducted and analyzed using thematic content analysis. Most frequently reported drivers to comply with the diet were a fit with existing habits, knowledge on the health benefits, and product properties (taste, convenience, package). Drivers for physical exercises were existing habits, social contacts, customized support, and experienced physical improvement. It is suggested that customized support is important to successfully implement exercise-protein interventions amongst older adults, especially regarding participants' habits, product preferences, and social environment.

Effectiveness of Taste Lessons with and without additional experiential learning activities on children's willingness to taste vegetables.

This study assessed the effectiveness of the Dutch school programme Taste Lessons with and without additional experiential learning activities on children's willingness to taste unfamiliar vegetables. Thirty-three primary schools (877 children in grades 6-7 with a mean age of 10.3 years) participated in Taste Lessons Vegetable Menu (TLVM, lessons and extra activities), Taste Lessons (TL, lessons), or a control group. A baseline and follow-up measurement was used to assess for each child: number of four familiar and four unfamiliar vegetables tasted, quantity tasted, choice of vegetable of which to eat more, and number of vegetables willing to taste again later. Furthermore, children filled out a questionnaire on daily vegetable intake and food neophobia. Multilevel and Cox regression analyses were conducted to compare changes in the outcome measures between the three study groups. No significant intervention effects were found on willingness to taste unfamiliar vegetables. Neither were effects found on familiar vegetables, except for number of familiar vegetables tasted (p < 0.05). Furthermore, no significant intervention effects were found on daily vegetable consumption and food neophobia. These results indicate that more intensive school-based nutrition education activities are needed to increase children's willingness to taste unfamiliar vegetables and increase their vegetable intake.

Unravelling the effect of the Dutch school-based nutrition programme Taste Lessons: the role of dose, appreciation and interpersonal communication.

BACKGROUND: To unravel the effect of school-based nutrition education, insight into the implementation process is needed. In this study, process indicators of Taste Lessons (a nutrition education programme for Dutch elementary schools) and their association with changes in behavioural determinants relevant to healthy eating behaviour are studied. METHODS: The study sample consisted of 392 Dutch primary school children from 12 schools. Data were collected using teacher and child questionnaires at baseline, and at one and six months after the intervention. Multilevel regression analyses were conducted to study the association between dose, appreciation and children's engagement in interpersonal communication (talking about Taste Lessons with others after the lessons), and change in knowledge, awareness, skills, attitude, emotion, subjective norm and intention towards two target behaviours. RESULTS: With an average implementation of a third of the programme activities, dose positively predicted change in children's subjective norm of the teacher after one month. Teachers and children highly appreciated Taste Lessons. Whereas teacher appreciation was inversely associated, child appreciation was positively associated with children's change in awareness, emotion and subjective norm of teachers after one month and in attitude and subjective norm of parents after six months. Interpersonal communication was positively associated with children's change in five determinants after one month and in attitude and intention after six months. CONCLUSIONS: The implementation process is related to the programme outcomes of Taste Lessons. Process data provide valuable insights into factors that contribute to the effect of interventions in real-life settings.

Effectiveness of Taste Lessons with and without additional experiential learning activities on children's psychosocial determinants of vegetables consumption.

Experiential learning methods seem to be promising to enhance healthy eating behaviour in children. Therefore, this study compared the effectiveness of the Dutch programme Taste Lessons with and without additional experiential learning activities on children's psychosocial determinants of vegetable consumption. In a quasi-experimental design, 800 children aged 8-11 years old from 34 elementary schools participated in a Taste Lessons (TL: 5 lessons) group, a Taste Lessons Vegetable Menu (TLVM: TL with 3 added experiential learning activities) group, and a control group. During a baseline and follow-up measurement, children completed a questionnaire on psychosocial determinants towards vegetables consumption. Multilevel regression analyses were conducted to compare changes in the determinants between the TLVM group and the TL group, and between the two intervention groups and the control group. The TLVM group showed a significantly higher increase in knowledge (p < 0.001), attitude and subjective norm of the teacher (both p < 0.05), whereas the TL group only showed a significantly higher increase in knowledge (p < 0.001) compared to the control group. Increases in knowledge (p < 0.10), subjective norm (p < 0.10) and cooking self-efficacy (p < 0.05) were higher in the TLVM group than in the TL group. Therefore, more and stronger effects were found in children who participated in the additional hands-on activities.

The Baltimore Urban Food Distribution (BUD) App: Study Protocol to Assess the Feasibility of a Food Systems Intervention.

Low-income urban communities in the United States commonly lack ready access to healthy foods. This is due in part to a food distribution system that favors the provision of high-fat, high-sugar, high-sodium processed foods to small retail food stores, and impedes their healthier alternatives, such as fresh produce. The Baltimore Urban food Distribution (BUD) study is a multilevel, multicomponent systems intervention that aims to improve healthy food access in low-income neighborhoods of Baltimore, Maryland. The primary intervention is the BUD application (app), which uses the power of collective purchasing and delivery to affordably move foods from local producers and wholesalers to the city's many corner stores. We will implement the BUD app in a sample of 38 corner stores, randomized to intervention and comparison. Extensive evaluation will be conducted at each level of the intervention to assess overall feasibility and effectiveness via mixed methods, including app usage data, and process and impact measures on suppliers, corner stores, and consumers. BUD represents one of the first attempts to implement an intervention that engages multiple levels of a local food system. We anticipate that the app will provide a financially viable alternative for Baltimore corner stores to increase their stocking and sales of healthier foods, subsequently increasing healthy food access and improving diet-related health outcomes for under-resourced consumers. The design of the intervention and the evaluation plan of the BUD project are documented here, including future steps for scale-up. Trial registration #: NCT05010018.

Digital Strategies to Improve Food Assistance in Disasters: A Scoping Review.

OBJECTIVE: Modern digital strategies, including Internet of Things, machine learning, and mobile applications, have revolutionized situational awareness during disaster management. Despite their importance, no review of digital strategies to support emergency food security efforts has been conducted. This scoping review fills that gap. METHODS: Keywords were defined within the concepts of food assistance, digital technology, and disasters. After the database searches, PRISMA guidelines were followed to perform a partnered, 2-round scoping literature review. RESULTS: The search identified 3201 articles, and 26 articles met criteria and were included in the analysis. The data types used to describe the tools were text/opinion (42.3%), qualitative (23.1%), system architecture (19.2%), quantitative and qualitative (11.5 %), and quantitative (3.8%). The tools' main functions were Resource Allocation (41.7%), Data Collection and Management (33%), Interagency Communications (15.4 %), Beneficiary Communications (11.5%), and Fundraising (7.7%). The platforms used to achieve these goals were Mobile Application (36%), Internet of Things (20%), Website (20%), and Mobile Survey (8%); 92% covered the disaster response phase. CONCLUSIONS: Digital tools for planning, situational awareness, client choice, and recovery are needed to support emergency food assistance, but there is a lack of these tools and research on their effectiveness across all disaster phases.

In-Depth Analyses of the Effects of a Diet and Resistance Exercise Intervention in Older Adults: Who Benefits Most From ProMuscle in Practice?

BACKGROUND: The ProMuscle in Practice intervention, comprising resistance exercise and an increased protein intake, was effective in improving muscle strength, lean body mass, and physical functioning in older adults aged 65 years and older (N = 168). However, a heterogeneous response to such interventions is common. Therefore, we explored the differences in responsiveness to the intervention in subgroups based on demographic characteristics and mobility-impairing disorders. METHOD: Multiple regression analyses were performed to study mean changes between baseline and 12 weeks on the Short Physical Performance Battery, chair rise test, lean body mass, knee extension strength, leg press strength, and leg extension strength. The interaction term Treatment × Subgroup was included to study differences in effects between subgroups. Subgroups comprised age (≤75 vs >75 years), sex (men vs women), presence of frailty, presence of sarcopenia, and presence of osteoarthritis. RESULTS: A significant interaction effect including age was found on lean body mass (ß = -0.8; 95% CI: -1.5, -0.2), favoring participants aged 75 years and younger. A significant interaction effect including sex was found on leg press strength (ß = 15.5; 95% CI: 0.6, 30.3), favoring women. Participants with or without frailty, sarcopenia, or osteoarthritis responded equally to the intervention in terms of absolute effects. CONCLUSIONS: Participants aged 75 years and younger and women benefited to a great extent from the intervention, as they improved significantly on nearly every outcome. Effects in participants with and without a mobility-impairing disorder were comparable, indicating that the intervention is suitable for both groups.

Exposure to a Multilevel, Multicomponent Obesity Prevention Intervention (OPREVENT2) in Rural Native American Communities: Variability and Association with Change in Diet Quality.

The OPREVENT2 obesity prevention trial was a multilevel multicomponent (MLMC) intervention implemented in rural Native American communities in the Midwest and Southwest U.S. Intervention components were delivered through local food stores, worksites, schools, community action coalitions, and by social and community media. Due to the complex nature of MLMC intervention trials, it is useful to assess participants' exposure to each component of the intervention in order to assess impact. In this paper, we present a detailed methodology for evaluating participant exposure to MLMC intervention, and we explore how exposure to the OPREVENT2 trial impacted participant diet quality. There were no significant differences in total exposure score by age group, sex, or geographic region, but exposure to sub-components of the intervention differed significantly by age group, sex, and geographical region. Participants with the highest overall exposure scores showed significantly more improvement in diet quality from baseline to follow up compared to those who were least exposed to the intervention. Improved diet quality was also significantly positively associated with several exposure sub-components. While evaluating exposure to an entire MLMC intervention is complex and imperfect, it can provide useful insight into an intervention's impact on key outcome measures, and it can help identify which components of the intervention were most effective.

Cost-effectiveness of a Diet and Resistance Exercise Intervention in Community-Dwelling Older Adults: ProMuscle in Practice.

OBJECTIVES: Ageing is associated with a decline in functioning and a loss of independence, which will lead to increased health care costs in the future. The ProMuscle in Practice intervention was found to be effective in improving muscle strength, muscle mass, and functioning of older adults. The current study assesses the cost-effectiveness and perceived benefits of the intervention. DESIGN: Trial-based cost-effectiveness analysis complemented by interviews. SETTING AND PARTICIPANTS: A total of 168 community-dwelling older adults were included. Intervention participants started with a 12-week intensive support program, comprising resistance exercise guided by physiotherapists and consultations with a dietitian to increase protein intake. To maintain the adapted lifestyle pattern, they continued with a 12-week moderate support intervention. The control group received usual care. METHODS: Costs and outcomes were measured at baseline, after 12 and 24 weeks. Costs were assessed from a societal perspective. Health care use, out-of-pocket costs, and productivity losses were measured using questionnaires. Intervention costs were quantified according to bottom-up micro-costing. Outcomes included quality of life (EQ-5D-5L) and physical functioning (Short Physical Performance Battery [SPPB]). Bootstrap analyses were used to generate cost-effectiveness planes and acceptability curves. Interviews with participants and professionals were conducted after 24 weeks to measure perceived benefits. RESULTS: An Incremental Cost-Effectiveness Ratio of €2988 ($3385)/point increase in SPPB was found. The intervention has an 82.4% probability of being cost-effective at a willingness to pay (WTP) of €12.000 ($13.559)/point increase in SPPB. No change in quality of life was found according to EQ-5D-5L. Interviews, however, revealed a wide range of function-related perceived benefits. CONCLUSIONS AND IMPLICATIONS: At a WTP of €12.000 ($13.559)/point increase in SPPB, the intervention was found to have an 82.4% probability of being cost-effective. Because generic quality of life questionnaires seem unable to detect subtle changes in public health interventions, future studies are advised to include targeted and specific questionnaires.

Process Evaluation of a Combined Lifestyle Intervention for Community-Dwelling Older Adults: ProMuscle in Practice.

BACKGROUND AND OBJECTIVES: The ProMuscle in Practice intervention combines resistance exercise training and dietary protein intake for community-dwelling older adults, implemented by health care professionals (HCPs). This study aimed to evaluate implementation and context of this intervention in Dutch health care practice. RESEARCH DESIGN AND METHODS: We conducted a randomized controlled multicenter intervention study in 5 Dutch municipalities. Eighty-two older adults received the 12-week intensive support intervention (resistance exercise training and individual dietary counseling) and the optional 12-week moderate support intervention (resistance exercise training and a nutrition course). Mixed method data were collected from both participants and HCPs (n = 37) on process indicators recruitment, dose received, acceptability, fidelity, applicability, and context. RESULTS: Overall, the intervention was feasible to implement and accepted by participants and HCPs. About two thirds of participants continued with the moderate support intervention after the first 12 weeks. The mean dose received for the training sessions was 83.6% in the intensive intervention, 63.6% in the moderate intervention, >90% for individual dietitian consultations, and 76.8% for the nutrition course. The intensive support intervention was implemented with high fidelity, whereas for the moderate support intervention resistance exercise trainings varied in implementation between exercise providers. DISCUSSION AND IMPLICATIONS: A combined resistance exercise training and dietary protein intervention for community-dwelling older adults can be successfully implemented in practice. Well-tailored interventions, intensive supervision by skilled HCPs, social aspects, fidelity, and fit within real-world settings appeared essential for successful implementation. These elements are important for continuous intervention optimization to accomplish broader and successful implementation.

Effectiveness of a Diet and Resistance Exercise Intervention on Muscle Health in Older Adults: ProMuscle in Practice.

OBJECTIVES: Clinical studies show that resistance exercise and a protein-rich diet can counteract the age-related decline of muscle mass, strength, and physical performance. The aim of the ProMuscle in Practice study was to test effectiveness of a resistance exercise and dietary protein intervention for older adults implemented in a real-life setting. DESIGN: A randomized controlled multicenter intervention study. SETTING AND PARTICIPANTS: One hundred sixty-eight community-dwelling older adults were included (age 75 ± 6 years). A 12-week intensive support intervention including progressive resistance exercise supervised by a physiotherapist and dietitian guidance on increasing protein intake was followed by a voluntary 12-week moderate support intervention to continue the adapted lifestyle pattern. The control group received no intervention. METHODS: Compliance was measured through attendance lists and 3-day food records. Physical functioning, leg strength (3-repetition maximum, knee extension strength), lean body mass [(LBM) dual-energy X-ray absorptiometry], and quality of life (5-level EQ-5D) were measured at baseline, and after 12 and 24 weeks. Differences in change between groups were assessed with linear mixed model analysis. RESULTS: The intervention group increased protein intake and attended 83.6% of the training sessions. Short Physical Performance Battery score slightly increased in intervention participants [from 10.1 (95% confidence interval 9.7-10.5) to 10.4 (10.0-10.8) at week 12 and 10.6 (10.2-10.9) at week 24], where control participants decreased (time × treatment interactions, P < .05). Improvements in intervention group compared with controls were also observed for Timed Up-and-Go, strength and LBM at both time points (time × treatment interactions, P < .05). No difference between groups was found for the 6-Minute Walking Test, activities of daily living, and quality of life. CONCLUSIONS AND IMPLICATIONS: ProMuscle in Practice was effective on improving muscle strength and LBM, with small changes in the composite function score in community-dwelling older adults in a real-life setting. Further research should explore feasibility of real-life implementation, as well as improving long-term compliance.

Protein Intake and Distribution in Relation to Physical Functioning and Quality of Life in Community-Dwelling Elderly People: Acknowledging the Role of Physical Activity.

Increasing total protein intake and a spread protein intake distribution are potential strategies to attenuate sarcopenia related loss of physical function and quality of life. The aim of this cross-sectional study was to investigate whether protein intake and protein intake distribution are associated with muscle strength, physical function and quality of life in community-dwelling elderly people with a wide range of physical activity. Dietary and physical activity data were obtained from two studies (N = 140, age 81 ± 6, 64% male), with the following outcome measures: physical functioning (Short Physical Performance Battery (SPPB), comprising balance, gait speed and chair rise tests), handgrip strength and quality of life (EQ-5D-5L). Protein intake distribution was calculated for each participant as a coefficient of variance (CV = SD of grams of protein intake per main meal divided by the average total amount of proteins (grams) of the main meals). Based on the CV, participants were divided into tertiles and classified as spread, intermediate or pulse. The average total protein intake was 1.08 ± 0.29 g/kg/day. Total protein intake was not associated with outcome measures using multivariate regression analyses. Individuals with a spread protein diet during the main meals (CV < 0.43) had higher gait speed compared to those with an intermediate diet (CV 0.43⁻0.62) (ß = -0.42, p = 0.035), whereas a spread and pulse protein diet were not associated with SPPB total score, chair rise, grip strength and Quality-Adjusted Life Year (QALY). The interaction of higher physical activity and higher total protein intake was significantly associated with higher quality of life (ß = 0.71, p = 0.049). While this interaction was not associated with SPPB or grip strength, the association with quality of life emphasizes the need for a higher total protein intake together with an active lifestyle in the elderly.