David R. Sinacore

Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults

BACKGROUND Obesity exacerbates the age-related decline in physical function and causes frailty in older adults; however, the appropriate treatment for obese older adults is controversial. METHODS In this 1-year, randomized, controlled trial, we evaluated the independent and combined effects of weight loss and exercise in 107 adults who were 65 years of age or older and obese. Participants were randomly assigned to a control group, a weight-management (diet) group, an exercise group, or a weight-management-plus-exercise (diet-exercise) group. The primary outcome was the change in score on the modified Physical Performance Test. Secondary outcomes included other measures of frailty, body composition, bone mineral density, specific physical functions, and quality of life. RESULTS A total of 93 participants (87%) completed the study. In the intention-to-treat analysis, the score on the Physical Performance Test, in which higher scores indicate better physical status, increased more in the diet-exercise group than in the diet group or the exercise group (increases from baseline of 21% vs. 12% and 15%, respectively); the scores in all three of those groups increased more than the scores in the control group (in which the score increased by 1%) (P<0.001 for the between-group differences). Moreover, the peak oxygen consumption improved more in the diet-exercise group than in the diet group or the exercise group (increases of 17% vs. 10% and 8%, respectively; P<0.001); the score on the Functional Status Questionnaire, in which higher scores indicate better physical function, increased more in the diet-exercise group than in the diet group (increase of 10% vs. 4%, P<0.001). Body weight decreased by 10% in the diet group and by 9% in the diet-exercise group, but did not decrease in the exercise group or the control group (P<0.001). Lean body mass and bone mineral density at the hip decreased less in the diet-exercise group than in the diet group (reductions of 3% and 1%, respectively, in the diet-exercise group vs. reductions of 5% and 3%, respectively, in the diet group; P<0.05 for both comparisons). Strength, balance, and gait improved consistently in the diet-exercise group (P<0.05 for all comparisons). Adverse events included a small number of exercise-associated musculoskeletal injuries. CONCLUSIONS These findings suggest that a combination of weight loss and exercise provides greater improvement in physical function than either intervention alone. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00146107.).

Effects of Exercise Training on Frailty in Community‐Dwelling Older Adults: Results of a Randomized, Controlled Trial

OBJECTIVES: Although deficits in skeletal muscle strength, gait, balance, and oxygen uptake are potentially reversible causes of frailty, the efficacy of exercise in reversing frailty in community‐dwelling older adults has not been proven. The aim of this study was to determine the effects of intensive exercise training (ET) on measures of physical frailty in older community‐dwelling men and women.

Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial.

Background:Limited ankle dorsiflexion has been implicated as a contributing factor to plantar ulceration of the forefoot in diabetes mellitus. The purpose of this study was to compare outcomes for patients with diabetes mellitus and a neuropathic plantar ulcer treated with a total-contact cast with

Resistance exercise training increases mixed muscle protein synthesis rate in frail women and men

Muscle atrophy (sarcopenia) in the elderly is associated with a reduced rate of muscle protein synthesis. The purpose of this study was to determine if weight-lifting exercise increases the rate of muscle protein synthesis in physically frail 76- to 92-yr-old women and men. Eight women and 4 men with mild to moderate physical frailty were enrolled in a 3-mo physical therapy program that was followed by 3 mo of supervised weight-lifting exercise. Supervised weight-lifting exercise was performed 3 days/wk at 65-100% of initial 1-repetition maximum on five upper and three lower body exercises. Compared with before resistance training, the in vivo incorporation rate of [13C]leucine into vastus lateralis muscle protein was increased after resistance training in women and men ( P < 0.01), although it was unchanged in five 82 ± 2-yr-old control subjects studied two times in 3 mo. Maximum voluntary knee extensor muscle torque production increased in the supervised resistance exercise group. These findings suggest that muscle contractile protein synthetic pathways in physically frail 76- to 92-yr-old women and men respond and adapt to the increased contractile activity associated with progressive resistance exercise training.Muscle atrophy (sarcopenia) in the elderly is associated with a reduced rate of muscle protein synthesis. The purpose of this study was to determine if weight-lifting exercise increases the rate of muscle protein synthesis in physically frail 76- to 92-yr-old women and men. Eight women and 4 men with mild to moderate physical frailty were enrolled in a 3-mo physical therapy program that was followed by 3 mo of supervised weight-lifting exercise. Supervised weight-lifting exercise was performed 3 days/wk at 65-100% of initial 1-repetition maximum on five upper and three lower body exercises. Compared with before resistance training, the in vivo incorporation rate of [(13)C]leucine into vastus lateralis muscle protein was increased after resistance training in women and men (P < 0.01), although it was unchanged in five 82 +/- 2-yr-old control subjects studied two times in 3 mo. Maximum voluntary knee extensor muscle torque production increased in the supervised resistance exercise group. These findings suggest that muscle contractile protein synthetic pathways in physically frail 76- to 92-yr-old women and men respond and adapt to the increased contractile activity associated with progressive resistance exercise training.

76 yr old

Background and Purpose: The primary purpose of this study was to report differences in calf intermuscular adipose tissue (IMAT), muscle strength (peak torque), power, and physical function in individuals with obesity, diabetes mellitus (DM), and peripheral neuropathy (PN) compared with those without these impairments. A secondary purpose was to assess the relationship between IMAT and muscle strength, power, and physical function. Subjects and Methods: Six participants with obesity, DM, and PN (2 women, 4 men; mean age=58 years, SD=10; mean body mass index=36.3, SD=5; mean modified Physical Performance Test [PPT] score=22, SD=3) and 6 age- and sex-matched control subjects without these impairments were assessed and compared in muscle strength, muscle power, physical functioning, and muscle and fat volume, including IMAT in the calf muscles. Muscle, adipose tissue, and IMAT volumes of each calf were quantified by noninvasive magnetic resonance imaging. Muscle strength and power of the plantar-flexor and dorsiflexor muscles were quantified using isokinetic dynamometry. The modified PPT was used to assess physical function. Results: Leg muscle and fat volumes were similar between groups, although IMAT volumes were 2.2-fold higher in the subjects with obesity, DM, and PN (X̄=120 cm3, SD=47) than in the control subjects (X̄=54 cm3, SD=41). Muscle strength, muscle power, ratio of leg muscle power to leg muscle volume, and modified PPT scores were lower in subjects with obesity, DM, and PN compared with the control subjects. Discussion and Conclusion: The data indicate that excess fat infiltration in leg skeletal muscles is associated with low calf muscle strength, low calf muscle power, and impaired physical function in individuals who are obese with DM and PN.

Excessive Adipose Tissue Infiltration in Skeletal Muscle in Individuals With Obesity, Diabetes Mellitus, and Peripheral Neuropathy: Association With Performance and Function

Both obesity and aging increase intrahepatic fat (IHF) content, which leads to nonalcoholic fatty liver disease (NAFLD) and metabolic abnormalities such as insulin resistance. We evaluated the effects of diet and diet in conjunction with exercise on IHF content and associated metabolic abnormalities in obese older adults. Eighteen obese (BMI ≥30 kg/m2) older (≥65 years old) adults completed a 6‐month clinical trial. Participants were randomized to diet (D group; n = 9) or diet + exercise (D+E group; n = 9). Primary outcome was IHF quantified by magnetic resonance spectroscopy (MRS). Secondary outcomes included insulin sensitivity (assessed by oral glucose tolerance), body composition (assessed by dual‐energy X‐ray absorptiometry), physical function (VO2peak and strength), glucose, lipids, and blood pressure (BP). Body weight (D: −9 ± 1%, D+E: −10 ± 2%, both P < 0.05) and fat mass (D: −13 ± 3%, D+E −16 ± 3%, both P < 0.05) decreased in both groups but there was no difference between groups. IHF decreased to a similar extent in both groups (D: −46 ± 11%, D+E: −45 ± 8%, both P < 0.05), which was accompanied by comparable improvements in insulin sensitivity (D: 66 ± 25%, D+E: 68 ± 28%, both P < 0.05). The relative decreases in IHF correlated directly with relative increases in insulin sensitivity index (ISI) (r = −0.52; P < 0.05). Improvements in VO2peak, strength, plasma triglyceride (TG), and low‐density lipoprotein–cholesterol concentration, and diastolic BP occurred in the D+E group (all P < 0.05) but not in the D group. Diet with or without exercise results in significant decreases in IHF content accompanied by considerable improvements in insulin sensitivity in obese older adults. The addition of exercise to diet therapy improves physical function and other obesity‐ and aging‐related metabolic abnormalities.

Diet and exercise interventions reduce intrahepatic fat content and improve insulin sensitivity in obese older adults.

Study Design. A cross‐sectional study was used to determine whether limited range of motion in the hip was present in 100 patients‐one group with unspecified low back pain and another group with signs suggesting sacroiliac joint dysfunction. Objectives. To determine whether a characteristic pattern of range of motion in the hip is related to low back pain in patients and to determine whether such a pattern is associated with and without signs of sacroiliac joint dysfunction. Summary of Background Data. The sacroiliac joint is often considered a potential site of low back pain. Problems with the sacroiliac joint, as well as with the low back, have often been related to reduced or asymmetric range of motion in the hip. The correlation between sacroiliac joint dysfunction and hip range of motion, however, has not been thoroughly evaluated with reliable tests in a population of patients with low back pain. Methods. Passive hip internal and external rotation goniometric measurements were taken by a blinded examiner, while a separate examiner evaluated the patient for signs of sacroiliac joint dysfunction. Patients with sacroiliac joint dysfunction were further classified as having a left or a right posteriorly tilted innominate. Results. The patients with low back pain but without evidence of sacroiliac joint dysfunction had significantly greater external hip rotation than internal rotation bilaterally, whereas those with evidence of sacroiliac joint dysfunction had significantly more external hip rotation than internal rotation unilaterally, specifically on the side of the posterior innominate. Conclusions. Clinicians should consider evaluating for unilateral asymmetry in range of motion in the hip in patients with low back pain. The presence of such asymmetry in patients with low back pain may help identify those with sacroiliac joint dysfunction.

Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain

PURPOSE To evaluate the effect of adding exercise to a hypocaloric diet on changes in appendicular lean mass and strength in frail obese older adults undergoing voluntary weight loss. METHODS Thirty frail older (age, 70 +/- 5 yr) obese (body mass index, 37 +/- 5 kg.m) adults were randomly assigned to 6 months of diet/behavioral therapy (diet group, n = 15) or diet or behavioral therapy plus exercise that incorporated progressive resistance training (PRT; diet + exercise group; n = 15). Body composition was assessed using dual-energy x-ray absorptiometry, and muscle strength was assessed using one-repetition maximum. The volume of upper extremity (UE) and lower extremity (LE) exercise training was determined by multiplying the average number of repetitions performed by the average weight lifted during the first three exercise sessions and during the last three exercise sessions of the study. RESULTS The diet and the diet + exercise groups had similar (P > 0.05) decreases in weight (10.7 +/- 4.5 vs 9.7 +/- 4.0 kg) and fat mass (6.8 +/- 3.7 vs 7.7 +/- 2.9 kg). However, the diet + exercise group lost less fat-free mass (FFM; 1.8 +/- 1.5 vs 3.5 +/- 2.1 kg), LE lean mass (0.9 +/- 0.8 vs 2.0 +/- 0.9 kg), and UE lean mass (0.1 +/- 0.2 vs 0.2 +/- 0.2 kg) than the diet group (P < 0.05). The diet + exercise group had greater increases in percent of weight as FFM (FFM / weight x 100) than the diet group (7.9 +/- 3.3 vs 5.4 +/- 3.7%; P < 0.05). Despite lean mass losses, the diet + exercise group increased UE and LE strength in response to exercise (17-43%), whereas the diet group maintained strength. The volume of UE and LE exercises correlated with the amount of UE and LE lean mass (r = 0.64-0.84; P < 0.05). CONCLUSION Exercise added to diet reduces muscle mass loss during voluntary weight loss and increases muscle strength in frail obese older adults. Regular exercise that incorporates PRT should be used to attenuate muscle mass loss in frail obese older adults on weight-loss therapy.

Exercise Attenuates the Weight-Loss-Induced Reduction in Muscle Mass in Frail Obese Older Adults

BACKGROUND Although weight loss and exercise ameliorates frailty and improves cardiac risk factors in obese older adults, the long-term effect of lifestyle intervention on bone metabolism and mass is unknown. OBJECTIVE The objective was to evaluate the effects of diet-induced weight loss in conjunction with exercise on bone metabolism and mass in obese older adults. DESIGN AND SETTING We conducted a one-year randomized, controlled clinical trial in a university-based research center. PARTICIPANTS Twenty-seven frail, obese (body mass index = 39 +/- 5 kg/m(2)), older (age 70 +/- 5 yr) adults participated in the study. INTERVENTION Participants were randomly assigned to diet and exercise (treatment group; n = 17) or no therapy (control group; n = 10). OUTCOME MEASURES Body weight decreased in the treatment group but not in the control group (-10 +/- 2 vs. +1 +/- 1%, P < 0.001). Compared with the control group, the treatment group had greater changes in bone mass, bone markers, and hormones, including 1) bone mineral density (BMD) in total hip (0.1 +/- 2.1 vs. -2.4 +/- 2.5%), trochanter (0.2 +/- 3.3 vs. -3.3 +/- 3.1%), and intertrochanter (0.3 +/- 2.7 vs. -2.7 +/- .3.0%); 2) C-terminal telopeptide (12 +/- 35 vs. 101 +/- 79%) and osteocalcin (-5 +/- 15 vs. 66 +/- 61%); and 3) leptin (2 +/- 12 vs. -30 +/- 25%) and estradiol (0.1 +/- 14% vs. -14 +/- 21%) (all P < 0.05). Changes in weight (r = 0.55), bone markers (r = -0.54), and leptin (r = 0.61) correlated with changes in hip BMD (all P < 0.05). CONCLUSION Weight loss, even when combined with exercise, decreases hip BMD in obese older adults. It is not known whether the beneficial effects of weight loss and exercise on physical function lower the overall risk of falls and fractures, despite the decline in hip BMD.

Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial

Weight loss therapy to improve health in obese older adults is controversial because it causes further bone loss. Therefore, it is recommended that weight loss therapy should include an intervention such as exercise training (ET) to minimize bone loss. The purpose of this study was to determine the independent and combined effects of weight loss and ET on bone metabolism in relation to bone mineral density (BMD) in obese older adults. One‐hundred‐seven older (age >65 years) obese (body mass index [BMI] ≥30 kg/m2) adults were randomly assigned to a control group, diet group, exercise group, and diet‐exercise group for 1 year. Body weight decreased in the diet (−9.6%) and diet‐exercise (−9.4%) groups, not in the exercise (−1%) and control (−0.2%) groups (between‐group p < 0.001). However, despite comparable weight loss, bone loss at the total hip was relatively less in the diet‐exercise group (−1.1%) than in the diet group (−2.6%), whereas BMD increased in the exercise group (1.5%) (between‐group p < 0.001). Serum C‐terminal telopeptide (CTX) and osteocalcin concentrations increased in the diet group (31% and 24%, respectively), whereas they decreased in the exercise group (−13% and −15%, respectively) (between‐group p < 0.001). In contrast, similar to the control group, serum CTX and osteocalcin concentrations did not change in the diet‐exercise group. Serum procollagen propeptide concentrations decreased in the exercise group (−15%) compared with the diet group (9%) (p = 0.04). Serum leptin and estradiol concentrations decreased in the diet (−25% and −15%, respectively) and diet‐exercise (−38% and −13%, respectively) groups, not in the exercise and control groups (between‐group p = 0.001). Multivariate analyses revealed that changes in lean body mass (β = 0.33), serum osteocalcin (β = −0.24), and one‐repetition maximum (1‐RM) strength (β = 0.23) were independent predictors of changes in hip BMD (all p < 0.05). In conclusion, the addition of ET to weight loss therapy among obese older adults prevents weight loss–induced increase in bone turnover and attenuates weight loss–induced reduction in hip BMD despite weight loss–induced decrease in bone‐active hormones.