Shannon L. Mihalko

Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial.

IMPORTANCE Knee osteoarthritis (OA), a common cause of chronic pain and disability, has biomechanical and inflammatory origins and is exacerbated by obesity. OBJECTIVE To determine whether a ≥10% reduction in body weight induced by diet, with or without exercise, would improve mechanistic and clinical outcomes more than exercise alone. DESIGN, SETTING, AND PARTICIPANTS Single-blind, 18-month, randomized clinical trial at Wake Forest University between July 2006 and April 2011. The diet and exercise interventions were center-based with options for the exercise groups to transition to a home-based program. Participants were 454 overweight and obese older community-dwelling adults (age ≥55 years with body mass index of 27-41) with pain and radiographic knee OA. INTERVENTIONS Intensive diet-induced weight loss plus exercise, intensive diet-induced weight loss, or exercise. MAIN OUTCOMES AND MEASURES Mechanistic primary outcomes: knee joint compressive force and plasma IL-6 levels; secondary clinical outcomes: self-reported pain (range, 0-20), function (range, 0-68), mobility, and health-related quality of life (range, 0-100). RESULTS Three hundred ninety-nine participants (88%) completed the study. Mean weight loss for diet + exercise participants was 10.6 kg (11.4%); for the diet group, 8.9 kg (9.5%); and for the exercise group, 1.8 kg (2.0%). After 18 months, knee compressive forces were lower in diet participants (mean, 2487 N; 95% CI, 2393 to 2581) compared with exercise participants (2687 N; 95% CI, 2590 to 2784, pairwise difference [Δ](exercise vs diet )= 200 N; 95% CI, 55 to 345; P = .007). Concentrations of IL-6 were lower in diet + exercise (2.7 pg/mL; 95% CI, 2.5 to 3.0) and diet participants (2.7 pg/mL; 95% CI, 2.4 to 3.0) compared with exercise participants (3.1 pg/mL; 95% CI, 2.9 to 3.4; Δ(exercise vs diet + exercise) = 0.39 pg/mL; 95% CI, -0.03 to 0.81; P = .007; Δ(exercise vs diet )= 0.43 pg/mL; 95% CI, 0.01 to 0.85, P = .006). The diet + exercise group had less pain (3.6; 95% CI, 3.2 to 4.1) and better function (14.1; 95% CI, 12.6 to 15.6) than both the diet group (4.8; 95% CI, 4.3 to 5.2) and exercise group (4.7; 95% CI, 4.2 to 5.1, Δ(exercise vs diet + exercise) = 1.02; 95% CI, 0.33 to 1.71; P(pain) = .004; 18.4; 95% CI, 16.9 to 19.9; Δ(exercise vs diet + exercise), 4.29; 95% CI, 2.07 to 6.50; P(function )< .001). The diet + exercise group (44.7; 95% CI, 43.4 to 46.0) also had better physical health-related quality of life scores than the exercise group (41.9; 95% CI, 40.5 to 43.2; Δ(exercise vs diet + exercise) = -2.81; 95% CI, -4.76 to -0.86; P = .005). CONCLUSIONS AND RELEVANCE Among overweight and obese adults with knee OA, after 18 months, participants in the diet + exercise and diet groups had more weight loss and greater reductions in IL-6 levels than those in the exercise group; those in the diet group had greater reductions in knee compressive force than those in the exercise group. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00381290.

Physical activity, self-esteem, and self-efficacy relationships in older adults: A randomized controlled trial

A randomized controlled trial examined the growth and form of multidimensional self-esteem over a 12-month period (6-month exercise intervention and 6-month follow-up) in 174 older adults engaged in either a walking or stretching/toning program. The extent to which changes in physical fitness parameters and physical self-efficacy were related to changes in perceptions of attractive body, strength, physical conditioning, and physical self-worth was also determined. Latent growth curve analyses showed a curvilinear pattern of growth in esteem with significant increases at all levels of self-esteem upon completion of the intervention followed by significant declines at 6 months poistintervention in both groups. Frequency of activity and changes in physical fitness, body fat, and self-efficacy were related to improvements in esteem perceptions relative to attractive body, strength, and physical condition. Model fitting procedures suggested that the best fit of the data was to a model in which the influence of changes in efficacy and physical parameters on physical self-worth were mediated by perceptions of attractive body and physical conditions.

Restorative yoga for women with breast cancer: findings from a randomized pilot study.

Objectives: Restorative yoga (RY) is a gentle type of yoga that may be beneficial for cancer patients and post‐treatment survivors. Study goals were: to determine the feasibility of implementing a RY intervention for women with breast cancer; and to examine group differences in self‐reported emotional, health‐related quality of life, and symptom outcomes.

Gait adjustments in older adults: activity and efficacy influences.

Factors that influence gait adjustments in active and sedentary older adults were examined in this study. Fifty-five older adults (60-85 years) completed a series of physical activity and self-efficacy measures (gait, falls) and the Berg Balance Scale (K. O. Berg, S. L. Wood-Dauphinee, J. I. Williams, & B. Maki, 1992). Participants then completed a series of walking trials that included walking with and without obstacles placed in their path. Sedentary older adults adopted a more cautious walking style than active ones, exhibiting shorter step lengths and slower step velocities. Age, physical activity level, balance, and the efficacy measures were all found to be significantly correlated with gait speed. Hierarchical regression analyses indicated that once age, sex, and body mass index were controlled for, gait efficacy had a significant independent effect on gait speed. These results highlight the importance of examining multiple factors when examining the control of gait.

The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale

BackgroundObesity is the most modifiable risk factor, and dietary induced weight loss potentially the best nonpharmacologic intervention to prevent or to slow osteoarthritis (OA) disease progression. We are currently conducting a study to test the hypothesis that intensive weight loss will reduce inflammation and joint loads sufficiently to alter disease progression, either with or without exercise. This article describes the intervention, the empirical evidence to support it, and test-retest reliability data.Methods/DesignThis is a prospective, single-blind, randomized controlled trial. The study population consists of 450 overweight and obese (BMI = 27–40.5 kg/m2) older (age ≥ 55 yrs) adults with tibiofemoral osteoarthritis. Participants are randomized to one of three 18-month interventions: intensive dietary restriction-plus-exercise; exercise-only; or intensive dietary restriction-only. The primary aims are to compare the effects of these interventions on inflammatory biomarkers and knee joint loads. Secondary aims will examine the effects of these interventions on function, pain, and mobility; the dose response to weight loss on disease progression; if inflammatory biomarkers and knee joint loads are mediators of the interventions; and the association between quadriceps strength and disease progression.ResultsTest-retest reliability results indicated that the ICCs for knee joint load variables were excellent, ranging from 0.86 – 0.98. Knee flexion/extension moments were most affected by BMI, with lower reliability with the highest tertile of BMI. The reliability of the semi-quantitative scoring of the knee joint using MRI exceeded previously reported results, ranging from a low of 0.66 for synovitis to a high of 0.99 for bone marrow lesion size.DiscussionThe IDEA trial has the potential to enhance our understanding of the OA disease process, refine weight loss and exercise recommendations in this prevalent disease, and reduce the burden of disability.Trial RegistrationNCT00381290

Active living for assisted living: Promoting partnerships within a systems framework

In response to a growing need for assistance among our aging population, assisted-living facilities have been designed to fill the widening chasm between community living and nursing care. Although sedentary behavior has been linked to functional limitations and disability, no comprehensive information exists about the social and physical environments and the programming available to promote physical activity in assisted living. Accordingly, this article includes data from an exploratory study that underscores the issues clearly related to physical activity for older adults in assisted living. The intent of this exploratory study was to partner with executive directors in order to conduct an analysis of the social and physical characteristics of assisted living. Interviews were conducted with executive directors (N=21) to discuss methods for assessing and promoting positive lifestyle behaviors with distinct emphasis on the targeted behavior of physical activity. Potential ways in which the social and physical environments could be modified to promote and support physically active living were identified. Clearly, promoting physical activity in assisted living is a challenge and will require a partnership with assisted living communities to develop effective and feasible systems-based interventions designed to make environments more engaging and, thereby, promote active living.

Weight Loss and Self-Regulatory Eating Efficacy in Older Adults: The Cooperative Lifestyle Intervention Program

Objectives. Using the weight efficacy lifestyle questionnaire (WEL), we examined whether a group-mediated intervention for weight loss among older, obese adults resulted in changes in self-regulatory self-efficacy for eating behavior and whether these changes mediated weight loss. Methods. This was a randomized controlled design, and 288 older adults received 1 of 3 treatments for 6 months: physical activity only (PA), weight loss + physical activity (WL + PA), or a successful aging (SA) health education program. The WEL was administered prior to randomization and again at the 6-month follow-up visit. Results. A significant treatment effect was observed for the WEL, F (2,249) = 15.11, p < .0001, partial eta2 = .11, showing that improvement occurred only in the WL + PA group as compared with PA and SA. Changes in WEL scores partially mediated the effects of the WL + PA intervention on weight loss. Discussion. These results illustrate that WL + PA can be effective in improving older adults’ self-efficacy for the self-regulation of eating behavior and that these changes are prospectively related to the amount of weight loss. Further research is warranted on an expanded concept of self-efficacy as well as controlled experimental studies on eating behavior in older adults.

Effects of total and regional fat loss on plasma CRP and IL-6 in overweight and obese, older adults with knee osteoarthritis.

OBJECTIVE To describe associations between total and regional body fat mass loss and reduction of systemic levels of inflammation (C-reactive protein (CRP) and interleukin-6 (IL-6)) in obese, older adults with osteoarthritis (OA), undergoing intentional weight loss. DESIGN Data come from a single-blind, 18-month, randomized controlled trial in adults (age: 65.6 ± 6.2; Body mass index (BMI): 33.6 ± 3.7) with knee OA. Participants were randomized to diet-induced weight loss plus exercise (D + E; n = 150), diet-induced weight loss-only (D; n = 149), or exercise-only (E; n = 151). Total body and region-specific (abdomen and thigh) fat mass were measured at baseline and 18 months. High-sensitivity CRP and IL-6 were measured at baseline, six and 18 months. Intervention effects were assessed using mixed models and associations between inflammation and adiposity were compared using logistic and mixed linear regression models. RESULTS Intentional total body fat mass reduction was associated with significant reductions in log-adjusted CRP (β = 0.06 (95% CI = 0.04, 0.08) mg/L) and IL-6 (β = 0.02 (95% CI = 0.01, 0.04) pg/mL). Loss of abdominal fat volume was also associated with reduced inflammation, independent of total body fat mass; although models containing measures of total adiposity yielded the best fit. The odds of achieving clinically desirable levels of CRP (<3.0 mg/L) and IL-6 (<2.5 pg/mL) were 3.8 (95% CI = 1.6, 8.9) and 2.2 (95% CI = 1.1, 4.6), respectively, with 5% total weight and fat mass loss. CONCLUSIONS Achievement of clinically desirable levels of CRP and IL-6 more than double with intentional 5% loss of total body weight and fat mass. Global, rather than regional, measures of adiposity are better predictors of change in inflammatory burden. CLINICAL TRIAL REGISTRATION NUMBER NCT00381290.

Exercise for Older Cancer Patients: Feasible and Helpful?

Older adults are at high risk for functional decline after a cancer diagnosis. Physiologic changes of aging which negatively impact body composition, strength, and fitness increase vulnerability to the development of short- and long-term disability when stressed with cancer burden and treatments. Treatment-associated physical disability impairs quality of life, limits therapeutic options, and contributes to the social and economic burden of cancer care in the elderly. Despite this, few clinical trials capture disability as an outcome or focus on whether it can be ameliorated in this population. Exercise has multiple positive effects on physical health and well-being in non-cancer elderly populations and holds promise as a supportive care intervention to improve physical function and symptoms during and after cancer treatments. The majority of studies supporting the positive benefits of exercise among cancer survivors have been performed in younger patients. Results from limited elderly-specific trials suggest that physical activity interventions are safe and effective in older cancer survivors, with prostate cancer survivors representing the best studied cohort of older persons with cancer. Many questions remain unanswered with respect to optimal timing, mode, intensity, and delivery of exercise interventions for older patients. While available data support the potential benefit of exercise for elders with cancer, recommendations will need to be individualized to optimize participation, safety, and efficacy.

Effect of Intensive Chemotherapy on Physical, Cognitive, and Emotional Health of Older Adults with Acute Myeloid Leukemia

To measure short‐term changes in physical and cognitive function and emotional well‐being of older adults receiving intensive chemotherapy for acute myeloid leukemia (AML).