Nutritional and physical exercise programs for older people: program format preferences and (dis)incentives to participate

Understanding the complexity of barriers and facilitators to adherence to oral nutritional supplements among patients with malnutrition: a systematic mixed-studies review

The aim of this systematic mixed-studies review is to summarise barriers/facilitators to adherence to and/or consumption of oral nutritional supplements (ONS) among patients with disease-related malnutrition. In March 2022, the Cochrane CENTRAL, PUBMED, PsycINFO (Ovid) and CINAHL were searched for articles with various study designs, published since 2000. Articles were identified on the basis of 'population' (patients ≥18 years with malnutrition/at nutritional risk), 'intervention' (ONS with ≥2 macronutrients and micronutrients), 'comparison' (any comparator/no comparator) and 'outcome' (factors affecting adherence or consumption) criteria. A sequential exploratory synthesis was conducted: first, a thematic synthesis was performed identifying barriers/facilitators; and second, the randomised controlled trials (RCTs) were used to support these findings. The five WHO dimensions of adherence guided the analysis. Study inclusion, data extraction, analysis and risk-of-bias assessment (MMAT 2018) were carried out independently by two researchers. From 21 835 screened articles, 171 were included with 42% RCTs and 20% qualitative studies. The two major populations were patients with malignancies (34%) and older adults (35%). In total, fifty-nine barriers/facilitators were identified. Patients' health status, motivation, product tolerance and satisfaction as well as well-functioning healthcare routines and support were factors impacting ONS consumption. Few barriers/facilitators (n = 13) were investigated in RCTs. Two of those were serving a small ONS volume and integrating ONS into ward routines. Given the complexity of ONS adherence, non-adherence to ONS should be addressed using a holistic approach. More studies are needed to investigate the effect of different approaches to increase adherence to ONS.

Dimensions of the diet-exercise relationship in later life: A qualitative study

OBJECTIVE

Diet and physical activity are two lifestyle behaviours that are critical for healthy ageing. The aim of this study was to explore how older adults negotiate dietary and physical activity decisions to identify areas of intersection between these two behaviours and inform health promotion interventions targeting both diet and exercise.

METHODS

This exploratory study utilised a novel data collection approach that involved lay interviewers recruiting their peers to (i) participate in two interviews over a period of six months and (ii) make notes on their thoughts relating to diet and physical activity. Participants were 75 adults aged 60+ years in Western Australia (n = 64 females).

RESULTS

Three primary themes were identified: (i) the importance but difficulty of achieving energy balance; (ii) issues relating to managing food intake before, during, and after physical activity; and (iii) reciprocal opportunities for eating and physical activity.

CONCLUSIONS

Diet and physical activity are linked in complex ways, highlighting the need for multi-factorial interventions.

IMPLICATIONS FOR PUBLIC HEALTH

When developing communications strategies designed to encourage older people to both improve their diets and increase their physical activity, consideration could be given to leveraging existing perceived alignments between healthy eating and being active.

Feasibility and Safety of Whole-Body Electromyostimulation in Frail Older People—A Pilot Trial

Whole-body electromyostimulation (WB-EMS) induces high-intense stimuli to skeletal muscles with low strain on joints and the autonomic nervous system and may thus be suitable for frail, older people. However, if trained at very high intensities, WB-EMS may damage muscles and kidneys (rhabdomyolysis). This study aimed at investigating the feasibility, safety and preliminary efficacy of WB-EMS in frail, older people. Seven frail (81.3 ± 3.5 years), 11 robust (79.5 ± 3.6 years), 10 young (29.1 ± 6.4 years) participants completed an eight-week WB-EMS training (week 1–4: 1x/week; week 5–8: 1.5x/week) consisting of functional exercises addressing lower extremity strength and balance. Feasibility was assessed using recruitment, adherence, retention, and dropout rates. The satisfaction with WB-EMS was measured using the Physical Activity Enjoyment Scale for older adults (PACES-8). In week 1, 3, and 8 creatine kinase (CK) was assessed immediately before, 48 and 72 h after WB-EMS. Symptoms of rhabdomyolysis (muscle pain, muscle weakness, myoglobinuria) and adverse events were recorded. Functional capacity was assessed at baseline and after 8 weeks using the Short Physical Performance Battery (SPPB), Timed Up-and-Go Test (TUG), Choice Stepping Reaction Time Test (CSRT), 30-second Chair-Stand Test (30-STS), maximum isometric leg strength and handgrip strength. The recruitment rate of frail individuals was 46.2%, adherence 88.3% and the dropout rate 16.7%. All groups indicated a high satisfaction with WB-EMS. CK activity was more pronounced in young individuals with significant changes over time. Within older people CK increased borderline-significantly in the frail group from baseline to week 1 but not afterwards. In robust individuals CK increased significantly from baseline to week 1 and 3. No participant reached CK elevations close to the threshold of ≥5,000 U/l and no symptoms of rhabdomyolysis were observed. With the exception of the TUG (p = 0.173), frail individuals improved in all tests of functional capacity. Compared to the young and robust groups, frail individuals showed the greater improvements in the SPPB, handgrip strength, maximum isokinetic hip-/knee extension and flexion strength. WB-EMS is feasible for frail older people. There were no clinical signs of exertional rhabdomyolysis. WB-EMS proved to be sufficiently intense to induce meaningful changes in functional capacity with frail individuals showing greater improvements for several measures.

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.

The Contribution of Leisure Center Usage to Physical Activity in the United Kingdom: Evidence From a Large Population-Based Cohort

BACKGROUND

Physical activity (PA) levels vary across specific population groups, contributing to health inequalities. Little is known about how local authority leisure centers contribute to population PA and whether this differs by age, sex, or socioeconomic group.

METHODS

The authors calculated weekly leisure center-based moderate/vigorous PA for 20,904 registered adult users of local authority leisure facilities in Northumberland, United Kingdom, between July 2018 and June 2019, using administrative data. The authors categorized activity levels (<30, 30-149, and ≥150 min/wk) and used ordinal regression to examine predictors for activity category achieved.

RESULTS

Registered users were mainly female (58.7%), younger (23.9% of users aged 18-29 y vs 10.1% of those aged 70+ y), and from the 2 most affluent socioeconomic quintiles (53.7%). Median weekly moderate/vigorous leisure center-based activity was 55 minutes per week (interquartile range: 30-99). Being female (odds ratio: 2.09; 95% confidence interval, 1.95-2.35), older (odds ratio: 1.14; 95% confidence interval, 1.11-1.16), and using a large facility (odds ratio: 1.21; 95% confidence interval, 1.03-1.42) were positive predictors of leisure center-based PA.

CONCLUSION

Older adults and females were more likely to be active and achieve the recommended PA levels through usage of the centers. Widespread use of this novel measure of leisure center-based activity would improve the understanding of how local authority leisure centers can address physical inactivity and its associated inequalities.

The Effect of MicroRNA-Mediated Exercise on Delaying Sarcopenia in Elderly Individuals

Sarcopenia is often regarded as an early sign of weakness and is the core element of muscle weakness in elderly individuals. Sarcopenia is closely related to the reduction of exercise, and elderly individuals often suffer from decreased muscle mass and function due to a lack of exercise. At present, studies have confirmed that resistance and aerobic exercise are related to muscle mass, strength and fiber type and to the activation and proliferation of muscle stem cells (MuSCs). Increasing evidence shows that microRNAs (miRNAs) play an important role in exercise-related changes in the quantity, composition and function of skeletal muscle. At the cellular level, miRNAs have been shown to regulate the proliferation and differentiation of muscle cells. In addition, miRNAs are related to the composition and transformation of muscle fibers and involved in the transition of MuSCs from the resting state to the activated state. Therefore, exercise may delay sarcopenia in elderly individuals by regulating miRNAs in skeletal muscle. In future miRNA-focused treatment strategies, these studies will provide valuable information for the formulation of exercise methods and will provide useful and targeted exercise programs for elderly individuals with sarcopenia.

Exercise and Nutrition for Healthy AgeiNg (ENHANce) project - effects and mechanisms of action of combined anabolic interventions to improve physical functioning in sarcopenic older adults: study protocol of a triple blinded, randomized controlled trial

Background

The Exercise and Nutrition for Healthy AgeiNg (ENHANce) project aims to assess the combined effects of exercise and nutritional interventions to prevent loss of skeletal muscle mass and function with ageing, and to determine the underlying mechanisms of action.

Methods

One hundred eightycommunity-dwelling sarcopenic individuals (≥ 65 years) are allocated in a randomized controlled trial (RCT) in a 1:1 ratio into five groups for a 12-week intervention period, followed by a 12-week follow-up period: 1) exercise intervention +protein placebo +omega-3 fatty acids placebo; 2) protein +omega-3 fatty acids placebo; 3) exercise intervention +protein +omega-3 fatty acids placebo; 4) exercise intervention +protein +omega-3 fatty acids; 5) protein placebo +omega-3 fatty acids placebo. All interventions are in line with recommendations of expert groups such as the American College of Sports Medicine and the PROT-AGE study group and individualized to the physical capabilities and nutritional intake of each participant. Sarcopenia is diagnosed by the assessment of gait speed, handgrip strength (Jamar handheld dynamometer), chair stand test and muscle mass (DXA) according to the European Working Group on Sarcopenia in Older People (EWGSOP2) criteria. Participants, researchers and statisticians are blinded to omega-3 fatty acids and protein treatment. Compliance to the exercise program, protein and omega-3 fatty acids interventions is objectively measured, by monitoring movement by an activity monitor, determining nitrogen content in urine and analyzing the fatty acid composition of the red blood cell membrane. The primary outcome of the RCT is the change in Short Physical Performance Battery (SPPB) score. Secondary endpoints are, among others, changes in muscle mass, strength and function, objective compliance to interventions, changes in muscle and blood biomarkers related to sarcopenia, cognition, quality of life and falls.

Discussion

This RCT in well-defined sarcopenic older adults assesses the effects of combined anabolic interventions, including the additive effects of omega-3 fatty acids supplements, compared to single or placebo interventions. Compliance with the exercise intervention and with the intake of nutritional supplements is measured objectively. Also, blood and muscle samples will be used to explore the underlying determinants that contribute to the mechanism of action of anabolic interventions.

Trial registration

Clinicaltrials.gov: NCT03649698, retrospectively registered at 28 August 2018, first participant was randomized 16 February 2018.

Preserving Mobility in Older Adults with Physical Frailty and Sarcopenia: Opportunities, Challenges, and Recommendations for Physical Activity Interventions

One of the most widely conserved hallmarks of aging is a decline in functional capabilities. Mobility loss is particularly burdensome due to its association with negative health outcomes, loss of independence and disability, and the heavy impact on quality of life. Recently, a new condition, physical frailty and sarcopenia, has been proposed to define a critical stage in the disabling cascade. Physical frailty and sarcopenia are characterized by weakness, slowness, and reduced muscle mass, yet with preserved ability to move independently. One of the strategies that have shown some benefits in combatting mobility loss and its consequences for older adults is physical activity. Here, we describe the opportunities and challenges for the development of physical activity interventions in people with physical frailty and sarcopenia. The aim of this article is to review age-related physio(patho)logical changes that impact mobility in old age and to provide recommendations and procedures in accordance with the available literature.

Feasibility and acceptability of a milk and resistance exercise intervention to improve muscle function in community-dwelling older adults (MIlkMAN): Pilot study

BACKGROUND

Dietary protein supplementation combined with resistance exercise (RE) may counteract declines in muscle strength, mass, and function (sarcopenia), but the role of whole foods rich in protein, such as milk, is less well understood. In the MIlkMAN study, we aimed to examine the feasibility and acceptability of milk+RE as an intervention for muscle function in community-dwelling older adults, and provide exploratory pilot data for future substantive research in population at risk of sarcopenia.

METHODS

In a parallel groups design, 30 older adults (71.7±3.6 years; 12 women) were randomised into three groups: WM (whole milk 3.6% fat)+RE, SM (skimmed milk 0.3% fat)+RE, and C (isocaloric carbohydrate drink)+RE. RE was performed twice-weekly over 6 weeks in a community gym, followed by the consumption of 500 ml of milk (~20 g protein) or carbohydrate drink immediately after exercise and a further 500 ml at home within the following 4-5 hours. The feasibility and acceptability of the study was determined by calculating recruitment and attendance rates, compliance with the intervention, rating participants' experiences, and recording adverse health events.

RESULTS

The response rate was 49% (out of 400 invitations sent), and the recruitment rate was 73.2% (30 participants recruited out of 41 screened for eligibility). Twenty-nine participants completed the intervention-an attendance rate of 97.1%; 89.7% rated their experience as 'excellent'/very good'. Compliance with taking the drinks was 97.1% (WM), 98.3% (SM), and 95.0% (C); 93.1% rated their drink intake as 'easy'/'very easy' with no adverse effects. Collection of exploratory pilot data to inform future trials was successful. Mean change in grip strength, 5-chair rises, and gait speed were 0.9±3.4 kg, 1.8±2.2 s, 0.1±0.1 m/s, respectively with no differences between the groups.

CONCLUSIONS

This community-based milk+RE intervention was feasible and acceptable to older adults. The study successfully collected pilot data for future substantive research.

Orthopaedic surgeons' perceptions of frailty and frailty screening

Background

Over the past decade, there has been significant growth in the awareness and understanding of fragility among orthopaedic surgeons in the context of osteoporotic fractures and with it, improvements in the recognition and management of fragility fractures. Emerging as a major clinical and research focus in aged care is the concept of frailty and its associations with fragility, sarcopenia, falls and rehabilitation. Currently, research is lacking on how orthopaedic surgeons perceive frailty and the role of frailty screening. A baseline understanding of these perceptions is needed to inform integration of frailty identification and management for patient optimization in orthopaedic practices, as well as research and education efforts of patients and healthcare professionals in orthopaedic contexts.

Methods

We used an exploratory design guided by qualitative description to conduct 15 semi-structured telephone and in-person interviews across three orthopaedic surgeon subgroups (Registrars, Junior Consultants, and Senior Consultants). Data collection and analysis occurred iteratively and was guided by thematic saturation.

Results

Orthopaedic surgeons have a disparate understanding of frailty. Between colleagues, frailty is often referred to non-specifically to suggest a general state of risk to the patient. Frailty screening is regarded positively but its specific utility in orthopaedic environments is questioned. Easy-to-administer frailty screening tools that are not exclusive assessments of functional status are viewed most satisfactorily. However these tools are rarely used.

Conclusions

There is little understanding among orthopaedic surgeons of frailty as a phenotype. Beliefs around modifiability of frailty were dissimilar as were the impact of related risk factors, such a cognitive status, chronic disease, social isolation, and environmental influences. This in turn may significantly impact on the occurrence and treatment outcomes of fragility fracture, a common orthopaedic problem in older populations. This study highlights need for knowledge translation efforts (e.g. education) to achieve cohesive understanding of frailty among health professionals.

Association between fulfilling the recommendations for health-enhancing physical activity with (instrumental) activities of daily living in older Austrians

Aim

The aim of the study was to describe the association between fulfilling the recommendation for health-enhancing physical activity (PA), and deficits in activities of daily living (ADL) and instrumental activities of daily living (IADL) in 3308 subjects aged 65+ years from the Austrian Health Interview Survey 2014.

Methods

The proportion of subjects who fulfilled the minimal recommendations for health-enhancing PA was assessed with the Physical Activity Questionnaire of the European Health Interview Survey (EHIS-PAQ). The ADLs were assessed based on the Barthel index, and IADLs by the IADL scale of Lawton and Brody. Additionally, various sociodemographic and health-related factors were assessed.

Results

Of the participants 54.7% did not fulfil the minimal requirements for aerobic PA, and 67.1% not for muscle strengthening PA, 16.4% reported ADL deficits, and 47.1% IADL deficits. Adjusted for sociodemographic and health-related parameters, not fulfilling the recommendations for aerobe PA was associated with a higher chance for ADL deficits (odds ratio, OR 1.73, 95%-confidence interval 1.36–2.21), and IADL deficits (1.57; 1.34–1.84). Not fulfilling the recommendations for muscle strengthening PA also increased the chance for ADL and IADLs deficits (1.34; 1.04–1.72, and 1.29; 1.09–1.53, respectively).

Conclusion

The number of participants who did not fulfil the minimal requirements for aerobic or strengthening PA was very high, and these participants showed significantly more problems in ADLs and IADLs. Therefore, all future efforts should focus on increasing participation and adherence in exercise programs for older people with the intention to improve their performance status and functions in daily life.