Effects of Protein Supplementation Combined with Exercise Intervention on Frailty Indices, Body Composition, and Physical Function in Frail Older Adults

Low muscle quality on a procedural computed tomography scan assessed with deep learning as a practical useful predictor of mortality in patients with severe aortic valve stenosis

BACKGROUND & AIMS

Accurate diagnosis of sarcopenia requires evaluation of muscle quality, which refers to the amount of fat infiltration in muscle tissue. In this study, we aim to investigate whether we can independently predict mortality risk in transcatheter aortic valve implantation (TAVI) patients, using automatic deep learning algorithms to assess muscle quality on procedural computed tomography (CT) scans.

METHODS

This study included 1199 patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) between January 2010 and January 2020. A procedural CT scan was performed as part of the preprocedural-TAVI evaluation, and the scans were analyzed using deep-learning-based software to automatically determine skeletal muscle density (SMD) and intermuscular adipose tissue (IMAT). The association of SMD and IMAT with all-cause mortality was analyzed using a Cox regression model, adjusted for other known mortality predictors, including muscle mass.

RESULTS

The mean age of the participants was 80 ± 7 years, 53% were female. The median observation time was 1084 days, and the overall mortality rate was 39%. We found that the lowest tertile of muscle quality, as determined by SMD, was associated with an increased risk of mortality (HR 1.40 [95%CI: 1.15-1.70], p < 0.01). Similarly, low muscle quality as defined by high IMAT in the lowest tertile was also associated with increased mortality risk (HR 1.24 [95%CI: 1.01-1.52], p = 0.04).

CONCLUSIONS

Our findings suggest that deep learning-assessed low muscle quality, as indicated by fat infiltration in muscle tissue, is a practical, useful and independent predictor of mortality after TAVI.

Outcomes of the LEAP feasibility trial-A low-threshold, exercise programme with protein supplementation to target frailty and poor physical functioning in people experiencing homelessness and addiction issues

BACKGROUND

People experiencing homelessness are more likely to experience poor health with physical functioning deficits and frailty commonly reported. It is not well known how strategies to target physical functioning deficits and frailty work in practice in this group. The primary aim of this study was to explore the feasibility of an exercise intervention with protein supplementation to target physical functioning and frailty in people experiencing homelessness evaluated by recruitment and retention rates, adherence to the exercise sessions and protein supplement, adverse effects, programme feedback and characteristics of non-returners, sporadic and frequent attenders. The secondary aim was to evaluate changes in effectiveness outcomes of grip strength, muscle mass, lower extremity physical function, pain, frailty, and risk of malnutrition.

METHOD

This prospective single-arm study evaluated the feasibility of a 16-week rolling, low-threshold, 'drop-in' once weekly exercise programme with protein supplementation. The main recruitment site was a day-service centre for people who are homeless. Feasibility was assessed by the recruitment and retention rates, adherence to the exercise sessions and protein supplement as well as adverse effects, programme feedback and evaluation of characteristics of non-returners, sporadic (≤50% of available sessions) and frequent attenders (≥50% of available sessions). Effectiveness outcomes included pain (Visual Analogue Scale), physical functioning and performance (hand-grip dynamometry, limb circumference, the Short Physical Performance Battery), frailty (SHARE-FI and Clinical Frailty Scale) and nutritional status (Mini Nutritional Assessment).

RESULTS

Thirty-one participants were recruited mean (SD) age 45(16) years. There was a recruitment rate of a median (IQR) of 2(1-3) new participants per week. The retention rate was 45% (n = 14) to the main recruitment site. Adherence to the exercise sessions and nutritional intervention was 90% and 100% respectively. Three adverse events were recorded during 74 interventions over the 16-week programme. The acceptability of the programme was highlighted in participant feedback. Characteristics of frequent returners (≥50%) were older age, female, more stably housed and more stable in addiction. The programme did not induce any changes in effectiveness outcomes.

CONCLUSION

The feasibility of this programme was demonstrated. Overall, the programme was well received with higher retention rates in older participants, females, those more stably housed and those stable in addiction. A higher powered, more intense programme is needed to demonstrate programme effectiveness.

Effectiveness of interventions to prevent or reverse pre-frailty and frailty in middle-aged community dwelling adults: A systematic review

INTRODUCTION

Frailty, marked by diminished physiological capacity and higher health risks, is less understood in middle-aged individuals (40-65 years) than older adults. This review synthesises intervention studies for pre-frailty and frailty in this demographic, assessing effectiveness, feasibility, and implementation factors including participant experience and cost-effectiveness.

METHOD

Registered on the Open Science Framework and adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and the template for intervention description and replication (TIDieR) guidelines, this review searched six databases for interventions targeting middle-aged adults. Dual screening, data extraction, risk assessment, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) certainty evaluation were conducted. Findings were narratively synthesized due to heterogeneity.

RESULTS

Eight studies (2018-2023) with 2838 participants were included. Resistance training and multicomponent exercise reduced frailty; though, not always significantly. Low-intensity exercises and education-based interventions yielded mixed results, suggesting a need for further research. Positive participant experiences and cost-effectiveness of interventions such as resistance training and educational interventions supports their feasibility. Varying quality, methodologies and levels of bias indicated a need for more rigorous future research.

DISCUSSION

This review reveals an evidence gap in middle-aged frailty interventions. Multicomponent interventions and resistance training showed promise, but their comparative effectiveness remains uncertain. Educational and low-intensity interventions need further research to establish their effectiveness. The findings diverge from those in older adults, emphasising the need for age-specific approaches. Future studies should employ higher-quality methods and explore emerging technologies to enhance intervention effectiveness for pre-frailty and frailty in middle-aged adults.

E-PROOF: E-intervention for protein intake and resistance training to optimize function: A study protocol

BACKGROUND

Accounting for more than 60% of cancer survivors, older (≥65 years) cancer survivors have a 2- to 5-fold risk of physical function impairment, compared to cancer-free peers. One strategy to improve physical function is dietary and resistance training interventions, which improve muscle strength and mass by stimulating muscle protein synthesis. The E-PROOF (E-intervention for Protein Intake and Resistance Training to Optimize Function) study will examine the feasibility, acceptability, and preliminary efficacy of a 12-week randomized controlled trial of an online, tailored nutritional and resistance training education and counseling intervention to improve physical function and associated health outcomes (muscle strength, health-related quality of life (HRQoL), self-efficacy, and weight management).

METHODS

In this study, 70 older cancer survivors will be randomized to one of two groups: experimental (receiving remote behavioral counseling and evidence-based education and resources), and control (general survivorship education). We will examine the intervention effects on physical function, muscle strength, HRQoL, self-efficacy, weight, and waist circumference during a 12-week period between the experimental and control groups. Three months following the end of the intervention, we will conduct a follow-up assessment to measure physical function, muscle strength, and HRQoL.

SIGNIFICANCE AND IMPACT

This study is the first synchronous, online protein-focused diet and resistance training intervention among older cancer survivors. This novel study advances science by promoting independent health behaviors among older cancer survivors to improve health outcomes, and provide foundational knowledge to further address this growing problem on a wider scale through online platforms.

Comparative Efficacy of Different Protein Supplements on Muscle Mass, Strength, and Physical Indices of Sarcopenia among Community-Dwelling, Hospitalized or Institutionalized Older Adults Undergoing Resistance Training: A Network Meta-Analysis of Randomized Controlled Trials

Aging-related sarcopenia exerts harmful impacts on muscle mass, strength, and physical mobility. Protein supplementation has been demonstrated to augment efficacy of resistance training (RT) in elderly. This study compared the relative effects of different protein supplements on muscle mass, strength, and mobility outcomes in middle-aged and older individuals undergoing RT. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) examining the efficacy of protein supplement plus RT in untrained community-dwelling adults, hospitalized, or institutionalized residents who suffered acute or chronic health conditions. Network meta-analysis (NMA) was performed using a frequentist method for all analyses. Treatment effects for main outcomes were expressed as standard mean difference (SMD) with 95% confidence interval (CI). We used the surface-under-the cumulative-ranking (SUCRA) scores to rank probabilities of effect estimation among all identified treatments. Meta-regression analyses were performed to identify any relevant moderator of the treatment efficacy and results were expressed as β with 95% credible interval (CrI). We finally included 78 RCTs (5272 participants) for analyses. Among the six protein sources identified in this NMA, namely whey, milk, casein, meat, soy, and peanut, whey supplement yielded the most effective treatments augmenting efficacy of RT on muscle mass (SMD = 1.29, 95% CI: 0.96, 1.62; SUCRA = 0.86), handgrip strength (SMD = 1.46, 95% CI: 0.92, 2.00; SUCRA = 0.85), and walking speed (SMD = 0.73, 95% CI: 0.39, 1.07; SUCRA = 0.84). Participant's health condition, sex, and supplementation dose were significant factors moderating the treatment efficacy on muscle mass (β = 0.74; 95% CrI: 0.22, 1.25), handgrip strength (β = -1.72; 95% CrI: -2.68, -0.77), and leg strength (β = 0.76; 95% CrI: 0.06, 1.47), respectively. Our findings suggest whey protein yields the optimal supplements to counter sarcopenia in older individuals undergoing RT.

Protein intake and body weight, fat mass and waist circumference: an umbrella review of systematic reviews for the evidence-based guideline on protein intake of the German Nutrition Society

PURPOSE

This umbrella review aimed to assess whether dietary protein intake with regard to quantitative (higher vs. lower dietary protein intake) and qualitative considerations (total, plant-based or animal-based protein intake) affects body weight (BW), fat mass (FM) and waist circumference (WC).

METHODS

A systematic literature search was conducted in PubMed, Embase and Cochrane Database of Systematic Reviews for systematic reviews (SRs) with and without meta-analyses of prospective studies published between 04 October 2007 and 04 January 2022. Methodological quality and outcome-specific certainty of evidence of the retrieved SRs were assessed by using AMSTAR 2 and NutriGrade, respectively, in order to rate the overall certainty of evidence using predefined criteria.

RESULTS

Thirty-three SRs were included in this umbrella review; 29 were based on randomised controlled trials, a few included cohort studies. In studies without energy restriction, a high-protein diet did not modulate BW, FM and WC in adults in general (all "possible" evidence); for older adults, overall certainty of evidence was "insufficient" for all parameters. Under hypoenergetic diets, a high-protein diet mostly decreased BW and FM, but evidence was "insufficient" due to low methodological quality. Evidence regarding an influence of the protein type on BW, FM and WC was "insufficient".

CONCLUSION

"Possible" evidence exists that the amount of protein does not affect BW, FM and WC in adults under isoenergetic conditions. Its impact on the reduction in BW and FM under hypoenergetic conditions remains unclear; evidence for an influence of protein type on BW, FM and WC is "insufficient".

Home-Based Remote Rehabilitation Leads to Superior Outcomes for Older Women With Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVES

To examine the effects of a home-based lower-extremity strengthening exercise program in community-dwelling older women with knee osteoarthritis.

DESIGN

Randomized controlled trial.

SETTING AND PARTICIPANTS

Women aged ≥60 years with knee osteoarthritis and Kellgren-Lawrence grade 1 or 2 on anteroposterior/lateral radiographs of both knee joints.

METHODS

Patients (n = 36) were randomly divided into experimental (EG) and control (CG) groups. The EG performed home-based remote rehabilitation lower-extremity strengthening exercises for 8 weeks, whereas the CG received no intervention. Assessment was performed at baseline and week 8. The primary outcome was the five-times sit-to-stand test (FTSST) result. Secondary outcomes included timed up-and-go (TUG) test results, knee extensor and flexor strength, quadriceps (rectus femoris) muscle activity, skeletal muscle index, blood pressure (BP), visual analog scale (VAS) scores, C-reactive protein level, and erythrocyte sedimentation rate.

RESULTS

A statistically significant difference in the FTSST times was observed between the groups after 8 weeks of intervention (EG: 7.95 ± 1.08 seconds, CG: 10.01 ± 2.03 seconds, P < .001). In the EG, the TUG test score decreased by 0.75 ± 0.80 seconds (P = .002), right and left knee flexor strength increased by 4.69 ± 6.05 kg (P = .007) and 3.98 ± 6.98 kg (P = .038), respectively, and the right knee extensor root mean square (RMS) ratio increased by 1.24 ± 0.39 (P = .027). Additionally, systolic and diastolic BP decreased by 9.50 ± 10.75 mm Hg (P = .005) and 4.25 ± 4.91 mm Hg (P = .003), respectively. In the CG, the VAS scores decreased by 9.10 ± 13.68 mm (P = .022).

CONCLUSIONS AND IMPLICATIONS

The home-based exercise program using a remote rehabilitation medical device was effective in improving lower extremity strength and function in community-dwelling older women with knee osteoarthritis. This finding suggests that the remote rehabilitation medical device may be used as an alternative to exercise interventions for patients with knee osteoarthritis.

Dietary Implications of the Bidirectional Relationship between the Gut Microflora and Inflammatory Diseases with Special Emphasis on Irritable Bowel Disease: Current and Future Perspective

The immune system is vital for safeguarding the human body against infections and inflammatory diseases. The role of diet and meal patterns in modulating immune function is complex, and highlighting this topic is crucial for identifying potential ways to improve immune health. In Europe, the Mediterranean diet and Western diet are the most common dietary patterns, and gaining an understanding of how they affect immune function is essential for public health. There are numerous inflammatory diseases that are observed in younger and older people. Some of the common diseases include polymyalgia rheumatica (PMR), spinal muscular atrophy (SMA), vasculitis, sarcopenia, cirrhosis, cancer, and fibromyalgia, but the main focus in this review article is on irritable bowel disease (IBD). In general, dietary choices can have an immense impact on the microbial flora of the gut in people with inflammatory diseases. The intake of Mediterranean-style foods promotes the growth of healthy bacteria that enhances the function of the immune system. On the other hand, it is mostly seen that the intake of Western-style foods leads to the growth of harmful gut bacteria that contributes to inflammation and disease development by weakening the immune system. Additionally, inflammation in the gut can impact brain function, leading to mood disorders, such as anxiety and depression. Rare inflammatory diseases, such as psoriasis and sarcoidosis, are of main interest in this article. All the above-mentioned common and rare inflammatory diseases have a certain relationship with the microbiota of the gut. The gut microbiome plays a significant role in IBD; fiber and prebiotic interventions may represent promising adjunct therapies for pediatric IBD by targeting the gut microbiome. By advancing a good overall arrangement of microorganisms in the stomach through dietary mediations, working on the side effects and alleviating of diseases might be conceivable. The gut microbiota can be affected differently by various dietary fatty acid types. There is also an involvement of genetics in the progression of IBD, such as transcriptional factors, and one gene of interest is the LCT gene, which encodes for lactase, an enzyme responsible for digesting lactose in the gut.

A prospective clinical study evaluating short-term changes in body composition and quality of life after gastrectomy in elderly patients receiving postoperative exercise and nutritional therapies

BACKGROUND

Muscle mass loss after gastrectomy is associated with a negative impact on quality of life (QOL) and long-term prognosis following gastric cancer treatment, especially in elderly patients. We conducted a prospective study to examine short-term changes in body composition and QOL after gastrectomy in elderly patients with gastric cancer who received exercise and nutritional therapies.

METHODS

Patients over aged 65 years of age who underwent gastrectomies for gastric cancer were enrolled in our study. Patients received exercise and nutritional therapies with branched-chain amino acid (BCAA)-rich supplements during 1 month after surgery. Body composition was evaluated using InBody S10 before surgery, and at 1 week and 1 month postoperatively. Other variables including QOL status (EQ-5D-5 L), serum albumin level, hand grip strength, and gait speed were evaluated at the same time.

RESULTS

Eighteen patients were analyzed. The mean loss of skeletal muscle mass index (SMI) was 4.6% (1 week) and 2.1% (1 month) compared to the preoperative period. QOL scores showed almost the same degree of recovery at 1 month after gastrectomy as preoperative scores. Serum albumin levels, hand grip strength, and gait speed decreased at 1 week and then increased at 1 month after surgery, similar to the changes seen in SMI.

CONCLUSIONS

Multidisciplinary approaches play key role in the surgical treatment of elderly patients. Postoperative exercise and nutritional therapies with BCAA-rich supplements may benefit elderly patients after gastrectomy by reducing loss of SMI and decreases in QOL.

TRIAL REGISTRATION

UMIN Clinical Trials Registry; UMIN000034374 (registration date: 10/10/2018).

Effectiveness of interventions to address different types of vulnerabilities in community-dwelling older adults: An umbrella review

Background

Frailty, social isolation, loneliness, and poverty may render older adults vulnerable to social or health stressors. It is imperative to identify effective interventions to address them especially in the context of COVID-19 pandemic.

Objective

To identify effective community-based interventions to address frailty, social isolation, loneliness, and poverty among community-dwelling older adults.

Design

Umbrella review.

Data Source

We systematically searched PubMed, Ovid MEDLINE, Embase, Cochrane CENTRAL, EBM-Reviews, CINAHL via EBSCO, and APA PsycInfo via Ovid from January 2009 to December 2022.

Eligibility Criteria

We included systematic reviews or quantitative reviews of non-pharmacologic interventions targeting community-dwelling older adults.

Data Selection Extraction and Management

Two review authors independently screened the titles and abstracts, performed data extraction and appraised the methodological quality of the reviews. We used a narrative synthesis approach to summarize and interpret the findings. We assessed the methodological quality of the studies using AMSTAR 2.0 tool.

Results

We identified 27 reviews incorporating 372 unique primary studies that met our inclusion criteria. Ten of the reviews included studies conducted in low-middle-income countries. Twelve reviews (46%, 12/26) included interventions that addressed frailty. Seventeen reviews (65%, 17/26) included interventions that addressed either social isolation or loneliness. Eighteen reviews included studies with single component interventions, while 23 reviews included studies with multi-component interventions. Interventions including protein supplementation combined with physical activity may improve outcomes including frailty status, grip strength, and body weight. Physical activity alone or in combination with diet may prevent frailty. Additionally, physical activity may improve social functioning and interventions using digital technologies may decrease social isolation and loneliness. We did not find any review of interventions addressing poverty among older adults. We also noted that few reviews addressed multiple vulnerabilities within the same study, specifically addressed vulnerability among ethnic and sexual minority groups, or examined interventions that engaged communities and adapted programs to local needs.

Conclusion

Evidence from reviews support diets, physical activity, and digital technologies to improve frailty, social isolation or loneliness. However, interventions examined were primarily conducted under optimal conditions. There is a need for further interventions in community settings and conducted under real world settings in older adults living with multiple vulnerabilities.

Adherence of Older Cardiac Patients to a Home-Based Cardiac Rehabilitation Program

Referral to home-based cardiac rehabilitation (HBCR) is low among older and frailer patients due to low expectations regarding adherence by healthcare professionals. The aim of this study was to determine adherence to HBCR when old and frail patients are referred, and to explore any differences in baseline characteristics between adherent and nonadherent patients. Data of the Cardiac Care Bridge were used (Dutch trial register NTR6316). The study included hospitalized cardiac patients ≥ 70 years old and at high risk of functional loss. Adherence to HBCR was confirmed when two-thirds of the intended nine sessions were followed. Of the 153 patients included (age: 82 ± 6 years, 54% female), 29% could not be referred due to death before referral, not returning home, or practical problems. Of the 109 patients who were referred, 67% adhered. Characteristics associated with non-adherence were older age (84 ± 6 vs. 82 ± 6, p = 0.05) and higher handgrip strength in men (33 ± 8 vs. 25 ± 11, p = 0.01). There was no difference in comorbidity, symptoms, or physical capacity. Based on these observations, most older cardiac patients who return home after hospital admission appear to adhere to HBCR after referral, suggesting that most older cardiac patients are motivated and capable of receiving HBCR.

Do dietary supplements prevent loss of muscle mass and strength during muscle disuse? A systematic review and meta-analysis of randomized controlled trials

Objective

We performed a systematic review and meta-analysis of existing randomized controlled trials (RCTs) to assess whether dietary supplements can prevent loss of muscle mass and strength during muscle disuse.

Methods

We searched the following databases: PubMed, Embase, Cochrane, Scopus, Web of Science, and CINAHL for RCTs assessing the effect of dietary supplements on disuse muscular atrophy without language and time restrictions. Muscle strength and leg lean mass were used as the primary outcome indicators. Muscle cross-sectional area (CSA), muscle fiber type distribution, peak aerobic capacity and muscle volume were used as secondary outcome indicators. The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool. Heterogeneity was tested using the I² statistic index. Mean and standard deviation of outcome indicators were extracted from the intervention and control groups to calculate effect sizes and 95% confidence intervals, with the significance level set at P < 0.05.

Results

Twenty RCTs were included with a total of 339 subjects. The results showed that dietary supplements had no effect on muscle strength, CSA, muscle fiber type distribution, peak aerobic capacity or muscle volume. But dietary supplements have a protective effect on the lean mass of the legs.

Conclusion

Dietary supplements can improve lean leg mass, but did not show a tendency to have an effect on muscle strength, CSA, muscle fiber type distribution, peak aerobic capacity or muscle volume during muscle disuse.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42022370230.

Community-based exercise and nutritional interventions to improve frailty syndrome among older adults: A quasi-experimental study

This study aimed to explore the efficacy of single and combined effects of exercise and branched-chain amino acid (BCAA) supplements on improving frailty and quality of life in older adults. In total, 120 study participants were allocated into a combined exercise-and-BCAA supplementation group, an exercise-only group, a BCAA supplementation-only group, and a control group. Results showed that Fried's frailty score significantly decreased in the combined exercise-and-BCAA supplementation group (β= -1.73, p<0.001), exercise-only group (β= -1.68, p<0.001), and BCAA supplementation-only group (β= -0.73, p=0.005) compared to the control group. Moreover, the combination of exercise and BCAA supplements and the exercise-only program produced significant improvements in frailty compared to the BCAA supplement-only group and control group (p<0.05). Exercise should be a critical approach for older adults to improve frailty. Healthcare professionals in geriatric care should incorporate exercise programs as frailty management and prevention for older adults.

Recommendations for the prevention and management of obesity in the Iraqi population

Obesity is a chronic metabolic disease that has become one of the leading causes of disability and death in the world, affecting not only adults but also children and adolescents. In Iraq, one third of the adult population is overweight and another third obese. Clinical diagnosis is accomplished by measuring body mass index (BMI) and waist circumference (a marker for intra-visceral fat and higher metabolic and cardiovascular disease risk). A complex interaction between behavioral, social (rapid urbanization), environmental and genetic factors underlies the etiology of the disease. Treatment options for obesity may include a multicomponent approach, involving dietary changes to reduce calorie intake, an increase in physical activity, behavioral modification, pharmacotherapy and bariatric surgery. The purpose for these recommendations is to develop a management plan and standards of care that are relevant to the Iraqi population and that can prevent/manage obesity and obesity-related complications, for the promotion of a healthy community.

Comparative effectiveness of non-pharmacological interventions for frailty: a systematic review and network meta-analysis

BACKGROUND

Frailty endangers the health of older adults. Furthermore, the prevalence of frailty continues to increase as the global population ageing.

OBJECTIVE

To update evidence on the effectiveness of non-pharmacological interventions for frailty by conducting a network meta-analysis (NMA) of randomised controlled trials (RCTs).

METHODS

Eight databases were searched from January 1, 2000, until September 24, 2021. RCTs of interventions for frailty among participants aged ≥60 years were considered eligible. The primary outcome was frailty. Pairwise meta-analysis and NMA were performed, with the pooled standardised mean difference (SMD) and 95% confidence interval (CI) being reported.

RESULTS

A total of 69 RCTs were included after screening 16,058 retrieved citations. There were seven types of interventions (11 interventions) for frailty among the included RCTs. Physical activity (PA) (pooled SMD = 0.43, 95% CI: 0.34-0.51), multicomponent intervention (pooled SMD = 0.34, 95% CI: 0.23-0.45) and nutrition intervention (pooled SMD = 0.21, 95% CI: 0.06-0.35) were associated with reducing frailty compared to control, of which PA was the most effective type of intervention. In terms of specific types of PA, resistance training (pooled SMD = 0.58, 95% CI: 0.33-0.83), mind-body exercise (pooled SMD = 0.57, 95% CI: 0.24-0.90), mixed physical training (pooled SMD = 0.47, 95% CI: 0.37-0.57) and aerobic training (pooled SMD = 0.36, 95% CI: 0.09-0.62) were associated with a reduction in frailty compared to usual care. Resistance training was the most effective PA intervention.

CONCLUSION

Resistance training has the best potential to reduce frailty in older adults. This finding might be useful to clinicians in selecting interventions for older adults with frailty.

Assessment Tools of Biopsychosocial Frailty Dimensions in Community-Dwelling Older Adults: A Narrative Review

Frailty is a complex interplay between several factors, including physiological changes in ageing, multimorbidities, malnutrition, living environment, genetics, and lifestyle. Early screening for frailty risk factors in community-dwelling older people allows for preventive interventions on the clinical and social determinants of frailty, which allows adverse events to be avoided. By conducting a narrative review of the literature employing the International Narrative Systematic Assessment tool, the authors aimed to develop an updated framework for the main measurement tools to assess frailty risks in older adults, paying attention to use in the community and primary care settings. This search focused on the biopsychosocial domains of frailty that are covered in the SUNFRAIL tool. The study selected 178 reviews (polypharmacy: 20; nutrition: 13; physical activity: 74; medical visits: 0; falls: 39; cognitive decline: 12; loneliness: 15; social support: 5; economic constraints: 0) published between January 2010 and December 2021. Within the selected reviews, 123 assessment tools were identified (polypharmacy: 15; nutrition: 15; physical activity: 25; medical visits: 0; falls: 26; cognitive decline: 18; loneliness: 9; social support: 15; economic constraints: 0). The narrative review allowed us to evaluate assessment tools of frailty domains to be adopted for multidimensional health promotion and prevention interventions in community and primary care.

Effects of multidomain interventions on skeletal muscle architecture and function in pre-frail older women: The WiiProtein study

The aim was to investigate the effects of physical training with exergames and protein supplementation on musculoskeletal function, muscle architecture, and markers of physical frailty in pre-frail older women. Ninety participants were assigned to one of five groups: physical training using exergames (PTG); protein supplementation (PSG); physical training and protein supplementation (PTPSG); physical training and isoenergetic supplementation (PTISG); and control group (CG). We evaluated: strength and power of lower limbs; functional mobility; gait speed; handgrip strength; and muscle architecture. The PTPSG increased knee extensor and flexor strength (8.4% and 10.2% respectively), and knee extensor power (17.1%), reduced exhaustion (100%), and also reversed pre-frailty (43.8%). There were no significant differences among groups in all outcomes analyzed. Physical training using exergames with protein supplementation increased musculoskeletal function, reduced exhaustion, and reversed pre-frailty in older women.

Effect of Whey Protein Supplementation in Postmenopausal Women: A Systematic Review and Meta-Analysis

(1) Background: Whey protein (WP) in combination with resistance training (RT) is beneficial in improving sarcopenic obesity and its damaging effects in older adults, while the difference between men and women should be considered while interpreting results. This review aims to investigate WP's efficacy on postmenopausal women with or without RT; (2) Material and Methods: We searched electronic databases including PubMed, EMBASE, and the Cochrane Library from inception to August 2021 for randomized controlled trials that included comparison groups to evaluate WP's efficacy in women aged 55 years and above. The outcomes included body composition, muscular strength, functional capacity, and dietary intake. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were used to estimate the effect of WP. We also performed subgroup analysis with or without RT; (3) Results: We included 14 studies in the systematic review and 10 studies in the meta-analysis. Subgroup analyses showed RT was a major confounder for muscle strength, lean mass, and dietary protein intake (PI). In the RT subgroup, WP supplementation had a significant positive effect on biceps curl strength (BC) (SMD: 0.6805, 95% CI: 0.176, 1.185, I²: 0%), and lower limb lean-mass (LLLM) (SMD: 1.103, 95% CI: 0.632, 1.574, I²: 14%). In the subgroup without RT, a significant negative effect on PI (SMD: -0.4225, 95% CI: -0.774, -0.071, I²: 47%) was observed, while no significant effect on muscle strength or lean mass was revealed. WP supplementation did not show a significantly different effect on fat mass or body weight loss in both the subgroups; (4) Conclusions: In postmenopausal women, WP supplementation only in combination with RT enhances BC and LLLM compared to placebo controls. Without RT, WP has no significant benefit on muscle strength or lean mass.

Preprocedural muscle strength and physical performance and the association with functional decline or mortality in frail older patients after transcatheter aortic valve implementation: a systematic review and meta-analysis

BACKGROUND

A significant number of older patients planned for transcatheter aortic valve implantation (TAVI) experience a decline in physical functioning and death, despite a successful procedure.

OBJECTIVE

To systematically review the literature on the association of preprocedural muscle strength and physical performance with functional decline or long-term mortality after TAVI.

METHODS

We followed the PRISMA guidelines and pre-registered this review at PROSPERO (CRD42020208032). A systematic search was conducted in MEDLINE and EMBASE from inception to 10 December 2021. Studies reporting on the association of preprocedural muscle strength or physical performance with functional decline or long-term (>6 months) mortality after the TAVI procedure were included. For outcomes reported by three or more studies, a meta-analysis was performed.

RESULTS

In total, two studies reporting on functional decline and 29 studies reporting on mortality were included. The association with functional decline was inconclusive. For mortality, meta-analysis showed that low handgrip strength (hazard ratio (HR) 1.80 [95% confidence interval (CI): 1.22-2.63]), lower distance on the 6-minute walk test (HR 1.15 [95% CI: 1.09-1.21] per 50 m decrease), low performance on the timed up and go test (>20 s) (HR 2.77 [95% CI: 1.79-4.30]) and slow gait speed (<0.83 m/s) (HR 2.24 [95% CI: 1.32-3.81]) were associated with higher long-term mortality.

CONCLUSIONS

Low muscle strength and physical performance are associated with higher mortality after TAVI, while the association with functional decline stays inconclusive. Future research should focus on interventions to increase muscle strength and physical performance in older cardiac patients.

Protein Supplementation for Strength and Functionality in Older Adults: Is There Still Any Doubt? A Brief Update Review

It is widely known that the aging process induces relevant impairments on both muscle morphology and function. In this sense, resistance training alongside proper protein intake are important strategies to mitigate the sarcopenia process in older individuals. However, adding protein supplementation (PS) to resistance training interventions for enhancing muscle strength and functional performance has shown mixed results in this population. Therefore, the present study aimed to review the most recent evidence regarding PS and its effects on muscle strength and functional parameters of older adults. In addition, the effect size of each individual study (post-pre intervention) was also calculated to provide further clinical relevance on the topic. The results of the studies included do not seem to support PS for healthy older adults with proper protein intake. However, further studies with other sample characteristics (very old, frail, obese, and inadequate protein consumption) must be carried out to better understand the effects of PS in an older population.

Interventions for Body Composition and Upper and Lower Extremity Muscle Strength in Older Adults in Rural Taiwan: A Horizontal Case Study

The purpose of this study was to understand the effects of a physical activity program and high-protein supplementation on body composition and upper and lower extremity muscle strength in male older adults in rural areas. In this study, 60 healthy male older adults (mean age 77.5 ± 4.6 years) from rural areas were recruited and randomly assigned to experimental group A (intervention of the physical activity program and high-protein supplementation), experimental group B (daily routine, with only intervention of high-protein supplementation), or control group C (daily routine). Experimental group A (EGa) carried out a physical activity plan three times a week, with an exercise intensity and calorie consumption of 250 kcal (5METs × ⅔hr × 75) for 3 months and drank a high-protein supplement (1.3 g/kg BW/day) after each exercise; experimental group B (EGb) followed only the intervention of high-protein supplementation. All the participants underwent pre- and post-tests for body composition, waist–hip circumference (WC, HC), handgrip strength (HS), 30 s dominant arm curl, 30 s sit to stand, and 2 min step tests. The results of the study showed that EGa significantly decreased body mass index (BMI), body fat mass (BFM), body fat percentage (BFP), WC, HC, and waist-to-hip ratio (WHR) and increased basal metabolic rate and muscle mass. Although both EGa and EGb used high-protein supplementation, EGa’s added three-month intervention of a physical activity program made it easier for that group to increase muscle mass and muscle strength. The WHR decreased from 1.015 to 0.931, representing a decrease of 8.28%, and an obvious weight loss effect was achieved. Thus, we concluded that the best way to maintain muscle strength in older adults is through physical activity with resistance and protein supplementation, which can reduce muscle loss in older adults.

Evaluation of a Fully Automatic Deep Learning-Based Method for the Measurement of Psoas Muscle Area

Background

Manual muscle mass assessment based on Computed Tomography (CT) scans is recognized as a good marker for malnutrition, sarcopenia, and adverse outcomes. However, manual muscle mass analysis is cumbersome and time consuming. An accurate fully automated method is needed. In this study, we evaluate if manual psoas annotation can be substituted by a fully automatic deep learning-based method.

Methods

This study included a cohort of 583 patients with severe aortic valve stenosis planned to undergo Transcatheter Aortic Valve Replacement (TAVR). Psoas muscle area was annotated manually on the CT scan at the height of lumbar vertebra 3 (L3). The deep learning-based method mimics this approach by first determining the L3 level and subsequently segmenting the psoas at that level. The fully automatic approach was evaluated as well as segmentation and slice selection, using average bias 95% limits of agreement, Intraclass Correlation Coefficient (ICC) and within-subject Coefficient of Variation (CV). To evaluate performance of the slice selection visual inspection was performed. To evaluate segmentation Dice index was computed between the manual and automatic segmentations (0 = no overlap, 1 = perfect overlap).

Results

Included patients had a mean age of 81 ± 6 and 45% was female. The fully automatic method showed a bias and limits of agreement of -0.69 [-6.60 to 5.23] cm2, an ICC of 0.78 [95% CI: 0.74-0.82] and a within-subject CV of 11.2% [95% CI: 10.2-12.2]. For slice selection, 84% of the selections were on the same vertebra between methods, bias and limits of agreement was 3.4 [-24.5 to 31.4] mm. The Dice index for segmentation was 0.93 ± 0.04, bias and limits of agreement was -0.55 [1.71-2.80] cm2.

Conclusion

Fully automatic assessment of psoas muscle area demonstrates accurate performance at the L3 level in CT images. It is a reliable tool that offers great opportunities for analysis in large scale studies and in clinical applications.

Differences in preoperative function and outcome of patients with versus without sarcopenia after total hip arthroplasty

[Purpose] Public attention regarding sarcopenia has increased in recent years. Patients with sarcopenia reportedly show worse return home rates and activities of daily living at discharge. However, no reports have described the function and outcomes of hip osteoarthrosis patients with sarcopenia after total hip arthroplasty. This study aimed to clarify differences in preoperative physical function and outcomes of hip osteoarthrosis patients with versus without sarcopenia after total hip arthroplasty. [Participants and Methods] Twenty-five patients with hip osteoarthrosis who underwent total hip arthroplasty were included. Evaluation items were preoperative skeletal muscle mass of the extremities, isometric strength of the lower extremities (hip abduction and knee extension), grip strength, and the 10-m timed gait test results. [Results] The prevalence of sarcopenia was 8% (2/25 patients). The sarcopenic group displayed lower skeletal muscle mass index, grip strength, and 10-m timed gait test values. The sarcopenic group showed lower muscle mass in the upper and lower limbs and trunk and lower hip abductor strength than the non-sarcopenic group. [Conclusion] Eight percent of patients developed sarcopenia after total hip arthroplasty. Due to the low average age (66.0 ± 9.5 years), the prevalence was lower than that of other orthopedic diseases.

Health Effects of Increasing Protein Intake Above the Current Population Reference Intake in Older Adults: A Systematic Review of the Health Council of the Netherlands

Whether older adults need more protein than younger adults is debated. The population reference intake for adults set by the European Food Safety Authority is 0.83 g/kg body weight (BW)/d based primarily on nitrogen balance studies, but the underlying data on health outcomes are outdated. An expert committee of the Health Council of the Netherlands conducted a systematic review (SR) of randomized controlled trials (RCTs) examining the effect of increased protein intake on health outcomes in older adults from the general population with an average habitual protein intake ≥0.8 g/(kg BW · d). Exposures were the following: 1) extra protein compared with no protein and 2) extra protein and physical exercise compared with physical exercise. Outcomes included lean body mass, muscle strength, physical performance, bone health, blood pressure, serum glucose and insulin, serum lipids, kidney function, and cognition. Data of >1300 subjects from 18 RCTs were used. Risk of bias was judged as high (n = 9) or "some concerns" (n = 9). In 7 of 18 RCTs, increased protein intake beneficially affected ≥1 of the tested outcome measures of lean body mass. For muscle strength, this applied to 3 of 8 RCTs in the context of physical exercise and in 1 of 7 RCTs without physical exercise. For the other outcomes, <30% (0-29%) of RCTs showed a statistically significant effect. The committee concluded that increased protein intake has a possible beneficial effect on lean body mass and, when combined with physical exercise, muscle strength; likely no effect on muscle strength when not combined with physical exercise, or on physical performance and bone health; an ambiguous effect on serum lipids; and that too few RCTs were available to allow for conclusions on the other outcomes. This SR provides insufficiently convincing data that increasing protein in older adults with a protein intake ≥0.8 g/(kg BW · d) elicits health benefits.

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 (β = -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 (β = 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.

Oral frailty and neurodegeneration in Alzheimer's disease

Frailty is a critical intermediate status of the aging process with a multidimensional and multisystem nature and at higher risk for adverse health-related outcomes, including falls, disability, hospitalizations, institutionalization, mortality, dementia, and Alzheimer's disease. Among different frailty phenotypes, oral frailty has been recently suggested as a novel construct defined as a decrease in oral function with a coexisting decline in cognitive and physical functions. We briefly reviewed existing evidence on operational definitions of oral frailty, assessment and screening tools, and possible relationships among oral frailty, oral microbiota, and Alzheimer's disease neurodegeneration. Several underlying mechanism may explain the oral health-frailty links including undernutrition, sarcopenia linked to both poor nutrition and frailty, psychosocial factors, and the chronic inflammation typical of oral disease. Oral microbiota may influence Alzheimer's disease risk through circulatory or neural access to the brain and the interplay with periodontal disease, often causing tooth loss also linked to an increased Alzheimer's disease risk. On this bases, COR388, a bacterial protease inhibitor targeting Porphyromonas gingivalis implicated in periodontal disease, is now being tested in a double-blind, placebo-controlled Phase II/III study in mild-to-moderate Alzheimer's disease. Therefore, oral status may be an important contributor to general health, including Alzheimer's disease and late-life cognitive disorders, suggesting the central role of preventive strategies targeting the novel oral frailty phenotype and including maintenance and improvement of oral function and nutritional status to reduce the burden of both oral dysfunction and frailty.

Effects and contents of nutrition education relating to sarcopenia and frailty for Japanese older adults: A systematic review

This systematic review aimed to clarify whether nutrition education relating to sarcopenia and frailty for Japanese older adults has been effective and to identify the content of nutrition education that is provided to participants. We examined relevant studies published before January 2021. The inclusion criteria were as follows: (i) studies on nutrition education provided by experts; (ii) studies on Japanese participants aged 60 years or older; (iii) full papers published in English or Japanese; and (iv) studies with outcomes that include measurement items related to sarcopenia and frailty. A search strategy was designed using keywords such as "Japan" or "Japanese" and "nutrition education." In total, 798 titles and 179 abstracts were examined, and 63 full texts were selected for reading. Ten articles met all the inclusion criteria. Only two studies aimed to determine the effectiveness of nutrition education. We could not clarify whether nutrition education relating to sarcopenia and frailty for Japanese older adults was effective. However, we did identify various nutrition education contents on sarcopenia and frailty for Japanese older adults. Further studies are needed as follows: (i) studies designs that can determine whether nutrition education is effective; (ii) studies in which the content of the cooking training can be reproduced; (iii) studies in which the intervention group and the control group have the same educational content with different duration and frequency; (iv) studies that are written in English; and (v) studies that are conducted on men. Geriatr Gerontol Int 2021; 21: 1084-1092.

Effects of Exergames and Protein Supplementation on Body Composition and Musculoskeletal Function of Prefrail Community-Dwelling Older Women: A Randomized, Controlled Clinical Trial

This study aimed to investigate the effects of exergames and protein supplementation on the body composition and musculoskeletal function of pre-frail older women. Methods: A randomized controlled clinical trial was conducted with 90 pre-frail older women (71.2 ± 4.5 years old) divided into five groups: control (CG); exergames training (ETG); protein supplementation (PSG); exergames combined with protein supplementation (ETPSG); exergames combined with isoenergetic supplementation (ETISG). The primary outcomes were pre-frailty status, body composition (appendicular muscle mass (ASM); appendicular muscle mass index (ASMI)) assessed by dual energy X-ray absorptiometry and gastrocnemius muscle architecture via ultrasound. Secondary outcomes were protein intake, plasma levels of interleukin (IL)-6, plantar and dorsiflexion isokinetic peak torque, and handgrip strength (HS). Data were analyzed using an ANOVA mixed model test and Bonferroni post hoc test (p < 0.05). The ETG showed a reduction of ASM (16.7 ± 3.4 vs. 16.1 ± 3.3 kg; Δ = −0.5; p = 0.02; d = 0.26) and ASMI (6.8 ± 0.9 vs. 6.5 ± 0.9 kg; Δ = −0.2; p = 0.03; d = 0.35), without changing ASM in other groups. The average protein intake in the supplemented groups (PSG and ETPSG) was 1.1 ± 0.2 g/kg/day. The dorsiflexion peak torque increased 11.4% in ETPSG (16.3 ± 2.5 vs. 18.4 ± 4.2 Nm; p = 0.021; d = −0.58). The HS increased by 13.7% in ETG (20.1 ± 7.2 vs. 23.3 ± 6.2 kg, Δ = 3.2 ± 4.9, p = 0.004, d = −0.48). The fatigue/exhaustion reduced by 100% in ETG, 75% in PSG, and 100% in ETPSG. Physical training with exergames associated with protein supplementation reversed pre-frailty status, improved the ankle dorsiflexors torque, and ameliorated fatigue/exhaustion in pre-frail older women.

Effects of Milk Protein in Resistance Training-Induced Lean Mass Gains for Older Adults Aged ≥ 60 y: A Systematic Review and Meta-Analysis

This review evaluated the effects of milk-based protein supplementation on resistance training (RT)-induced gains in lean body mass or fat free mass (LBM/FFM) and muscle strength for older adults. A systematic search of PubMed, Scopus and EBSCOhost/SPORTDiscus was conducted. Eligibility criteria: Randomized controlled trials comparing all types of milk-based protein supplements with control supplements for the training older adults at mean age ≥ 60 y. Twenty studies were included in the qualitative synthesis, whilst seventeen studies were included in the quantitative synthesis. A dose of 10-15 g of milk protein supplementation was sufficient to augment RT-induced LBM/FFM. Intriguingly, four out of five studies show negative effect of whey protein supplementation at the same dose range (or even higher) compared with control supplementation (-0.49 kg, 95% CI: -0.69, -0.29, I² = 14%, Z = 4.82, p < 0.001). For milk-based protein supplementation, RT-induced improvements in muscle strength were observed only when the protein doses ≥22 g (+0.66 kg, 95% CI: 0.07, 1.25, I² = 0%, Z = 2.18, p = 0.03). Conclusion: Milk protein is superior to whey protein in enhancing RT-induced LBM/FFM gains for older adults. Optimal daily protein intake can dilute the protein supplementation effect.

Effects of Protein-Rich Nutritional Composition Supplementation on Sarcopenia Indices and Physical Activity during Resistance Exercise Training in Older Women with Knee Osteoarthritis

Older adults with knee osteoarthritis (KOA) are at high risk of sarcopenia. Protein-rich nutritional composition supplementation (PS) combined with resistance exercise training (RET) improves muscle gains and facilitates physical activity in older adults. However, whether PS augments the effects of RET on muscle mass and PA in patients with KOA remains unclear. Therefore, this study identified the effects of PS on sarcopenic indices and PA in older women with KOA subjected to an RET program. Eligible older women aged 60–85 years and diagnosed as having KOA were randomly assigned to either the experimental group (EG) or the control group (CG). Both groups performed RET twice a week for 12 weeks. The EG received additional PS during this period. Outcome measures included appendicular lean mass index, walking speed, physical activity, and scores on the Western Ontario and McMaster Universities Osteoarthritis Index—WOMAC). All measures were tested at baseline and after intervention. With participant characteristics and baseline scores as covariates, analysis of variance was performed to identify between-group differences in changes in all outcome measures after intervention. Statistical significance was defined as p < 0.05. Compared with the CG, the EG achieved greater changes in appendicular lean mass index (adjusted mean difference (aMD) = 0.19 kg/m², p < 0.01), physical activity (aMD = 30.0 MET-hour/week, p < 0.001), walking speed (aMD = 0.09 m/s, p < 0.05), and WOMAC global function (aMD = −8.21, p < 0.001) after intervention. In conclusion, PS exerted augmentative effects on sarcopenic indices, physical activity, and perceived global WOMAC score in older women with KOA through 12 weeks of RET.

Nutrition and Frailty: Opportunities for Prevention and Treatment

Frailty is a syndrome of growing importance given the global ageing population. While frailty is a multifactorial process, poor nutritional status is considered a key contributor to its pathophysiology. As nutrition is a modifiable risk factor for frailty, strategies to prevent and treat frailty should consider dietary change. Observational evidence linking nutrition with frailty appears most robust for dietary quality: for example, dietary patterns such as the Mediterranean diet appear to be protective. In addition, research on specific foods, such as a higher consumption of fruit and vegetables and lower consumption of ultra-processed foods are consistent, with healthier profiles linked to lower frailty risk. Few dietary intervention studies have been conducted to date, although a growing number of trials that combine supplementation with exercise training suggest a multi-domain approach may be more effective. This review is based on an interdisciplinary workshop, held in November 2020, and synthesises current understanding of dietary influences on frailty, focusing on opportunities for prevention and treatment. Longer term prospective studies and well-designed trials are needed to determine the causal effects of nutrition on frailty risk and progression and how dietary change can be used to prevent and/or treat frailty in the future.

Response and Adherence of Nursing Home Residents to a Nutrition/Exercise Intervention

OBJECTIVES

Interindividual response variability to nutrition and exercise interventions is extensive in older adults. A group of nursing home (NH) residents participated in a combined intervention. The objective of this post-hoc analysis was to identify factors associated with intervention response measured by change in physical function and body composition.

DESIGN

Post-hoc analyses in the Older Person's Exercise and Nutrition study, a 2-arm randomized trial. The primary outcomes were 30-second Chair Stand Test and composite scores combining physical function and fat-free mass. A secondary outcome was intervention adherence. A 12-week intervention of sit-to-stand exercises and protein-rich nutritional supplements did not improve chair-stand capacity vs control on intention-to-treat basis.

SETTING AND PARTICIPANTS

Residents ≥75 years of age from dementia and somatic units in eight NHs in Sweden.

METHODS

Logistic regressions were performed to define factors associated with response (maintenance/improvement) or nonresponse (deterioration) in 30-second Chair Stand Test, and with intervention adherence. Linear regressions were performed to explore factors associated with response in composite scores.

RESULTS

Mean age of participants (n = 52 intervention, n = 49 control) was 85.8 years. Sarcopenia was occurring in 74%. Sarcopenia at baseline (P = .005) and high adherence to nutritional supplements (P = .002) increased the odds of response. Higher independence in daily activities increased the odds of adherence to sit-to-stand exercises (P = .027) and the combined intervention (P = .020). Allocation to the intervention group and higher self-perceived health were associated with higher composite scores.

CONCLUSIONS AND IMPLICATIONS

NH residents with baseline sarcopenia, better self-perceived health, and high adherence to nutritional supplements benefitted most from a combined nutrition and exercise intervention regarding chair-stand capacity and composite scores of function and fat-free mass. Adherence was related to higher grade of independence. Understanding factors associated with response and adherence to an intervention will help target susceptible residents in most need of support and to optimize the outcome.

A higher protein intake at breakfast and lunch is associated with a higher total daily protein intake in older adults: a post-hoc cross-sectional analysis of four randomised controlled trials

BACKGROUND

A protein intake of 30-40 g per meal is suggested to maximally stimulate muscle protein synthesis in older adults and could therefore contribute to the prevention of sarcopenia. Protein intake at breakfast and lunch is often low and offers a great opportunity to improve daily protein intake. Protein, however, is known for its satiating effects. Therefore, we explored the association between the amount of protein intake at breakfast and lunch and total daily protein intake in older adults.

METHODS

Protein intake was assessed by a 3-day food record in 498 community dwelling older adults (≥55 years) participating different lifestyle interventions. Linear mixed model analysis was used to examine the association between protein intake at breakfast or lunch and total daily protein intake, adjusted for sex, age, body mass index, smoking status, study and total energy intake.

RESULTS

After adjustment for potential confounders, a 10 g higher protein intake at breakfast was associated with a 3.2 g higher total daily protein intake (P = 0.008) for males and a 4.9 g (P < 0.001) higher total daily protein intake for females. A 10 g higher protein intake at lunch was associated with a 3.7 g higher total daily protein intake (P < 0.001) for males, and a 5.8 g higher total daily protein intake (P < 0.001) for females.

CONCLUSIONS

A higher protein intake at breakfast and lunch is associated with a higher total daily protein intake in community dwelling older adults. Stimulating a higher protein intake at breakfast and lunch might represent a promising nutritional strategy to optimise the amount of protein per meal without compromising total daily protein intake.

New Therapeutic Approaches and Biomarkers for Increased Healthspan

Healthcare costs have increased in developing countries over the last few decades, mostly due to the escalation in average life expectancy and the concomitant increase in age-related disorders. To address this issue, widespread research is now being undertaken across the globe with the aim of finding a way of increasing healthy aging. A number of potential interventions have already shown promise, including lifestyle changes and the use of natural products or pharmaceuticals that may delay the onset of diseases associated with the aging process. In parallel, a number of potential biomarkers have already been identified that can be used for assessing risk of developing age-associated disorders and for monitoring response to therapeutic interventions. This review describes the most recent advances towards the goal of achieving healthier aging with fewer disabilities that may lead to enhanced quality of life and reduced healthcare costs around the world.

Exercise training in patients after kidney transplantation

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. Next to the risk of allograft failure, major obstacles for disease-free survival after kidney transplantation include a higher incidence of cancer, infection and cardiovascular events. Risk factors for adverse clinical outcomes include pre-existent comorbidities, the introduction of an immunodeficient status and (lack of) lifestyle changes after transplantation. Indeed, physical inactivity and poor physical fitness are important targets to address in order to improve clinical outcomes after kidney transplantation. This review summarizes the current evidence on exercise training after kidney transplantation, derived from randomized controlled trials. As much as possible, results are discussed in the perspective of the Standardized Outcomes in Nephrology-Transplantation core outcomes, which were recently described as critically important outcome domains for trials in kidney transplant recipients.

Effects of In-Hospital Exercise on Frailty in Patients with Hepatocellular Carcinoma

Frailty including physical inactivity is associated with the survival of patients with hepatocellular carcinoma (HCC). We aimed to investigate the effects of in-hospital exercise on frailty in patients with HCC. This was a multi-center observational study. Patients with HCC were classified into exercise (n = 114) and non-exercise (n = 67) groups. The exercise group was treated with a mixture of aerobic and resistance exercises (20-40 min/day, median four days). Frailty was assessed using the liver frailty index (LFI). Factors for changes in LFI were examined by multivariate and decision-tree analyses. The factors were also examined after propensity score matching. During hospitalization, LFI was significantly improved in the exercise group compared to the non-exercise group (ΔLFI -0.17 vs. -0.02, p = 0.0119). In multivariate analysis, exercise (odds ratio (OR) 2.38, 95% confidence interval (CI) 1.240-4.570, p = 0.0091) and females (OR 2.09; 95%CI, 1.062-4.109; p = 0.0328) were identified as independent factors for the improvement of LFI. In the decision-tree analysis, exercise was identified as an initial classifier associated with the improvement of LFI. Similar findings were also seen in the propensity score matching analyses. We demonstrated that in-hospital exercise improved frailty in patients with HCC. Thus, in-hospital exercise may be beneficial for improving physical function in patients with HCC.

Prevalence and Prognostic Significance of Frailty in Gerontal Inpatients With Pre-clinical Heart Failure: A Subgroup Analysis of a Prospective Observational Cohort Study in China

Objective: To evaluate the prognostic value of frailty in gerontal pre-clinical heart failure (stage B heart failure, SBHF) inpatients.

Background: The association between frailty and SBHF remains unknown.

Methods: We conducted a subgroup analysis of a prospective observational cohort study on frailty. The previous study recruited 1,000 elderly inpatients who were consecutively admitted to a tertiary referral hospital in Beijing, China, from September 2018 to February 2019. The outcomes were all-cause death or readmission at 1-year follow-up. SBHF was diagnosed for asymptomatic cardiac structural or functional abnormalities. Frailty was assessed using the Comprehensive Geriatric Assessment-Frailty Index (CGA-FI).

Results: Overall, 531 inpatients aged ≥65 years were deemed to have SBHF and followed up for 1 year. Of them, 34.5% exhibited frailty. During the follow-up period, all-cause death or readmission occurred in 157 (29.5%) participants. Of these participants, 36.6% (67/183) and 25.9% (90/348) belonged to the frail and non-frail groups, respectively (χ² = 6.655, P = 0.010). Frailty, defined by the CGA-FI, rather than Fried frailty phenotype, could independently predict 1-year all-cause death or readmission (hazard ratio, 1.56; 95% confidence interval, 1.03–2.35; P = 0.034) and was more suitable for predicting all-cause death or readmission than N-terminal pro-B-type natriuretic peptide in female SBHF inpatients aged 80 years or over(AUC_CGA−FI vs. AUC_NT−proBNP 0.654 vs. 0.575, P = 0.017).

Conclusions: Frailty is highly prevalent even among SBHF inpatients aged ≥65 years. The CGA-FI can independently predict 1-year all-cause death or readmission, rather than Fried frailty phenotype. Frailty in gerontal SBHF inpatients deserves more attention.

Clinical Trial registration: ChiCTR1800017204; date of registration: 07/18/2018.

Nutritional interventions for the management of frailty in older adults: systematic review and meta-analysis of randomized clinical trials

CONTEXT

Although nutrition is considered an important intervention for the management of frailty, the actual effectiveness of interventions addressing nutrition in frail older people remains unclear.

OBJECTIVE

The aim for this systematic review was to appraise the evidence regarding the effectiveness of nutritional interventions for the management of frailty in older adults.

DATA EXTRACTION

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Sciences Literature databases were searched from January 2001 to November 2019. Two independent reviewers extracted relevant data. From 2370 initial records, 19 publications presenting data from 17 studies (1564 individuals; follow-up: 7-96 weeks) were included.

DATA ANALYSIS

None of the Bayesian random-effects meta-analyses comparing nutritional supplements with placebo regarding mortality, body mass index, weight, frailty status, muscle strength, gait speed, body composition, and cognitive function showed statistically significant differences. The same applies to a single meta-analysis comparing nutritional education with general health advice regarding muscle strength.

CONCLUSION

Our results suggest, mostly with low to very low degrees of certainty, that nutritional supplements or nutritional education delivered in isolation may not be effective for the management of frailty in older people.

REVIEW REGISTRATION NUMBER

CRD42018111510 (PROSPERO).

Effects of Protein Supplementation Combined with Exercise Training on Muscle Mass and Function in Older Adults with Lower-Extremity Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Trials

Aging and osteoarthritis (OA) are associated with a high risk of muscle mass loss, which can lead to physical disability. This study investigated the effectiveness of protein supplementation combined with exercise training (PS + ET) in improving muscle mass and functional outcomes in older adults with lower-limb OA. A comprehensive search of online databases was performed to identify randomized controlled trials (RCTs) on the effectiveness of PS + ET in older adults with hip or knee OA. Meta-analysis and risk of bias assessment of the included RCTs were conducted. Six RCTs were included in this systemic review; they had a median (range/total) Physiotherapy Evidence Database (PEDro) score of 7 (6-9) out of 10, respectively. Five RCTs that enrolled patients who underwent total joint replacement were included in this meta-analysis. The PS + ET group exhibited significant improvements in muscle mass (standard mean difference [SMD] = 1.13, p < 0.00001), pain (SMD = 1.36, p < 0.00001), and muscle strength (SMD = 0.44, p = 0.04). Our findings suggest that PS + ET improves muscle mass, muscle strength, and functional outcomes and reduces pain in older adults with lower-limb OA, particularly in those who have undergone total joint replacement.

Effects of a multinutrient-fortified milk drink combined with exercise on functional performance, muscle strength, body composition, inflammation, and oxidative stress in middle-aged women: a 4-month, double-blind, placebo-controlled, randomized trial

BACKGROUND

Multinutrient protein-enriched supplements are promoted to augment the effects of exercise on muscle mass and strength, but their effectiveness in middle-aged women, or whether there are any additional benefits to physical function, remains uncertain.

OBJECTIVES

We aimed to evaluate whether a multinutrient-fortified milk drink (MFMD) could enhance the effects of exercise on functional muscle power (stair climbing) in middle-aged women. Secondary aims were to evaluate the intervention effects on physical function, muscle strength, lean mass (LM), fat mass (FM), bone mineral content (BMC), muscle cross-sectional area (CSA), muscle density, balance, flexibility, aerobic fitness, inflammation, oxidative stress, bone and cartilage turnover, blood pressure, and blood lipids.

METHODS

In this 4-mo, double-blind, placebo-controlled, randomized trial, 244 women (45-65 y) participated in a multimodal resistance-type exercise program 3 d/wk, with random allocation to a twice-daily MFMD containing added protein, vitamin D, calcium, milk fat globule membrane (phospholipids and other bioactives), and other micronutrients (Ex + MFMD, n = 123) or an energy-matched placebo (Ex + placebo, n = 121).

RESULTS

A total of 216 women (89%) completed the study. After 4 mo, both groups experienced similar 3.6%-4.3% improvements in the primary outcomes of fast-pace 5- and 10-step stair ascent power. In contrast, Ex + MFMD experienced greater improvements in 5-step regular-pace stair descent time [net difference (95% CI): -0.09 s (-0.18, 0.00 s), P = 0.045], countermovement jump height [0.5 cm (0.04, 1.0 cm), P = 0.038], total body LM [0.3 kg (0.04, 0.60 kg), P = 0.020], FM [-0.6 kg (-1.0, -0.2 kg), P = 0.004], BMC [0.4% (0.1%, 0.6%), P = 0.020], muscle CSA [thigh: 1.8% (0.6%, 2.9%), P = 0.003; lower leg: 0.9% (0.3%, 1.6%), P = 0.005], balance eyes closed [3.3 s (1.1, 5.4 s), P = 0.005], 2-min step performance [8 steps (3, 12 steps), P = 0.003], and sit-and-reach flexibility [1.4 cm (0.6, 2.2 cm), P = 0.026]. MFMD did not enhance the effects of exercise on any measures of muscle strength, gait speed, dynamic balance, reaction time, or blood lipids, and there was no effect of either intervention on blood pressure, markers of inflammation, or cartilage turnover. Ex + placebo had a greater improvement in the oxidative stress marker protein carbonyls (P < 0.01).

CONCLUSIONS

In middle-aged women, daily consumption of an MFMD did not enhance the effects of a multimodal exercise program on the primary outcome of stair climbing ascent power, but did elicit greater improvements in multiple secondary outcomes including various other measures of functional performance, LM, muscle size, FM, balance, aerobic capacity, flexibility, and bone metabolism.This trial was registered at www.anzctr.org.au as ACTRN12617000383369.

Effects of Nutritional Interventions on Nutritional and Functional Outcomes in Geriatric Rehabilitation Patients: A Systematic Review and Meta-Analysis

OBJECTIVES

It has been recognized that nutritional interventions play a role in improving the nutritional and functional status of older persons. This systematic review summarizes the evidence on nutritional and functional outcomes of nutritional interventions alone or in combination with physical exercise in geriatric rehabilitation patients.

DESIGN

Eight electronic databases were searched until July 1, 2019 to identify nutritional intervention studies in patients aged ≥60 years who were admitted to geriatric rehabilitation. A meta-analysis was performed to quantify intervention effects on serum albumin, muscle mass, and hand grip strength (HGS).

RESULTS

A total of 1962 studies were screened and 13 included in the systematic review. Studies were heterogeneous in interventions (4 nutritional interventions, 6 physical exercise + nutritional intervention, 1 timing of protein provision, 1 exercise + dietary advice, 1 nutrition-related nursing care) and outcomes. Among the 9 interventions that tested oral nutritional supplements (ONS) with protein, with or without exercise, 7 studies reported protein intake and 6 showed increased protein intakes, 2 of 5 studies showed increased albumin levels, and 5 of 9 reported an improvement in functional outcomes (BI, Functional Independence Measure, mobility). Meta-analyses showed no significant intervention effects on albumin [standardized mean difference (SMD) 0.45, 95% confidence interval (CI) -0.14, 1.04 (4 studies)], muscle mass [mean difference (MD) 2.14 kg, 95% CI -2.17, 6.45 (3 studies)], and HGS [SMD -0.04, 95% CI -0.55, 0.63 (3 studies)], but was based on a very limited number of studies.

CONCLUSIONS AND IMPLICATIONS

Only a limited number of studies with heterogeneous nutritional interventions and outcomes were available in the geriatric rehabilitation population. Studies that included ONS improved nutritional outcomes, especially protein intake and albumin levels. Functional outcomes improved in the majority of reporting studies. This indicates benefits of protein supplementation, with or without exercise, in this population. Future well-designed and well-powered clinical trials are needed to clarify existing controversial aspects.

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.

Changes in Strength, Mobility, and Body Composition Following Self-Selected Exercise in Older Adults

The purpose of this trial was to examine the effects of self-selected exercise intensities plus either whey protein or placebo supplementation on vital signs, body composition, bone mineral density, muscle strength, and mobility in older adults. A total of 101 participants aged 55 years and older (males [n = 34] and females [n = 67]) were evaluated before and after 12 weeks of self-selected, free-weight resistance exercise plus 30 min of self-paced walking three times per week. The participants were randomized into two groups: whey protein (n = 46) or placebo (n = 55). Three-way mixed factorial analyses of variance were used to test for mean differences for each variable. The 12 weeks of self-selected, self-paced exercise intensities improved resting heart rate, fat-free mass, percent body fat, handgrip strength, bench press strength, leg press strength, and all mobility measurements (p < .05) in males and females despite supplementation status. This suggests that additional protein in well-fed healthy older adults does not enhance the benefit of exercise.

The Effects of Timing of a Leucine-Enriched Amino Acid Supplement on Body Composition and Physical Function in Stroke Patients: A Randomized Controlled Trial

The combination of exercise and nutritional intervention is widely used for stroke patients, as well as frail or sarcopenic older persons. As previously shown, supplemental branched chain amino acids (BCAAs) or protein to gain muscle mass has usually been given just after exercise. This study investigated the effect of the timing of supplemental BCAAs with exercise intervention on physical function in stroke patients. The participants were randomly assigned to two groups based on the timing of supplementation: breakfast (n = 23) and post-exercise (n = 23). The supplement in the breakfast group was provided at 08:00 with breakfast, and in the post-exercise group it was provided just after the exercise session in the afternoon at 14:00-18:00. In both groups, the exercise intervention was performed with two sessions a day for two months. The main effects were observed in body fat mass (p = 0.02, confidence interval (CI): 13.2-17.7), leg press strength (p = 0.04, CI: 94.5-124.5), and Berg balance scale (p = 0.03, CI: 41.6-52.6), but no interaction with intake timing was observed. Although the effect of the timing of supplementation on skeletal muscle mass was similar in both groups, BCAA intake with breakfast was effective for improving physical performance and decreasing body fat mass. The results suggest that a combination of BCAA intake with breakfast and an exercise program was effective for promoting rehabilitation of post-stroke patients.

L-Glutamine Supplementation Improves the Benefits of Combined-Exercise Training on Oral Redox Balance and Inflammatory Status in Elderly Individuals

Although regular combined aerobic-resistance exercises can ameliorate the inflammatory status and redox balance in elderly population, it is unclear whether protein or specific amino acid supplementation could improve such benefits. Therefore, we aimed to evaluate the inflammatory status and redox indexes through of the saliva of 34 elderly subject nonpractitioners (NP group, 73.3 ± 6.6 years) and 49 elderly subject practitioners of a combined-exercise training in moderate intensity (CET group, 71.9 ± 5.8 years) before (pre) and after (post) 30 days of supplementation with L-glutamine (Gln) or placebo (PL). Our results showed that, both in pre- and postsupplementation, the salivary levels of nitric oxide (NO^·) and TNF-α were lower, whereas the levels of uric acid and IL-10 (as well as IL-10/TNF-α ratio) were higher in the CET groups than in the NP groups. In postsupplementation, both groups supplemented with Gln (NP-Gln and CET-Gln) showed higher salivary uric acid levels compared to baseline. In addition, lower NO^· levels were found in the CET-Gln group postsupplementation than presupplementation values. Whereas the CET-Gln group showed lower GSH levels postsupplementation, NP-Gln subjects showed lower GSSG levels at the same time point, both compared to baseline. Interestingly, salivary peroxidase activity was lower only in NP groups (NP-PL and NP-Gln) postsupplementation than baseline values. A positive significant correlation between salivary peroxidase activity and GSH levels, and also between salivary peroxidase activity and uric acid levels were observed in the CET-Gln group both pre- and postsupplementation. No differences were found in albumin, total antioxidant activity (TEAC), and reducing power analysis between groups, pre- or postsupplementation. In conclusion, the elderly subjects from the CET group showed a better inflammatory response and redox balance and, for the first time, it was shown that daily supplementation with Gln for 30 days can improve these benefits with putative association with a healthy aging.

Effects of Leucine-Enriched Whey Protein Supplementation on Physical Function in Post-Hospitalized Older Adults Participating in 12-Weeks of Resistance Training Program: A Randomized Controlled Trial

Age-related strength and muscle mass loss is further increased after acute periods of inactivity. To avoid this, resistance training has been proposed as an effective countermeasure, but the additional effect of a protein supplement is not so clear. The aim of this study was to examine the effect of a whey protein supplement enriched with leucine after resistance training on muscle mass and strength gains in a post-hospitalized elderly population. A total of 28 participants were included and allocated to either protein supplementation or placebo supplementation following resistance training for 12 weeks (2 days/week). Physical function (lower and upper body strength, aerobic capacity and the Short Physical Performance Battery (SPPB) test), mini nutritional assessment (MNA) and body composition (Dual X-ray Absorptiometry) were assessed at baseline and after 12 weeks of resistance training. Both groups showed improvements in physical function after the intervention (p < 0.01), but there were no further effects for the protein group (p > 0.05). Muscle mass did not improve after resistance training in either group (p > 0.05). In conclusion, 12 weeks of resistance training are enough to improve physical function in a post-hospitalized elderly population with no further benefits for the protein-supplemented group.