# Exercise as it relates to Disease/Exercising the frail obese elderly - what is possible

This fact sheet has been created to discuss the relative benefits and considerations involved with exercising the frail obese elderly and is based on a review of Frimel, Sinacore and Villareal's 2008 article entitled: Exercise Attenuates the Weight-Loss-Induced Reduction in Muscle Mass in Frail Obese Older Adults.

## What is the background of this research?

The World Health Organisation defines obesity as "abnormal or excessive fat accumulation that may impair health". Both the number of older adults and prevalence of obesity are growing rapidly, with ABS data in 2007-8 revealing that the age group between 65–74 years old were the most overweight and obese demographic (males = 79%, females = 71%). While the BMI of elderly Australians actually improves past this threshold, Fat Free Mass (FFM) also declines, with the average older person becoming more sarcopenic. This decline in muscle strength decreases functional capacity and increases rates of disability. Resistance training of the frail obese elderly is one avenue which can help to improve the subjects body composition, while still losing weight through aerobic exercise and dietary changes.

## Where is the research from?

The research was conducted by two groups based in Washington University School of Medicine (Geriatrics and Physical Therapy). There is no obvious conflict of interest and funding from the study was wholly sourced from US National Institute of Health grants. Three other studies were identified which were published by one or more of the authors which considered attentuating sarcopenia in the elderly.

## What kind of research was this?

This study was a Randomised Controlled Trial (RCT). An RCT represents the highest level of evidence, with the exception of a systematic review, which collates information from multiple RCTs. Difficulty exists when trying to compare the results of this study with similar studies, as the majority of the literature which considers the effectiveness of weight loss and exercise focuses on subjects who are <65 years old and does not specifically consider a population at risk of sarcopenia.

## What did the research involve?

The study recruited 30 community living adults over the age of 65, who had a BMI < 30 kg.m-2, who were randomly assigned to either a diet + behavioral change group ("Diet", n=15) or a Diet + exercise group (n=15). The recruited individuals had to be sedentary (exercise less than 2 times per week), medically stable and possess at least two of the following three criteria:
* VO2 peak of 10-18 ml.Kg-1.min-1
* Modified Physical Performance Test between 18-32 (Moderately frail = 17-24, Mildly frail = 25-31, Not frail 32-36, 36 is the maximum score)
* Require assistance with at least 2 Activities of Daily Living (ADL)
The study duration was 6 months, with the diet consisting of a 750 kcal.d-1 deficit and the exercise intervention consisting of three 90 minute sessions per week (15 minutes flexibility, 30 minutes low impact aerobic, 30 minutes high intensity Progressive Resistance Training [PRT], and 15 minutes of balance challenges), supervised by a physical therapist. The PRT consisted of 2 x 6-8 reps at 0.65 Repetition Max (RM) for the first four weeks, progressing to 3 x 8-12 reps at 0.85 RM, with 1 RM measured monthly to continue the progression.
FFM was measured using a Dual Energy X-ray Absorptiometry (DEXA or DXA) scan at the beginning and conclusion of the study.
Baseline comparability was very strong in this study for the two measurable inclusion criteria of physical fragility (28.4 vs 29.3) and VO2 peak (17.7 vs 17.1 ml.Kg-1.min-1).
Key limitations of the study include the fact that intention to treat analysis does not appear to have been conducted, and with a relatively small sample size (n=15 in each group) and a relatively high number of participants unable to complete various resistance exercises (eg. 7 could not complete the bench press and seated row respectively) - this would appear to compromise the findings. Three participants also dropped out early due to difficulty complying with the dietary requirements.
Another limitation, which was acknowledged by the authors, was the lack of an exercise only control group (ie. no dietary changes). This would have helped to clarify the impact of exercise alone on FFM changes.
Due to the nature of the study, it was impossible to conceal the allocation, blind the subjects and therapists.

## What were the basic results?

Similar weight loss and fat mass loss occurred across both the Diet and Diet + Exercise groups, however the FFM loss was significantly less for the Diet + Exercise group (refer to the table below).
As could be expected, the Diet group made no significant change in 1 RM, however the Diet + Exercise group recorded a significant improvement to both upper and lower extremity strength, with two key metrics recording: +43 kg +/- 43% for leg press and +17 kg +/- 21% for bench press.

## What conclusions can we take from this research?

An interesting comparison can be made between the FFM / Weight loss of the Diet group (3.5 / 10.7 kg); which is approximately 33%; and a similar study which considered middle aged adults, which recorded a 25% loss of FFM with diet alone. This would indicate that the elderly population is more susceptible to loss of FFM with weight loss achieved through diet alone. In addition to this, the same study revealed that exercise + diet produced a comparable FFM loss (1.7 kg c.f. 1.8 kg) in the middle aged group, indicating that FFM loss control is independent of age or sarcopenic state.
When compared with more recent literature, the finding of coupling exercise with dietary changes to help promote a better body composition holds up well. The two key metrics the authors examined were LBM and strength, and there is no contention in the literature that weight loss through dietary changes alone is superior to diet and exercise regimes in improving these two outcome measures.

## Practical advice

A key consideration when exercising frail and elderly patients is the risk of falls, potentially complicated by their medication regime, vision impairment or past orthopaedic problems (hips, knees). A falls risk assessment should be undertaken by appropriately trained staff prior to engaging in a new exercise program. An additional complication in this context is that the participants are obese, increasing the likelihood of comorbidities such as diabetes, cardiovascular disease, hypertension, hyperlidpidemia, arthritis and lower back pain. A medical review by a GP should be conducted prior to beginning any new exercising program, encompassing consideration of their medications.
Once the appropriate clearance is gained, the exercise itself should be supervised (at least initially) and care should be taken to setup the exercise stations to eliminate trip hazards, provide chairs and suitable upper limb support for balance challenges. If comorbidities exist, ensure emergency medical equipment is on hand (eg. insulin, AED), key metrics are monitored (eg. heart rate, exertion) and supervising staff are appropriately trained.

## Further information/resources

If you, a friend or a family member are concerned about your/their declining ability to perform activities of daily living and are concerned about the prospect of entering a nursing home due to deconditioning or fatigue and want to do something about it, a good first port of call is your GP to discuss community based lifestyle programs. In a local context (ACT, Australia), community organisations such as the YMCA ("Ever Active 50+" and "Y's Weights 50+") and government programs such as the Falls and Falls Injury Prevention Program provide opportunities to improve your functional strength in a safe way, training with people in a similar position.

## References

* 1 2 Frimel, T. N., Sinacore, D. R., & Villareal, D. T. (2008). Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults. Medicine and science in sports and exercise, 40(7), 1213.
* ↑ Obesity and overweight, Fact sheet N°311. world health organisation; 2015 Jan
* ↑ Australian Bureau of Statistics (a). Overweight and obesity in adults in Australia: A snapshot, 2007-08. Canberra: ABS, 2011. (ABS Cat. No4842.0.55.001) http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup /4842.0.55.001Main+Features12007–08?OpenDocument (Accessed September 2016)
* ↑ Frimel, T. N., Sinacore, D., Wright, N. R., Villareal, D. T., & Klein, S. (2007). Sarcopenia in Frail ElderlY Obese Participants: Role of Excess Skeletal Muscle lipid Accumulation. Journal of Geriatric Physical Therapy, 30(3), 138.
* ↑ Frimel, T., Frye, E., Sinacore, D., & Villareal, D. (2005). ATTENUATION OF SARCOPENIA IN FRAIL ELDERLY OBESE SUBJECTS UNDERGOING WEIGHT LOSS. Journal of Geriatric Physical Therapy, 28(3), 111-112.
* ↑ Frimel, T. N., Host, H. H., Sinacore, D. R., Villareal, D. T., & Binder, E. F. (2006). SARCOPENIA: A COMMON PATHOGEN LEADING TO PHYSICAL FRAILTY IN AGING AND CHRONIC DISEASE. Journal of Geriatric Physical Therapy, 29(3), 116-117.
* ↑ Rehab Measures - Modified Physical Performance Test [Internet]. The Rehabilitation Measures Database. 2016 [cited 26 September 2016]. Available from: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1137
* 1 2 Garrow, J. S., & Summerbell, C. D. (1995). Meta-analysis: effect of exercise, with or without dieting, on the body composition of overweight subjects. European journal of clinical nutrition, 49(1), 1-10.
* ↑ Starr, K. N. P., McDonald, S. R., & Bales, C. W. (2014). Obesity and physical frailty in older adults: a scoping review of lifestyle intervention trials. Journal of the American Medical Directors Association, 15(4), 240-250.
* ↑ Kohara, K. (2014). Sarcopenic obesity in aging population: current status and future directions for research. Endocrine, 45(1), 15-25.
* ↑ Goisser, S., Kemmler, W., Porzel, S., Volkert, D., Sieber, C. C., Bollheimer, L. C., & Freiberger, E. (2015). Sarcopenic obesity and complex interventions with nutrition and exercise in community-dwelling older persons–a narrative review. Clinical interventions in aging, 10, 1267.
* ↑ Programs | Canberra YMCA [Internet]. Canberra.ymca.org.au. 2016 [cited 27 September 2016]. Available from: http://www.canberra.ymca.org.au/healthfitness/programs/Pages/default.aspx
* ↑ Falls and Falls Injury Prevention Program | ACT Health [Internet]. Health.act.gov.au. 2016 [cited 27 September 2016]. Available from: http://www.health.act.gov.au/our-services/rehabilitation-aged-and-community-care/falls-and-falls-injury-prevention-program