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Objectives: To explore associations among cognition, frailty, and obesity in older adults., Design: Descriptive, secondary analysis of baseline data from two related lifestyle intervention trials., Setting: Clinical study open to civilian population through the Center for Translational Research on Inflammatory Diseases at the Veterans Affairs Medical Center in Houston, TX., Participants: One hundred eight community-dwelling adults with obesity, aged 65 or older, recruited consecutively from two lifestyle intervention trials., Measurements: Cognition was assessed using Composite Age-Adjusted Scale Score from the National Institutes of Health Toolbox Cognition Battery: Obesity was assessed by body mass index (BMI) and also by truncal fat mas via dual energy x-ray absorptiometry. Frailty was assessed using the Physical Performance Test., Results: A significant linear regression model for cognition revealed frailty as the strongest predictor, followed by sex, and then truncal fat (R2=0.340, p<0.001)., Conclusion: Cognition among community-dwelling older adults with obese BMI may worsen with greater truncal fat mass. Frailty appears to be an important predictor of cognitive performance in this population., Competing Interests: Dr. Kunik is an unpaid member of the board of the Houston and Southeast Chapter of the Alzheimer’s Association, and he performs guardianship evaluation for the county probate court. Dr. Villareal is on the Clinical Trials Advisory Panel (CTAP) for the NIH-National Institute on Aging (NIA) and Data and Safety Monitoring Board (DSMB) for several NIH-supported clinical trials. The other authors have nothing to disclose.

Objectives: To determine the effect of diet, exercise, and diet-exercise in combination on measures of biological age., Design: Secondary analysis of a 1-year randomized, controlled trial., Setting: University-based Medical Center., Participants: One-hundred-seven older (age≥65 yrs.) adults with obesity (BMI≥30 kg/m2) were randomized and 93 completed the study. Analyses used intention-to-treat., Interventions: Participants were randomized to a control group, a weight-management (diet) group, an exercise group, or a weight-management-plus-exercise (diet-exercise) group., Main Outcome Measures: We calculated Klemera-Doubal Method (KDM) biological age, Homeostatic Dysregulation (HD) score, and Health Aging Index (HAI) score at baseline, and changes at 6- and 12-months., Results: Diet and diet-exercise decreased KDM biological age more than exercise and control (-2.4±0.4, -2.2±0.3, -0.2±0.4, and 0.2±0.5, respectively, P<0.05 for the between group-differences). Diet and diet-exercise also decreased HD score more than exercise and control (-1.0±0.3, -1.1±0.3, 0.1±0.3, and 0.3±0.3 respectively, P<0.05). Moreover, diet-exercise decreased HAI score more than exercise, diet, or control (-1.1±0.2, -0.5±0.2, -0.5±0.2, and 0.0±0.2, respectively, P<0.05)., Conclusions: These findings suggest that diet and diet-exercise are both effective methods of improving biological age, and that biological age may be a valuable method of assessing geroprotective interventions in older humans., Competing Interests: The authors declare no conflicts of interest relevant to this article.

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent., Competing Interests: Dr. Anker reports grants and personal fees from Vifor Int, personal fees from Bayer, personal fees from Boehringer Ingelheim, personal fees from Servier, grants and personal fees from Abbott Vascular, personal fees from Cardiac Dimensions, personal fees from Actimed, personal fees from Astra Zeneca, personal fees from Amgen, personal fees from Bioventrix, personal fees from Janssen, personal fees from Respicardia, personal fees from V-Wave, personal fees from Brahms, personal fees from Cordio, personal fees from Occlutech, outside the submitted work. Dr. Ruiz reports grants from Longeveron Inc, outside the submitted work. Dr. Marzetti reports personal fees from Abbott, personal fees from Nestlè, personal fees from Nutricia, personal fees from ThermoFisher, outside the submitted work. All the other authors have nothing to disclose.

Objectives: Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR)., Methods: To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process., Recommendations: We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Objective: Obesity-associated hypogonadism is hypothesized to be due to the suppressive effect of high estradiol (from an increase in aromatase activity present in the abundant adipose tissue) on the hypothalamic-pituitary-gonadal unit resulting in low testosterone production. Although weight loss has been found to be effective in reducing estradiol and raising testosterone levels in studies of younger men, its effect in frail, obese older men is understudied. Thus, the objective of this study was to determine the effect of lifestyle intervention on hormone levels in frail, obese older men., Design: Randomized controlled trial of lifestyle intervention in frail, obese older men (≥65 yo) for 1 year., Setting: University hospital., Methods: Forty frail, obese elderly men were randomized, for a 52-week study, to any of the following treatment groups: (1) control group, (2) diet-induced weight loss group (diet group), (3) exercise training group (exercise group), and (4) diet-induced weight loss and exercise training group (diet-exercise group). The objective was to achieve a ~10 % weight loss at 6 months and maintain this weight for an additional 6 months. Physical function was assessed by the modified physical performance testing (modified PPT). Estradiol was measured by radioimmunoassay, testosterone by automated immunoassay, and sex hormone-binding globulin by enzyme-linked immunoassay., Results: After 12 months of intervention, diet alone resulted in a weight loss of -10.1 ± 1.9 kg in the diet group and -9.1 ± 0.9 kg in the diet-exercise group. This resulted in a significant decrease (both p<0.05) in total estradiol compared to baseline among subjects in the diet (-2.5 ± 1.3 pg/ml) and diet-exercise group (-2.2 ± 4.0 pg/ml). Free estradiol index also significantly decreased (both p <0.05) in both the diet (-0.39 ± 0.14 pmol/nmol) and diet-exercise (-0.52 ± 0.12 pmol/nmol) group. Total testosterone significantly increased (p<0.05) in response to diet (71.0 ± 21.0 ng/dl) and diet-exercise (49.9 ± 15.5 pg/ml) resulting in values of 287.0 ± 28.1 ng/dl in the diet and 317.6 ± 33.1 ng/dl in the diet-exercise group. However, because there was a significant increase in sex hormone-binding globulin levels in both the diet and diet-exercise groups, free testosterone index and the changes in free testosterone index were not significant compared to baseline. Regardless of changes in hormonal levels, patients in the diet, exercise, and diet-exercise groups experienced significant improvements in the modified PPT from baseline., Conclusion: Weight loss from lifestyle intervention resulted in significant decreases in total and free estradiol levels in frail, obese older men, but this did not result in a clinically important increase in total testosterone nor a significant increase in free testosterone. Thus, alternative forms of treatment in addition to lifestyle intervention may be necessary to improve the hormonal profile among these patients. Nevertheless, whether further improvement in hormonal profile would result in better physical performance than what can be achieved by lifestyle alone in these subjects remains uncertain.

Objectives: Assess sex-specific nutritional intake and dietary habits of independently living older adults with normal and slow gait speeds., Design: New Mexico Aging Process Study, cross-sectional, secondary data analysis., Setting: Albuquerque, New Mexico USA., Participants: Three-hundred fifteen adults 60 years and older (194 women and 121 men)., Measurements: Gait speed test, 3-day diet records, Mini-Mental State Examination, and body mass index., Results: Slow gait speed was associated with lower total calories (-154 kcal/day) and zinc (1 mg/day) (.05 < p < .1). Slower men consumed less protein (-4.1 g/day), calcium (-140 mg), fiber (-2.8 g/day) and iron (-2.5 mg/day) (p≤.05). Slower women consumed less, protein (-5.5 g/day), carbohydrate (-19.1 g/day), fiber (-2.7 gm/day), vitamin C (-18.4 mg/day) and higher fat intake (p=0.03). Slower women snacked less, had trouble chewing/biting, and lived alone (p= .04). Slower men were less likely to snack., Conclusions: We found sex-specific nutritional differences associated with gait speed. Those presenting with slow gait speed may need encouragement to increase meat and whole grain breads/cereal. Those with trouble eating should be advised on adapting diet to maintain adequate nutrition and encouraged on regular snacking to achieve higher nutrient intake. Prospective and randomized controlled studies are needed to confirm these findings and provide further evidence for putting these suggestions into practice.

Objectives: To determine if long-term weight loss with associated improvement in physical and metabolic health can be maintained after lifestyle intervention in frail, obese older adults., Design: Thirty-month follow-up pilot study of a 1-year lifestyle intervention trial., Setting: Community., Participants: Sixteen frail, obese (body mass index=36±2 kg/m2) older (71±1 yr.) adults., Measurements: Body weight and composition, physical function, markers of the metabolic syndrome, glucose and insulin response to an oral glucose tolerance test, bone mineral density (BMD), liver and renal function tests, and food diaries., Results: At 30-month follow-up, weight (101.5±3.8 vs. 94.5±3.9 kg) and BMI (36.0 ±1.7 vs. 33.5±1.7 kg/m2) remained significantly below baseline (all p<0.05). No significant change in fat-free mass (56.7±2.1 vs. 56.9±2.2 kg) or appendicular lean mass (24.1±1.0 vs. 24.1±1.1kg, all p>0.05) occurred between 12 months (end of trial) and 30 months. Improvements in the physical performance test (PPT 27±0.7 vs. 30.2±0.6), insulin sensitivity (4.1±0.8 vs. 3.0±0.6), and insulin area under the curve (12484±2042 vs. 9270±1139 min.mg/dl) remained at 30 months compared to baseline (all p<0.05). Waist circumference (116±3 vs. 109±3 cm) and systolic blood pressure (134±6 vs. 123±5 mm HG) remained decreased at 30 months compared to baseline (all p<0.05). Whole body and lumbar spine BMD did not change; however, total hip BMD progressively decreased at 30 months compared to baseline (0.985±.026 vs. 0.941±.024 g/cm2; p<0.05). There were no adverse effects on liver or renal function. Food frequency questionnaire data showed lower overall caloric intake (-619±157 kcal/day) at 30 months compared to baseline (p<0.05)., Conclusion: These findings suggest that long-term maintenance of clinically important weight loss is possible in frail, obese older adults. Weight maintenance appears to be achieved through continued caloric restriction. Larger, long-term studies are needed to follow up on these findings and investigate mechanisms and behaviors underlying maintenance of weight loss and physical function.