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The retirement phase is an opportunity to integrate healthy (nutrition/exercise) habits into daily life. We conducted this systematic review to assess which nutrition and exercise interventions most effectively improve body composition (fat/muscle mass), body mass index (BMI), and waist circumference (WC) in persons with obesity/overweight near retirement age (ages 55–70 y). We conducted a systematic review and network meta-analysis (NMA) of randomized controlled trials, searching 4 databases from their inception up to July 12, 2022. The NMA was based on a random effects model, pooled mean differences, standardized mean differences, their 95% confidence intervals, and correlations with multi-arm studies. Subgroup and sensitivity analyses were also conducted. Ninety-two studies were included, 66 of which with 4957 participants could be used for the NMA. Identified interventions were clustered into 12 groups: no intervention, energy restriction (i.e., 500–1000 kcal), energy restriction plus high-protein intake (1.1–1.7 g/kg/body weight), intermittent fasting, mixed exercise (aerobic and resistance), resistance training, aerobic training, high protein plus resistance training, energy restriction plus high protein plus exercise, energy restriction plus resistance training, energy restriction plus aerobic training, and energy restriction plus mixed exercise. Intervention durations ranged from 8 wk to 6 mo. Body fat was reduced with energy restriction plus any exercise or plus high-protein intake. Energy restriction alone was less effective and tended to decrease muscle mass. Muscle mass was only significantly increased with mixed exercise. All other interventions including exercise effectively preserved muscle mass. A BMI and/or WC decrease was achieved with all interventions except aerobic training/resistance training alone or resistance training plus high protein. Overall, the most effective strategy for nearly all outcomes was combining energy restriction with resistance training or mixed exercise and high protein. Health care professionals involved in the management of persons with obesity need to be aware that an energy-restricted diet alone may contribute to sarcopenic obesity in persons near retirement age. This network meta-analysis is registered at https://www.crd.york.ac.uk/prospero/ as CRD42021276465.

Introduction: The association between obesity and outcome in critical illness is unclear. Since the amount of visceral adipose tissue(VAT) rather than BMI mediates the health effects of obesity we aimed to investigate the association between visceral obesity, BMI and 90-day mortality in critically ill patients. Method: In 555 critically ill patients (68% male), the VAT Index(VATI) was measured using Computed Tomography scans on the level of vertebra L3. The association between visceral obesity, BMI and 90-day mortality was investigated using univariable and multivariable analyses, correcting for age, sex, APACHE II score, sarcopenia and muscle quality. Results: Visceral obesity was present in 48.1% of the patients and its prevalence was similar in males and females. Mortality was similar amongst patients with and without visceral obesity (27.7% vs 24.0%, p = 0.31). The corrected odds ratio of 90-day mortality for visceral obesity was 0.667 (95%CI 0.424–1.049, p = 0.080). Using normal BMI as reference, the corrected odds ratio for overweight was 0.721 (95%CI 0.447–1.164 p = 0.181) and for obesity 0.462 (95%CI 0.208–1.027, p = 0.058). Conclusion: No significant association of visceral obesity and BMI with 90-day mortality was observed in critically ill patients, although obesity and visceral obesity tended to be associated with improved 90-day mortality.

Objective The aim of this study was to evaluate whether using surface neuromuscular electrical stimulation (NMES) for paralyzed lower-limb muscles results in an increase in energy expenditure and whether the number of activated muscles and duty cycle affect the potential increase. Design This was a cross-sectional study. Results Energy expenditure during all NMES protocols was significantly higher than the condition without NMES (1.2 ± 0.2 kcal/min), with the highest increase (+51%; +0.7 kcal/min, 95% confidence interval, 0.3-1.2) for the protocol with more muscles activated and the duty cycle with a shorter rest period. A significant decrease in muscle contraction size during NMES was found with a longer stimulation time, more muscles activated, or the duty cycle with a shorter rest period. Conclusion Using NMES for paralyzed lower-limb muscles can significantly increase energy expenditure compared with sitting without NMES, with the highest increase for the protocol with more muscles activated and the duty cycle with a shorter rest period. Muscle fatigue occurred significantly with the more intense NMES protocols, which might cause a lower energy expenditure in a longer protocol. Future studies should further optimize the NMES parameters and investigate the long-term effects of NMES on weight management in people with SCI.

Background The COVID-19 pandemic has led to a national lockdown in the Netherlands, which also affected transcatheter aortic valve implantation (TAVI) patients. The objective of the study was to describe physical activity, dietary intake and quality of life (QoL) in patients on the waiting list for TAVI pre-lockdown and during lockdown. Methods Consecutive patients awaiting TAVI at the Amsterdam University Medical Centers, the Netherlands were included. Measurements were self-reported effect of lockdown, physical activity, dietary intake and QoL. Results In total, 58 patients (median age 80, interquartile range (IQR) 76–84, 45% female) were observed pre-lockdown and 16 patients (median age 78, IQR 76–82, 25% female) during lockdown. Ten of the 16 patients during lockdown reported a decline in physical activity. However, we observed a median number of 5861 steps a day (IQR 4579–7074) pre-lockdown and 8404 steps a day (IQR 7653–10,829) during lockdown. Median daily protein intake was 69 g (IQR 59–82) pre-lockdown and 90 g (IQR 68–107) during lockdown. Self-rated health on a visual analogue scale was 63 points (IQR 51–74) pre-lockdown and 73 points (IQR 65–86) during lockdown. Conclusions More than half of the patients during lockdown reported less physical activity, while we observed a higher number of steps a day, a similar dietary intake and a higher QoL. Therefore, patients on the TAVI waiting list appeared to be able to cope with the lockdown measures.

PURPOSE OF REVIEW: The loss of muscle mass in critically ill patients contributes to morbidity and mortality, and results in impaired recovery of physical functioning. The number of publications on the topic is increasing. However, there is a lack of consistent methodology and the most optimal methodology remains unclear, hampering its broad use in clinical practice.RECENT FINDINGS: There is a large variety of studies recently published on the use of ultrasound for assessment of muscle mass. A selection of studies has been made, focusing on monitoring of muscle mass (repeated measurements), practical aspects, feasibility and possible nutrition and physical therapy interventions. In this review, 14 new small (n = 19-121) studies are categorized and reviewed as individual studies.SUMMARY: The use of ultrasound in clinical practice is feasible for monitoring muscle mass in critically ill patients. Assessment of muscle mass by ultrasound is clinically relevant and adds value for guiding therapeutic interventions, such as nutritional and physical therapy interventions to maintain muscle mass and promote recovery in critically ill patients.

BACKGROUND AND AIMS: Patients with COVID-19 infection presents with a broad clinical spectrum of symptoms and complications. As a consequence nutritional requirements are not met, resulting in weight- and muscle loss, and malnutrition. The aim of the present study is to delineate nutritional complaints, the (course of the) nutritional status and risk of sarcopenia of COVID-19 patients, during hospitalisation and after discharge.METHODS: In this prospective observational study in 407 hospital admitted COVID-19 patients in four university and peripheral hospitals, data were collected during dietetic consultations. Presence of nutrition related complaints (decreased appetite, loss of smell, changed taste, loss of taste, chewing and swallowing problems, nausea, vomiting, feeling of being full, stool frequency and consistency, gastric retention, need for help with food intake due to weakness and shortness of breath and nutritional status (weight loss, BMI, risk of sarcopenia with SARC-F ≥4 points) before, during hospital stay and after discharge were, where possible, collected.RESULTS: Included patients were most men (69%), median age of 64.8 ± 12.4 years, 60% were admitted to ICU at any time point during hospitalisation with a median LOS of 15 days and an in-hospital mortality rate of 21%. The most commonly reported complaints were: decreased appetite (58%), feeling of being full (49%) and shortness of breath (43%). One in three patients experienced changed taste, loss of taste and/or loss of smell. Prior to hospital admission, 67% of the patients was overweight (BMI >25 kg/m2), 35% of the patients was characterised as malnourished, mainly caused by considerable weight loss. Serious acute weight loss (>5 kg) was showed in 22% of the patents during the hospital stay; most of these patients (85%) were admitted to the ICU at any point in time. A high risk of sarcopenia (SARC-F ≥ 4 points) was scored in 73% of the patients during hospital admission.CONCLUSION: In conclusion, one in five hospital admitted COVID-19 patients suffered from serious acute weight loss and 73% had a high risk of sarcopenia. Moreover, almost all patients had one or more nutritional complaints. Of these complaints, decreased appetite, feeling of being full, shortness of breath and changed taste and loss of taste were the most predominant nutrition related complaints. These symptoms have serious repercussions on nutritional status. Although nutritional complaints persisted a long time after discharge, only a small group of patients received dietetic treatment after hospital discharge in recovery phase. Clinicians should consider the risks of acute malnutrition and sarcopenia in COVID-19 patients and investigate multidisciplinary treatment including dietetics during hospital stay and after discharge.

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, A higher protein intake at breakfast and lunch is associated with a higher total daily protein intake in community dwelling older adults. This association holds true for animal protein, although not for plant protein for which no association was observed. In all, stimulating a higher protein intake at breakfast and lunch might represent a promising nutritional strategy for optimising the amount of protein per meal without compromising total daily protein intake.

Background: Visceral obesity is associated with the metabolic syndrome. The metabolic risk differs per ethnicity, but reference values for visceral obesity for body composition analyses using Computed Tomography (CT) scans in the Caucasian population are lacking. Therefore, the aim of this study was to define gender specific reference values for visceral obesity in a Caucasian cohort based upon the association between the amount of visceral adipose tissue (VAT) and markers of increased metabolic risk.Methods: Visceral Adipose Tissue Area Index (VATI cm(2)/m(2)) at the level of vertebra L3 was analyzed using CT scans of 416 healthy living kidney donor candidates. The use of antihypertensive drugs and/or statins was used as an indicator for increased metabolic risk. Gender specific cut-off values for VATI with a sensitivity >= 80% were calculated using receiver operating characteristic (ROC) curves.Results: In both men and women who used antihypertensive drugs, statins or both, VATI was higher than in those who did not use these drugs (p = 38.7 cm(2)/m(2) and >= 24.9 cm(2)/m(2) was associated with increased metabolic risk with a sensitivity of 80%. ROC analysis showed that VATI was a better predictor of increased metabolic risk than BMI (area under ROC curve (AUC) = 0.702 vs AUC = 0.556 in males and AUC = 0.757 vs AUC = 0.630 in females).Conclusion: Gender and ethnicity specific cut-off values for visceral obesity are important in body composition research, although further validation is needed. This study also showed that quantification of VATI is a better predictor for metabolic risk than BMI. (C) 2022 The Author(s). Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism.

Summary Background & aims Optimal nutritional support during the acute phase of critical illness remains controversial. We hypothesized that patients with low skeletal muscle area and -density may specifically benefit from early high protein intake. Aim of the present study was to determine the association between early protein intake (day 2–4) and mortality in critically ill intensive care unit (ICU) patients with normal skeletal muscle area, low skeletal muscle area, or combined low skeletal muscle area and -density. Methods Retrospective database study in mechanically ventilated, adult critically ill patients with an abdominal CT-scan suitable for skeletal muscle assessment around ICU admission, admitted from January 2004 to January 2016 (n = 739). Patients received protocolized nutrition with protein target 1.2–1.5 g/kg/day. Skeletal muscle area and -density were assessed on abdominal CT-scans at the 3rd lumbar vertebra level using previously defined cut-offs. Results Of 739 included patients (mean age 58 years, 483 male (65%), APACHE II score 23), 294 (40%) were admitted with normal skeletal muscle area and 445 (60%) with low skeletal muscle area. Two hundred (45% of the low skeletal muscle area group) had combined low skeletal muscle area and -density. In the normal skeletal muscle area group, no significant associations were found. In the low skeletal muscle area group, higher early protein intake was associated with lower 60-day mortality (adjusted hazard ratio (HR) per 0.1 g/kg/day 0.82, 95%CI 0.73–0.94) and lower 6-month mortality (HR 0.88, 95%CI 0.79–0.98). Similar associations were found in the combined low skeletal muscle area and -density subgroup (HR 0.76, 95%CI 0.64–0.90 for 60-day mortality and HR 0.80, 95%CI 0.68–0.93 for 6-month mortality). Conclusions Early high protein intake is associated with lower mortality in critically ill patients with low skeletal muscle area and -density, but not in patients with normal skeletal muscle area on admission. These findings may be a further step to personalized nutrition, although randomized studies are needed to assess causality.

Study designCross-sectional study.ObjectivesThis study: (1) investigated the accuracy of bioelectrical impedance analysis (BIA) and skinfold thickness relative to dual-energy X-ray absorptiometry (DXA) in the assessment of body composition in people with spinal cord injury (SCI), and whether sex and lesion characteristics affect the accuracy, (2) developed new prediction equations to estimate fat free mass (FFM) and percentage fat mass (FM%) in a general SCI population using BIA and skinfolds outcomes.SettingUniversity, the Netherlands.MethodsFifty participants with SCI (19 females; median time since injury: 15 years) were tested by DXA, single-frequency BIA (SF-BIA), segmental multi-frequency BIA (segmental MF-BIA), and anthropometry (height, body mass, calf circumference, and skinfold thickness) during a visit. Personal and lesion characteristics were registered.ResultsCompared to DXA, SF-BIA showed the smallest mean difference in estimating FM%, but with large limits of agreement (mean difference = −2.2%; limits of agreement: −12.8 to 8.3%). BIA and skinfold thickness tended to show a better estimation of FM% in females, participants with tetraplegia, or with motor incomplete injury. New equations for predicting FFM and FM% were developed with good explained variances (FFM: R2 = 0.94; FM%: R2 = 0.66).ConclusionsNone of the measurement techniques accurately estimated FM% because of the wide individual variation and, therefore, should be used with caution. The accuracy of the techniques differed in different subgroups. The newly developed equations for predicting FFM and FM% should be cross-validated in future studies.

Objective: To examine the prevalence of sarcopenia and its association with protein intake in men and women in a multi-ethnic population. Design: We used cross-sectional data from the HELIUS (Healthy Life in an Urban Setting) study, which includes nearly 25,000 participants (aged 18–70 years) of Dutch, South-Asian Surinamese, African Surinamese, Turkish, Moroccan, and Ghanaian ethnic origin. For the current study, we included 5161 individuals aged 55 years and older. Sarcopenia was defined according to the EWGSOP2. In a subsample (N = 1371), protein intake was measured using ethnic-specific Food Frequency Questionnaires. Descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analyses were used to study associations between protein intake and sarcopenia. Results: Sarcopenia prevalence was found to be sex- and ethnic-specific, varying from 29.8% in Turkish to 61.3% in South-Asian Surinamese men and ranging from 2.4% in Turkish up to 30.5% in South-Asian Surinamese women. Higher protein intake was associated with a 4% lower odds of sarcopenia in the subsample (OR = 0.96, 95%-CI: 0.92–0.99) and across ethnic groups, being only significant in the South-Asian Surinamese group. Conclusion: Ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia.

Low-grade inflammation and metabolic syndrome are seen in many chronic diseases, including rheumatoid arthritis (RA) and osteoarthritis (OA). Lifestyle interventions which combine different non-pharmacological therapies have shown synergizing effects in improving outcomes in patients with other chronic diseases or increased risk thereof, especially cardiovascular disease. For RA and metabolic syndrome-associated OA (MSOA), whole food plant-based diets (WFPDs) have shown promising results. A WFPD, however, had not yet been combined with other lifestyle interventions for RA and OA patients. In this protocol paper, we therefore present Plants for Joints, a multidisciplinary lifestyle program, based on a WFPD, exercise, and stress management. The objective is to study the effect of this program on disease activity in patients with RA (randomized controlled trial [RCT] 1), on a risk score for developing RA in patients with anti-citrullinated protein antibody (ACPA) positive arthralgia (RCT 2) and on pain, stiffness, and function in patients with MSOA (RCT 3), all in comparison with usual care.We designed three 16-week observer-blind RCTs with a waiting-list control group for patients with RA with low to moderate disease activity (2.6 ≤ Disease Activity Score [DAS28] ≤ 5.1, RCT 1, n = 80), for patients at risk for RA, defined by ACPA-positive arthralgia (RCT 2, n = 16) and for patients with metabolic syndrome and OA in the knee and/or hip (RCT 3, n = 80). After personal counseling on diet and exercise, participants join 10 group meetings with 6–12 other patients to receive theoretical and practical training on a WFPD, exercise, and stress management, while medication remains unchanged. The waiting-list control group receives usual care, while entering the program after the RCT. Primary outcomes are: difference in mean change between intervention and control groups within 16 weeks for the DAS28 in RA patients (RCT 1), the RA-risk score for ACPA positive arthralgia patients (RCT 2), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score for MSOA patients (RCT 3). Continued adherence to the lifestyle program is measured in a two-year observational extension study.

BACKGROUND & AIMS: Sufficient protein intake is of great importance in hemodialysis (HD) patients, especially for maintaining muscle mass. Daily protein needs are generally estimated using bodyweight (BW), in which individual differences in body composition are not accounted for. As body protein mass is best represented by fat free mass (FFM), there is a rationale to apply FFM instead of BW. The agreement between both estimations is unclear. Therefore, the aim of this study is to compare protein needs based on either FFM or BW in HD patients.METHODS: Protein needs were estimated in 115 HD patients by three different equations; FFM, BW and BW adjusted for low or high BMI. FFM was measured by multi-frequency bioelectrical impedance spectroscopy and considered the reference method. Estimations of FFM x 1.5 g/kg and FFM x 1.9 g/kg were compared with (adjusted)BW x 1.2 and x 1.5, respectively. Differences were assessed with repeated measures ANOVA and Bland-Altman plots.RESULTS: Mean protein needs estimated by (adjusted)BW were higher compared to those based on FFM, across all BMI categories (P < 0.01) and most explicitly in obese patients. In females with BMI >30, protein needs were 69 ± 17.4 g/day higher based on BW and 45 ± 9.3 g/day higher based on BMI adjusted BW, compared to FFM. In males with BMI >30, protein needs were 51 ± 20.4 g/day and 23 ± 20.9 g/day higher compared to FFM, respectively.CONCLUSIONS: Our data show large differences and possible overestimations of protein needs when comparing BW to FFM. We emphasize the importance of more research and discussion on this topic.

The need for excess weight gain prevention in disadvantaged young children is widely recognised. Early Childhood Education and Care teachers are potential key actors in early interventions to prevent overweight and obesity. This study examines the effects of a preschool-based intervention for teachers in promoting healthy eating and physical activity in young children. A cluster randomised controlled trial was conducted at 41 preschools in a deprived area of Amsterdam, The Netherlands. The intervention consisted of 2 programmes that were applied in succession: A Healthy Start and PLAYgrounds for TODdlers. The study period was 9 months. Primary outcomes were assessed via questionnaires and included teachers’ knowledge, attitude, food/activity-related practices, and level of confidence in promoting healthy behaviours. Secondary outcomes in this study were teachers’ and children’s BMI (z-score), body composition, dietary intake and physical activity level. Intention-to-treat analyses were performed using linear mixed models. In total, 115 teachers and 249 children (mean age 3.0 (0.2) years) were included. A positive effect on teachers’ knowledge about the Dutch dietary guidelines was found after the programme A Healthy Start (difference = 1.38; 1-sided 95% CL = 0.29; p = 0.02). This effect was not sustained at 9 months (difference = 0.34; 1-sided 95% CL = -0.76; p = 0.31). The overall intervention had a positive effect on 3 of the 5 attitude statements regarding a healthy lifestyle (difference ranged from 0.34 to 0.55) and on the practice scale Activity-related-Modelling (difference = 0.16; 1-sided 95% CL = 0.06; p = 0.01). No intervention effects were observed on food-related practice scales and the level of confidence in promoting healthy behaviours. At this stage, no effects were seen on teachers’ and children’s BMI (z-score). This study contributes to the professional development of Early Childhood Education and Care teachers and addresses the call for interventions to prevent overweight/obesity and to minimise health inequalities in young children.

Background & aims: High protein delivery during early critical illness is associated with lower mortality, while energy overfeeding is associated with higher mortality. Protein-to-energy ratios of traditional enteral formulae are sometimes too low to reach protein targets without energy overfeeding. This prospective feasibility study aimed to evaluate the ability of a new enteral formula with a high protein-to-energy ratio to achieve the desired protein target while avoiding energy overfeeding. Methods: Mechanically ventilated non-septic patients received the high protein-to-energy ratio nutrition during the first 4 days of ICU stay (n = 20). Nutritional prescription was 90% of measured energy expenditure. Primary endpoint was the percentage of patients reaching a protein target of ≥1.2 g/kg ideal body weight on day 4. Other endpoints included a comparison of nutritional intake to matched historic controls and the response of plasma amino acid concentrations. Safety endpoints were gastro-intestinal tolerance and plasma urea concentrations. Results: Nineteen (95%) patients reached the protein intake target of ≥1.2 g/kg ideal body weight on day 4, compared to 65% in historic controls (p = 0.024). Mean plasma concentrations of all essential amino acids increased significantly from baseline to day 4. Predefined gastro-intestinal tolerance was good, but unexplained foul smelling diarrhoea occurred in two patients. In one patient plasma urea increased unrelated to acute kidney injury. Conclusions: In selected non-septic patients tolerating enteral nutrition, recommended protein targets can be achieved without energy overfeeding using a new high protein-to-energy ratio enteral nutrition. Keywords: Amino acids; Caloric overfeeding; Critical illness; Gastro-intestinal tolerance; High protein; Intensive care unit.

Background & aims: Indirect calorimetry is recommended to measure energy expenditure (EE) in critically ill, mechanically ventilated patients. The most validated system, the Deltatrac® (Datex-Ohmeda, Helsinki, Finland) is no longer in production. We tested the agreement of a new breath-by-breath metabolic monitor E-sCOVX® (GE healthcare, Helsinki, Finland), with the Deltatrac. We also compared the performance of the E-sCOVX to commonly used predictive equations. Methods: We included mechanically ventilated patients eligible to undergo indirect calorimetry. After a stabilization period, EE was measured simultaneously with the Deltatrac and the E-sCOVX for 2 h. Agreement and precision of the E-sCOVX was tested by determining bias, limits of agreement and agreement rates compared to the Deltatrac. Performance of the E-sCOVX was also compared to four predictive equations: the 25 kcal/kg, Penn State University 2003b, Faisy, and Harris–Benedict equation. Results: We performed 29 measurements in 16 patients. Mean EE-Deltatrac was 1942 ± 274 kcal/day, and mean EE-E-sCOVX was 2177 ± 319 kcal/day (p < 0.001). E-sCOVX overestimated EE with a bias of 235 ± 149 kcal/day, being 12.1% of EE-Deltatrac. Limits of agreement were −63 to +532 kcal/day. The 10% and 15% agreement rates of EE-E-sCOVX compared to the Deltatrac were 34% and 72% respectively. The bias of E-sCOVX was lower than the bias of the 25 kcal/kg-equation, but higher than bias of the other equations. Agreement rates for E-sCOVX were similar to the equations. The Faisy-equation had the highest 15% agreement rate. Conclusion: The E-sCOVX metabolic monitor is not accurate in estimating EE in critically ill mechanically ventilated patients when compared to the Deltatrac, the present reference method. The E-sCOVX overestimates EE with a bias and precision that are clinically unacceptable.

Background: A higher protein intake is suggested to preserve muscle mass during aging and may therefore reduce the risk of sarcopenia.Objectives: We explored whether the amount and type (animal or vegetable) of protein intake were associated with 5-y change in mid-thigh muscle cross-sectional area (CSA) in older adults (n = 1561).Methods: Protein intake was assessed at year 2 by a Block foodfrequency questionnaire in participants (aged 70–79 y) of the Health, Aging, and Body Composition (Health ABC) Study, a prospective cohort study. At year 1 and year 6 mid-thigh muscle CSA in square centimeters was measured by computed tomography. Multiple linearregression analysis was used to examine the association between energy-adjusted protein residuals in grams per day (total, animal, and vegetable protein) and muscle CSA at year 6, adjusted for muscle CSA at year 1 and potential confounders including prevalent health conditions, physical activity, and 5-y change in fat mass.Results: Mean (95% CI) protein intake was 0.90 (0.88, 0.92) g ·kg–1 · d–1 and mean (95% CI) 5-y change in muscle CSA was −9.8 (−10.6, −8.9) cm2. No association was observed between energyadjusted total (β = −0.00; 95% CI: −0.06, 0.06 cm2; P = 0.982), animal (β = −0.00; 95% CI: −0.06, 0.05 cm2; P = 0.923), or plant(β = +0.07; 95% CI: −0.06, 0.21 cm2; P = 0.276) protein intake and muscle CSA at year 6, adjusted for baseline mid-thigh muscle CSA and potential confounders.Conclusions: This study suggests that a higher total, animal, or vegetable protein intake is not associated with 5-y change in midthigh muscle CSA in older adults. This conclusion contradicts some, but not all, previous research. This trial was registered at www.trialregister.nl as NTR6930.

Digitally supported dietary counselling may be helpful in increasing the protein intake in combined exercise and nutritional interventions in community-dwelling older adults. To study the effect of this approach, 212 older adults (72.2 ± 6.3 years) were randomised in three groups: control, exercise, or exercise plus dietary counselling. The dietary counselling during the 6-month intervention was a blended approach of face-to-face contacts and videoconferencing, and it was discontinued for a 6-month follow-up. Dietary protein intake, sources, product groups, resulting amino acid intake, and intake per eating occasion were assessed by a 3-day dietary record. The dietary counselling group was able to increase the protein intake by 32% at 6 months, and the intake remained 16% increased at 12 months. Protein intake mainly consisted of animal protein sources: dairy products, followed by fish and meat. This resulted in significantly more intake of essential amino acids, including leucine. The protein intake was distributed evenly over the day, resulting in more meals that reached the protein and leucine targets. Digitally supported dietary counselling was effective in increasing protein intake both per meal and per day in a lifestyle intervention in community-dwelling older adults. This was predominantly achieved by consuming more animal protein sources, particularly dairy products, and especially during breakfast and lunch.

International audience; The aging population faces two conditions that threaten healthy aging: high fat mass (obesity) and low muscle mass and function (sarcopenia). The combination of both—referred to as sarcopenic obesity—synergistically increases the risk of adverse health outcomes. The two conditions often co-occur because they reinforce each other and share common etiologies, including poor nutrition and inactivity. All aging people are at risk of gaining weight and losing muscle mass and could benefit from improvements in physical activity, exercise and dietary intake. one specific window of opportunity is during the transient time of retirement, as older adults already need to restructure their daily activities. It is key to change lifestyle behavior in a sustainable manner, providing scientifically proven, personalized, and acceptable principles that can be integrated in daily life. Health technologies (e.g., applications) can provide promising tools to deliver personalized and appealing lifestyle interventions to a large group of people while keeping health care costs low. Several studies show that health technologies have a strong positive effect on physical activity, exercise and dietary intake. Specifically, health technology is increasingly applied to older people, although strong evidence for long term effects in changing lifestyle behavior is generally lacking. Concluding, technology could play an important role in the highly warranted prevention of sarcopenic obesity in older adults. Although health technology seems to be a promising tool to stimulate changes in physical activity, exercise and dietary intake, studies on long lasting effects and specifically targeted on older people around the time of retirement are warranted.

Optimizing protein intake is a novel strategy to prevent age associated loss of muscle mass and strength in older adults. Such a strategy is still missing for older adults from ethnic minority populations. Protein intake in these populations is expected to be different in comparison to the majority of the population due to several socio-cultural factors. Therefore, the present study examined the dietary protein intake and underlying behavioral and environmental factors affecting protein intake among older adults from ethnic minorities in the Netherlands. We analyzed frequency questionnaire (FFQ) data from the Healthy Life in an Urban Setting (HELIUS) cohort using ANCOVA to describe dietary protein intake in older adults from ethnic minorities in the Netherlands (N = 1415, aged &gt, 55 years, African Surinamese, South Asian Surinamese, Moroccan, and Turkish). Additionally, we performed focus groups among older adults from the same ethnic minority populations (N = 69) to discover behavioral and environmental factors affecting protein intake, 40&ndash, 60% of the subjects did not reach minimal dietary protein recommendations needed to maintain muscle mass (1.0 g/kg bodyweight per day (BW/day)), except for Turkish men (where it was 91%). The major sources of protein originated from animal products and were ethnic specific. Participants in the focus groups showed little knowledge and awareness about protein and its role in aging. The amount of dietary protein and irregular eating patterns seemed to be the major concern in these populations. Optimizing protein intake in these groups requires a culturally sensitive approach, which accounts for specific protein product types and sociocultural factors.

Background: Weight loss is key to treatment of older adults with obesity and type 2 diabetes, but also a risk for muscle mass loss. This study investigated whether a whey protein drink enriched with leucine and vitamin D could preserve muscle mass and improve glycemic control during combined lifestyle intervention in this population. Methods: 123 older adults with obesity and type 2 diabetes were randomized into a 13-week lifestyle intervention with dietary advice and exercise, receiving either the enriched protein drink (test) or an isocaloric control (control). Muscle mass was assessed with dual-energy X-ray absorptiometry and glycemic control by oral glucose tolerance test. Statistical analyses were performed using a linear mixed model. Results: There was a nonsignificant increase in leg muscle mass (+0.28 kg, 95% CI, &minus, 0.01 to 0.56) and a significant increase in appendicular muscle mass (+0.36 kg, 95% CI, 0.005 to 0.71) and total lean mass (+0.92 kg, 95% CI, 0.19 to 1.65) in test vs. control. Insulin sensitivity (Matsuda index) also increased in test vs. control (+0.52, 95% CI, 0.07 to 0.97). Conclusions: Use of an enriched protein drink during combined lifestyle intervention shows beneficial effects on muscle mass and glycemic control in older adults with obesity and type 2 diabetes.

Background: Effective and sustainable interventions are needed to counteract the decline in physical function and sarcopenia in the growing aging population. The aim of this study was to determine the 6 and 12 month effectiveness of blended (e-health + coaching) home-based exercise and a dietary protein intervention on physical performance in community-dwelling older adults. Methods: This cluster randomized controlled trial allocated 45 clusters of older adults already engaged in a weekly community-based exercise programme. The clusters were randomized to three groups with ratio of 16:15:14; (i) no intervention, control (CON); (ii) blended home-based exercise intervention (HBex); and (iii) HBex with dietary protein counselling (HBex-Pro). Both interventions used a tablet PC with app and personalized coaching and were targeting on behaviour change. The study comprised coached 6 month interventions with a 6 month follow-up. The primary outcome physical performance was assessed by modified Physical Performance Test (m-PPT). Secondary outcomes were gait speed, physical activity level (PAL), handgrip muscle strength, protein intake, skeletal muscle mass, health status, and executive functioning. Linear mixed models of repeated measured were used to assess intervention effects at 6 and 12 months. Results: The population included 245 older adults (mean age 72 ± 6.5 (SD) years), 71% female, and 54% co-morbidities observed. Dropout of the intervention was 18% at 6 months and 26% at 12 months. Participants were well functioning, based on an m-PPT score of 33.9 (2.8) out of 36. For the primary outcome m-PPT, no significant intervention effects (HBex, +0.03, P = 0.933; HBex-Pro, −0.13, P = 0.730) were found. Gait speed (+0.20 m/s, P = 0.001), PAL (+0.06, P = 0.008), muscle strength (+2.32 kg, P = 0.001), protein intake (+0.32 g/kg/day, P Conclusions: This HBex and dietary protein interventions did not change the physical performance (m-PPT) in community-dwelling older adults. Changes were observed in gait speed, PAL, muscle mass, strength, and dietary protein intake, in response to this combined intervention.

ObjectiveWe examined whether the role of maternal education in children's unhealthy snacking diet is moderated by other socio-economic indicators.MethodsParticipants were selected from the Amsterdam Born Children and their Development cohort, a large ongoing community-based birth cohort. Validated Food Frequency Questionnaires (FFQ) (n = 2782) were filled in by mothers of children aged 5.7±0.5yrs. Based on these FFQs, a snacking dietary pattern was derived using Principal Component Analysis. Socio-economic indicators were: maternal and paternal education (low, middle, high; based on the highest education completed) household finance (low, high; based on ability to save money) and neighbourhood SES (composite score including educational level, household income and employment status of residents per postal code). Cross-sectional multivariable linear regression analysis was used to assess the association and possible moderation of maternal education and other socio-economic indicators on the snacking pattern score. Analyses were adjusted for children's age, sex and ethnicity.ResultsLow maternal education (B 0.95, 95% CI 0.83;1.06), low paternal education (B 0.36, 95% CI 0.20;0.52), lower household finance (B 0.18, 95% CI 0.11;0.26) and neighbourhood SES (B -0.09, 95% CI -0.11;-0.06) were independently associated with higher snacking pattern scores (pConclusionsAll socio-economic indicators were associated with increased risk of unhealthy dietary patterns in young children, with low maternal education conferring the highest risk. Yet, within the group of middle-high educated mothers, lower household finance was an extra risk factor for unhealthy dietary patterns. Intervention strategies should therefore focus on lower educated mothers and middle-high educated mothers with insufficient levels of household finance.

(1) Background: Recent research showed that subtypes of patients with type 2 diabetes may differ in response to lifestyle interventions based on their organ-specific insulin resistance (IR). (2) Methods: 123 Subjects with type 2 diabetes were randomized into 13-week lifestyle intervention, receiving either an enriched protein drink (protein+) or an isocaloric control drink (control). Before and after the intervention, anthropometrical and physiological data was collected. An oral glucose tolerance test was used to calculate indices representing organ insulin resistance (muscle, liver, and adipose tissue) and &beta, cell functioning. In 82 study-compliant subjects (per-protocol), we retrospectively examined the intervention effect in patients with muscle IR (MIR, n = 42) and without MIR (no-MIR, n = 40). (3) Results: Only in patients from the MIR subgroup that received protein+ drink, fasting plasma glucose and insulin, whole body, liver and adipose IR, and appendicular skeletal muscle mass improved versus control. Lifestyle intervention improved body weight and fat mass in both subgroups. Furthermore, for the MIR subgroup decreased systolic blood pressure and increased VO2peak and for the no-MIR subgroup, a decreased 2-h glucose concentration was found. (4) Conclusions: Enriched protein drink during combined lifestyle intervention seems to be especially effective on increasing muscle mass and improving insulin resistance in obese older, type 2 diabetes patients with muscle IR.

Background Physical activity can prolong the ability of older adults to live independently. Home-based exercises can help achieve the recommended physical activity levels. A blended intervention was developed to support older adults in performing home-based exercises. A tablet and a personal coach were provided to facilitate the self-regulation of exercise behavior. Objective In line with the Medical Research Council framework, this study aimed to carry out process evaluation of a blended intervention. The objectives were (1) to assess the long-term usability of the tablet adopted in the blended intervention and (2) to explore how the tablet, in conjunction with a personal coach, supported older adults in performing home-based exercises. Methods The process evaluation was conducted with a mixed-methods approach. At baseline, older adults participating in the blended intervention were asked to fill out a questionnaire about their general experience with information and communication technology (ICT) devices and rate their own skill level. After 6 months, participants filled out the Usefulness, Satisfaction, and Ease of use (USE) questionnaire to assess the usefulness, satisfaction, and ease of use of the tablet. With a random selection of participants, in-depth interviews were held to explore how the tablet and coach supported the self-regulation. The interviews were double coded and analyzed with the directed content analysis method. Results At baseline, 29% (65/224) of participants who started the intervention (mean age 72 years) filled out the ICT survey and 36% (37/103) of participants who used the tablet for 6 months (mean age 71 years) filled out the USE questionnaire. Furthermore, with 17% (18/103) of participants (mean age 73 years), follow-up interviews were held. The results of the baseline questionnaire showed that the large majority of participants already had experience with a tablet, used it regularly, and reported being skillful in operating ICT devices. After 6 months of use, the participants rated the usefulness, satisfaction, and ease of use of the tablet on average as 3.8, 4.2, and 4.1, respectively, on a 5-point scale. The analysis of the interviews showed that the participants felt that the tablet supported action planning, behavior execution, and self-monitoring. On the other hand, especially during the first few months, the personal coach added value during the goal setting, behavior execution, and evaluation phases of self-regulation. Conclusions The results of the process evaluation showed that older adults who participated in the study were positive about the blended intervention that was designed to support them in performing home-based exercises. Participants reported that the tablet helped them to perform the exercises better, more frequently, and safely. It supported them in various phases of self-regulation. The availability of a personal coach was nevertheless crucial. To support physical activity in older adults, a blended approach is promising.

Background Social inequalities in bodyweight start early in life and track into adulthood. Dietary patterns are an important determinant of weight development in children, towards both overweight and underweight. Therefore, we aimed to examine weight development between age 5 and 10 years by ethnicity, SES and thereafter by BMI category at age 5, to explore its association with dietary patterns at age 5. Methods Participants were 1765 children from the Amsterdam Born Children and their Development (ABCD) cohort that had valid data on BMI at age 5 and 10 and diet at age 5. Linear mixed model analysis was used to examine weight development between age 5 and 10 years and to assess if four previously identified dietary patterns at age 5 (snacking, full-fat, meat and healthy) were associated with weight development. Analyses were adjusted for relevant confounders, stratified by ethnicity and SES and thereafter stratified per BMI category at age 5. Results Overall, weight decreased in Dutch and high SES children and increased in non-Dutch and low/middle SES children. Across the range of bodyweight categories at age 5, we observed a conversion to normal weight, which was stronger in Dutch and high SES children but less pronounced in non-Dutch and low/middle SES children. Overall, the observed associations between weight development and dietary patterns were mixed with some unexpected findings: a healthy dietary pattern was positively associated with weight development in most groups, regardless of ethnicity and SES (e.g. Dutch B 0.084, 95% CI 0.038;0.130 and high SES B 0.096, 95% CI 0.047;0.143) whereas the full-fat pattern was negatively associated with weight development (e.g. Dutch B -0.069, 95% CI -0.114;-0.024 and high SES B -0.072, 95% CI -0.119;-0.026). Conclusions We observed differential weight development per ethnic and SES group. Our results indicate that each ethnic and SES group follows its own path of weight development. Associations between dietary patterns and weight development showed some unexpected findings; follow-up research is needed to understand the association between dietary patterns and weight development.

Physical activity can prolong the ability of older adults to live independently at home. A blended intervention was developed to sustain healthy aging. During a clinical trial 133 participants, with an average age of 71 years old, received a tablet and coaching to support them in performing home-based exercises for 6 months. To investigate how the blended intervention influenced exercise motivation, 17 participants were interviewed. Transcripts were analyzed according to the directed content analysis method. The analysis revealed that the intervention supported the autonomy of participants, by letting them set their own personal goals and compile a personalized exercise program. It also supported their feelings of competence, by offering clear instructions, structure, and the ability to track their progress. Finally, some participants valued the emotional support offered by the personal coach, while others preferred combining the home-based exercises with group-based activities with peers to fulfill their relatedness needs.

OBJECTIVES: Weight loss is a key element in the treatment of obesity and type 2 diabetes (T2D), but also a risk factor for lean mass (LM) loss in older adults. We evaluated whether a whey protein drink enriched with leucine and vitamin D preserved LM during 3-month lifestyle intervention and whether effects sustained during 6 months follow-up after intervention (FU). METHODS: 123 older adults (66 ± 6 y) with obesity (BMI 34 ± 4 kg/m(2)) and T2D participated in a 3-month lifestyle intervention with dietary advice (−600 kcal/d) and resistance exercise (3×/wk). In this double-blind RCT (PROBE) subjects were randomised to receive 10×/wk a test (21 g protein) or isocaloric control (0 g protein) drink. LM, appendicular muscle mass (AMM), leg muscle mass (LMM), and fat mass (FM) were assessed with DXA. Mixed linear model analysis was used with baseline value in the outcome vector and adjustment for stratification factors sex and SU-derivate use. Data represent EMM ± SE (within group) or 95% CI (between groups). RESULTS: 105 subjects completed intervention and 76 subjects participated in FU. At 3 months, body weight (−2.2 ± 0.4 kg, P

Interventions to improve children&rsquo, s physical activity in Early Childhood Education and Care (ECEC) settings are needed. This randomized controlled trial examines the effects of a preschool-based playground program for ECEC teachers in a deprived urban area. On intervention preschools, the PLAYgrounds for TODdlers program (PLAYTOD) was performed. It focused on teacher&rsquo, s knowledge and skills in order to create a challenging outdoor environment in which young children (2.5 to 4 years old) are able to practice their motor skills. Observations were performed before and after the program with a modified version of the SOPLAY protocol. The activating role of teachers (score from 0 = inactive to 4 = participating), the number of different physical activities, and the quality of children&rsquo, s physical activity on playgrounds were observed. The latter included the number of performed fundamental movement skills and the estimated physical activity intensity (score from 0 = sedentary to 3 = vigorous). Descriptive statistics and linear regression analyses were used to evaluate the effects of PLAYTOD. After the program, the activating role of teachers on intervention playgrounds improved. Moreover, the program and consecutively the changes made by teachers had a positive effect on the number of different activities and the quality of children&rsquo, s physical activity. The results emphasize an important role for ECEC teachers in improving physical activity in young children.

ObjectiveThis study aims to identify determinants of dietary behaviour in wheelchair users with spinal cord injury or lower limb amputation, from the perspectives of both wheelchair users and rehabilitation professionals. The findings should contribute to the field of health promotion programs for wheelchair users.MethodsFive focus groups were held with wheelchair users (n = 25), and two with rehabilitation professionals (n = 11). A thematic approach was used for data analysis in which the determinants were categorized using an integrated International Classification of Functioning, Disability and Health and Attitude, Social influence and self-Efficacy model.ResultsReported personal factors influencing dietary behaviour in wheelchair users were knowledge, boredom, fatigue, stage of life, habits, appetite, self-control, multiple lifestyle problems, intrinsic motivation, goal setting, monitoring, risk perception, positive experiences, suffering, action planning, health condition, function impairments, attitude and self-efficacy. Reported environmental factors influencing dietary behaviour in wheelchair users were unadjusted kitchens, monitoring difficulties, eating out, costs, unfavourable food supply, nutrition education/counselling, access to simple healthy recipes, eating together, cooking for others, and awareness and support of family and friends.ConclusionsImportant modifiable determinants of dietary behaviour in wheelchair users that might be influenced in lifestyle interventions are knowledge, fatigue, habits, self-control, intrinsic motivation, risk perception, attitude and self-efficacy. It is recommended to involve relatives, since they appear to significantly influence dietary behaviour.

Provision of adequate protein is crucial for optimizing outcomes in hospitalized patients. However, the methodologies upon which current recommendations are based have limitations, and little is known about true requirements in any clinical population. In this tutorial, we aim to give clinicians an understanding of how current protein recommendations were developed, an appreciation for the limitations of these recommendations, and an overview of more sophisticated approaches that can be applied to better define protein requirements. A broader perspective of the challenges and opportunities in determining clinical protein requirements can help clinicians think critically about the individualized nutrition care they provide to their patients with the goal of administering adequate protein to optimize outcomes.

Background & aim: The aim of this study was to describe a decrease in resting energy expenditure during weight loss that is larger than expected based on changes in body composition, called adaptive thermogenesis (AT), in overweight and obese older adults. Methods: Multiple studies were combined to assess AT in younger and older subjects. Body composition and resting energy expenditure (REE) were measured before and after weight loss. Baseline values were used to predict fat free mass and fat mass adjusted REE after weight loss. AT was defined as the difference between predicted and measured REE after weight loss. The median age of 55 y was used as a cutoff to compare older with younger subjects. The relation between AT and age was investigated using linear regression analysis. Results: In this study 254 (M = 88, F = 166) overweight and obese subjects were included (BMI: 31.7 ± 4.4 kg/m 2 , age: 51 ± 14 y). The AT was only significant for older subjects (64 ± 185 kcal/d, 95% CI [32, 96]), but not for younger subjects (19 ± 152 kcal/d, 95% CI [−9, 46]). The size of the AT was significantly higher for older compared to younger adults (β = 47, p = 0.048), independent of gender and type and duration of the weight loss program. Conclusions: We conclude that adaptive thermogenesis is present only in older subjects, which might have implications for weight management in older adults. A reduced energy intake is advised to counteract the adaptive thermogenesis.

Rationale: While combined lifestyle interventions have multiple health benefits, their impact on the oral microbiome is not known. We explored the effects of a lifestyle intervention including protein drink on the oral microbiome in older adults with obesity and type 2 diabetes (T2D).Methods: In a post-hoc analysis of the PROBE study, 87 subjects (66.5±6.1 years, 33% female) with tongue dorsum samples at baseline and week 13 were included. All subjects participated in a 13-week lifestyle intervention with exercise (3x/week) and hypocaloric diet (-600 kcal/day), and had been randomized to receive a test product (21g whey protein enriched with leucine and vitamin D) or isocaloric control (0g protein) 10x/week. T2D was subtyped as muscle insulin resistance (MIR, n=34) or no-MIR (n=36) based on available muscle insulin sensitivity index. Microbiome was analysed by V4 16s rDNA sequencing. Diversity, measured as species richness and Shannon diversity index, was statistically analysed with paired (within group) and independent (between groups) samples t-test.Results: displayed below. Conclusion: Consuming a whey protein drink enriched with leucine and vitamin D during a combined lifestyle intervention increased species richness of the oral microbiome in obese T2D subjects with muscle insulin resistance.

Emerging evidence suggests that exogenous protein/amino acid supplementation has the potential to improve the recovery of critically ill patients. After a careful review of the published evidence, experts have concluded that critically ill patients should receive up to 2.0-2.5 g/kg/d of protein. Despite this, however, recent review of current International Nutrition Survey data suggests that protein in critically ill patients is underprescribed and grossly underdelivered. Furthermore, the survey suggests that most of protein administration comes from enteral nutrition (EN) despite the availability of products and protocols that enhance the delivery of protein/amino acids in the intensive care unit (ICU) setting. While future research clarifies the dose, timing, and composition for exogenous protein administration, as well as identification of patients who will benefit the most, ongoing process improvement initiatives should target a concerted effort to increase protein intake in the critically ill. This assertion follows from the notion that current patients are possibly being harmed while we wait for confirmatory evidence. Further research should also develop better tools to enable bedside practitioners to monitor optimal or adequate protein intake for individual patients. Finally, exploring the effect of combining adequate protein delivery with early mobility and/or resistance exercise in the ICU setting has the greatest potential for improving the functional outcomes of survivors of critical illness and warrants further study.

Inulin is a soluble dietary fibre, also classified as a prebiotic, extracted from chicory roots. The present study aimed to determine the effect of consumption of native chicory inulin on the stool frequency of middle-aged to older adults (40–75 years old) with uncomfortably but not clinically relevant low stool frequency, specified as two to four days without bowel movements per week. Two randomised, double blind, placebo-controlled crossover trials were conducted using similar protocols in differing populations. Trial A was conducted in Amsterdam, The Netherlands and subsequently Trial B was conducted in Newcastle, United Kingdom. Both trials involved supplementation for 5 weeks with 10 g per day of inulin or placebo, a washout period of 2 weeks, and then crossed over to receive the other treatment. In Trial B, faecal gut microbiota composition was assessed using 16S rRNA gene sequencing. In Trial A, which 10 volunteers completed, the stool frequency was significantly increased to an average 4.9 ± 0.23 (SEM) times per week during inulin periods versus 3.6 ± 0.25 in the periods with placebo (p = 0.01). In contrast, in Trial B which 20 volunteers completed, there was no significant effect of the inulin on stool frequency (7.5 ± 2.1 times per week with inulin, 8.1 ± 3.0 with placebo, p = 0.35). However, many subjects in Trial B had a stool frequency >5 per week also for the placebo period, in breach of the inclusion criteria. Combining the data of 16 low stool frequency subjects from Trials A and B showed a significant effect of inulin to increase stool frequency from 4.1 to 5.0 per week (p = 0.032). Regarding secondary outcomes, stool consistency was significantly softer with inulin treatment compared to placebo periods, it increased 0.29 on the Bristol stool scale (p = 0.008) when data from all subjects of Trials A and B were combined. No other differences in bowel habit parameters due to inulin consumption were significant. None of the differences in specific bacterial abundance, alpha or beta diversity were significant, however the trends were in directions consistent with published studies on other types of inulin. We conclude that 10 g per day of native chicory inulin can increase stool frequency in subjects with low stool frequency., Graphical abstract Image 1, Highlights • Inulin as 10g day-1 for 5 weeks significantly increased stool frequency in 16 older volunteers compared with maltodextrin.. • This increase was found in volunteers with low stool frequency (2 days or more per week without bowel movements). • Directions of changes in secondary outcomes were generally consistent with expectations for prebiotic effects of inulin. • Secondary outcomes included quality of life symptoms, stool consistency and composition of the faecal microbiota. • Among secondary outcomes, only softening of stool consistency reached significance within the present study.

Increasing awareness of the impact of frailty on elderly people resulted in research focusing on factors that contribute to the development and persistence of frailty including nutrition and physical activity. Most effort so far has been spent on understanding the association between protein intake and the physical domain of frailty. Far less is known for other domains of frailty: cognition, mood, social health and comorbidity. Therefore, in the present narrative review, we elaborate on the evidence currently known on the association between protein and exercise as well as the broader concept of frailty. Most, but not all, identified studies concluded that low protein intake is associated with a higher prevalence and incidence of physical frailty. Far less is known on the broader concept of frailty. The few studies that do look into this association find a clear beneficial effect of physical activity but no conclusions regarding protein intake can be made yet. Similar, for other important aspects of frailty including mood, cognition, and comorbidity, the number of studies are limited and results are inconclusive. Future studies need to focus on the relation between dietary protein and the broader concept of frailty and should also consider the protein source, amount and timing.

Background Patients treated with conventional hemodialysis have poor physical performance, explained by insufficient metabolic clearance and shortage of time by time-consuming dialysis. Nocturnal hemodialysis improves metabolic control and results in increased spare time. Our aim is to investigate whether physical performance in nocturnal hemodialysis is superior to conventional hemodialysis. Methods A systematic search was conducted in MEDLINE, Embase, CINAHL, PhycInfo and Web of Science until January 2018. Primary outcomes were physical performance, activity, strength and muscle mass in home or in-center nocturnal hemodialysis. Methodological quality was assessed with the Newcastle-Ottawa scale. Results Ten studies met the inclusion criteria, including 2 RCTs, evaluating 526 nocturnal hemodialysis patients with a mean follow-up of 15, 3 months. The methodological quality of 4 studies was limited. Physical capacity tests were done in 3 studies with different methodology: short-physical performance battery, exercise spirometry and 6-min walk test. The latter 2 showed significant improvements in physical performance. Four studies assessed lean mass using dual-energy X-ray absorptiometry (2×) and bioelectrical impedance analysis (2×), of which 1 demonstrated increased lean body and skeletal muscle mass. In 5 studies a Quality of Life questionnaire was used, of which 2 showed improved physical component score. Conclusions The evidence on the effect of nocturnal hemodialysis on physical performance is either of insufficient methodological quality or only measures isolated aspects of physical performance. As literature emphasizes the importance of physical activity on clinical outcomes, it is necessary to conduct larger studies of high methodological quality using capacity tests for answering the question whether nocturnal hemodialysis can improve physical performance of patients with end-stage renal disease. Trial registration NTR4715, Netherlands Trial Register. Registered 30 July 2014. Electronic supplementary material The online version of this article (10.1186/s12882-019-1518-4) contains supplementary material, which is available to authorized users.

Background & aims: Low muscle mass and -quality on ICU admission, as assessed by muscle area and -density on CT-scanning at lumbar level 3 (L3), are associated with increased mortality. However, CT-scan analysis is not feasible for standard care. Bioelectrical impedance analysis (BIA) assesses body composition by incorporating the raw measurements resistance, reactance, and phase angle in equations. Our purpose was to compare BIA- and CT-derived muscle mass, to determine whether BIA identified the patients with low skeletal muscle area on CT-scan, and to determine the relation between raw BIA and raw CT measurements. Methods: This prospective observational study included adult intensive care patients with an abdominal CT-scan. CT-scans were analysed at L3 level for skeletal muscle area (cm2) and skeletal muscle density (Hounsfield Units). Muscle area was converted to muscle mass (kg) using the Shen equation (MMCT). BIA was performed within 72 h of the CT-scan. BIA-derived muscle mass was calculated by three equations: Talluri (MMTalluri), Janssen (MMJanssen), and Kyle (MMKyle). To compare BIA- and CT-derived muscle mass correlations, bias, and limits of agreement were calculated. To test whether BIA identifies low skeletal muscle area on CT-scan, ROC-curves were constructed. Furthermore, raw BIA and CT measurements, were correlated and raw CT-measurements were compared between groups with normal and low phase angle. Results: 110 patients were included. Mean age 59 ± 17 years, mean APACHE II score 17 (11–25); 68% male. MMTalluri and MMJanssen were significantly higher (36.0 ± 9.9 kg and 31.5 ± 7.8 kg, respectively) and MMKyle significantly lower (25.2 ± 5.6 kg) than MMCT (29.2 ± 6.7 kg). For all BIA-derived muscle mass equations, a proportional bias was apparent with increasing disagreement at higher muscle mass. MMTalluri correlated strongest with CT-derived muscle mass (r = 0.834, p < 0.001) and had good discriminative capacity to identify patients with low skeletal muscle area on CT-scan (AUC: 0.919 for males; 0.912 for females). Of the raw measurements, phase angle and skeletal muscle density correlated best (r = 0.701, p < 0.001). CT-derived skeletal muscle area and -density were significantly lower in patients with low compared to normal phase angle. Conclusions: Although correlated, absolute values of BIA- and CT-derived muscle mass disagree, especially in the high muscle mass range. However, BIA and CT identified the same critically ill population with low skeletal muscle area on CT-scan. Furthermore, low phase angle corresponded to low skeletal muscle area and -density. Trial registration: ClinicalTrials.gov (NCT02555670).

BackgroundInterventions to prevent overweight and obesity in toddlers are needed to minimize health inequalities, especially in migration and lower socio-economic groups. Preschools are identified as important environments for interventions to prevent overweight and obesity. Early Childhood Education and Care (ECEC) teachers in preschools are potential key actors in promoting healthy eating and physical activity. This paper describes the research design of a Dutch preschool-based intervention for ECEC teachers in promoting healthy eating and physical activity in toddlers.MethodsPreSchool@HealthyWeight concerns a cluster randomized controlled trial on preschools in Amsterdam Nieuw-West, Netherlands. This city district is characterised by inhabitants with a migration background and low socio-economic status. Forty-one preschools, with 115 ECEC teachers and 249 toddlers/parents, were randomly allocated to an intervention or control group. An intervention for teachers will be carried out on intervention locations and consists of modified versions of 2 existing programs: ‘A Healthy Start’ and ‘PLAYgrounds’. In ‘A Healthy Start’, ECEC teachers learn to provide a healthy and active environment for toddlers. The ‘PLAYgrounds for Toddlers’ program, coaches ECEC teachers to stimulate physical activity in the playgrounds of preschools. PreSchool@HealthyWeight aims to evaluate the effectiveness of the intervention after 9 months. Primary outcomes are the teachers’ knowledge, attitude and practices concerning healthy eating and physical activity, and consequently the level of confidence of ECEC teachers in promoting healthy eating and physical activity in toddlers. Secondary outcomes include the Body Mass Index, body composition, dietary intake and physical activity level of teachers and toddlers. In addition, the activating role of ECEC teachers and the physical activity of toddlers on the playgrounds will be evaluated. Lastly, the knowledge, attitude and practices of parents concerning healthy eating and physical activity will be assessed.DiscussionIt is hypothesized that this preschool-based intervention for ECEC teachers improves the knowledge, attitude and practices regarding healthy eating and physical activity, and consequently the level of confidence of ECEC teachers in promoting healthy eating and physical activity of toddlers. The intervention addresses the call for early intervention to prevent overweight and obesity and to minimize health inequalities.Trial registrationNetherlands Trial Register (NTR): NL5850. Date registered: August 26, 2016.

Introduction:The recently published 2018 ESPEN Guidelines on Clinical Nutrition in the Intensive Care Unit [1] represents a valuable revision of the 2006 Enteral Nutrition Guidelines [2] and the 2009 Parenteral Nutrition Guidelines [3] published earlier by this European group. The guidelines committee members have done an excellent job in putting thismanuscript together, providing directives that are clear, concise, brief, and most importantly, transparent. They included only studies published since 2000 for use in their meta-analyses, commenting that this time of transition heralded a new era in the literature involving higher quality randomized control trials (RCTs) and methodologic innovations such as trial registry. Not mentioned (but felt by many within the nutrition community) was the sense that this particular time was a tipping point, following the publication of Van den Berghe’s seminal paper on intensive insulin therapy [4]. Studies published in nutrition prior to this date were felt to reflect an older more antiquated style of management that was less effective. These authors utilized the persistent inflammation catabolism syndrome (PICS) system where four parameters (the patient, intervention, controls, and outcomes) are clearly described, which in turn direct the questions that the guideline committee members were to address. Quality of evidence was assessed by GRADE methodology, and a cut-off date of August 2017 for data entry from the literature was clearly identified. Not all of the recommendations were based on RCTs. The authors are to be commended in that they provided recommendations based on Level 4 low-quality evidence, in areas where RCTs were not available, clearly taking advantage of the group of experts on the committee to provide practical guidance for clinicians where there was a paucity of literature to support evidence-based practices.

Background: For older adults, physical activity is vital for maintaining their health and ability to live independently. Home-based programs can help them achieve the recommended exercise frequency. An application for a tablet computer was developed to support older adults in following a personal training program. It featured goal setting, tailoring, progress tracking, and remote feedback.Objective: In line with the Medical Research Council Framework, which prescribes thorough testing before evaluating the efficacy with a randomized controlled trial, the aim of this study was to assess the usability of a tablet-based app that was designed to support older adults in doing exercises at home.Methods: A total of 15 older adults, age ranging from 69 to 99 years old, participated in a usability study that utilized a mixed-methods approach. In a laboratory setting, novice users were asked to complete a series of tasks while verbalizing their ongoing thoughts. The tasks ranged from looking up information about exercises and executing them to tailoring a weekly exercise schedule. Performance errors and time-on-task were calculated as proxies of effective and efficient usage. Overall satisfaction was assessed with a posttest interview. All responses were analyzed independently by 2 researchers.Results: The participants spent 13-85 seconds time-on-task. Moreover, 79% (11/14)-100% (14/14) participants completed the basic tasks with either no help or after having received 1 hint. For expert tasks, they needed a few more hints. During the posttest interview, the participants made 3 times more positive remarks about the app than negative remarks.Conclusions: The app that was developed to support older adults in doing exercises at home is usable by the target audience. First-time users were able to perform basic tasks in an effective and efficient manner. In general, they were satisfied with the app. Tasks that were associated with behavior execution and evaluation were performed with ease. Complex tasks such as tailoring a personal training schedule needed more effort. Learning effects, usefulness, and long-term satisfaction will be investigated through longitudinal follow-up studies.