Multimodal Exercise and Weight Loss in Older Veterans with Dysmobility

背景：肥胖是老年人活动受限的主要危险因素。据估计， 老年人有行动障碍，超过400万老年人使用步行辅助设备。行动不便 导致步态的经济性降低、身体失调和峰值有氧能力（VO 2 peak）降低。 步态经济性受损和生理储备减少可能导致疲劳增加， 耐力，并最终导致功能独立性降低。改善的最佳干预措施 老年肥胖成年人的移动性限制是未知的，特别是那些使用行走辅助装置的人， 并且关于身体功能的改善是否可以随时间持续的信息有限。 初步研究表明，我们的新型渐进式组多模式平衡干预（MMBI）， 注重横向运动、下肢力量训练和动态越障， 步态、平衡和力量在行动受限的老年人。然而，目前还不知道减肥是否与 与MMBI将提供附加或协同改善行动能力有限的老年肥胖退伍军人。 我们假设，我们的MMBI计划与低热量营养干预相结合（营养） 在改善肌肉质量、身体功能和步态经济性方面比单独使用MMBI更有效。在 此外，我们假设营养+ MMBI在改善自我方面比单独的MMBI更有效。 报告功能和残疾的措施。 目的：我们对120例老年（年龄> 60岁）社区肥胖（BMI）患者进行随机临床试验 >30 kg/m2），使用行走辅助设备的行动不便的退伍军人，我们将： 具体目标1：比较6个月MMBI单独干预与6个月联合干预的效果 + MMBI对身体功能和步态经济性的影响。 具体目标2：比较两种干预措施对身体成分、肌肉质量、力量和 相对肌肉减少症。 具体目标3：评估两种干预措施在基线、6个月、12个月和24个月时对他们自我的影响。 使用晚年功能和残疾工具（LLFDI）报告功能和残疾的措施。 方法：参加研究的退伍军人将在巴尔的摩GRECC和VAMHCS进行基线测试 人体性能实验室包括1）基于性能的结局指标，包括VO 2峰值、步态 速度（步态礼仪），椅子站立，横向移动和平衡（四个正方形步骤测试，8字），SPPB，手柄 力量（测力法）和步态经济性（6分钟步行期间的便携式VO 2测量），以及 功能状态（ADL，IADL）; 2）下肢力量测试，3）全身DXA扫描，以及 腹部、臀部和大腿，用于测定下肢和核心肌肉组成;以及4） 生物标志物。完成基线测试后，退伍军人将被随机分配到两个 干预措施。营养课程将由GRECC营养师领导。目标是让受试者失去10%的 体重在前6个月逐渐减轻。MMBI将由一组动态 平衡课，有监督的障碍课程，下肢和核心力量。在3-、6-、12-和 24个月后，受试者将重复他们在基线时进行的评估。 影响：很少有运动康复研究针对使用步行辅助设备的老年肥胖退伍军人， 事实上，使用行走辅助器具的人往往被排除在研究之外。本研究 直接受益退伍军人，因为它可能导致更有效的干预措施，提高流动性，减少跌倒风险， 减少行动不便的老年退伍军人因伤住院和死亡。这种营养 多模式平衡干预很容易出口到社区，如果有额外的资源， 作为临床护理的一部分，在其他VA中广泛实施。

Background: Obesity is a major risk factor for mobility limitation in older adults. It is estimated that 11 million older adults have mobility disability and > 4 million older adults use walking assistive devices. Mobility disability results in decreased economy of gait, physical deconditioning and reduced peak aerobic capacity (VO2peak). Impaired economy of gait and decreased physiological reserve may lead to increased fatigue, reduced endurance, and ultimately contribute to reduced functional independence. The optimal intervention to improve mobility limitations in older, obese adults is not known, particular in those who use walking assistive devices, and there is limited information on whether improvements in physical function can be sustained over time. Preliminary studies demonstrate that our novel progressive group multimodal balance intervention (MMBI), focusing on lateral movements, lower extremity strengthening and dynamic obstacle negotiation can improve gait, balance, and strength in mobility limited older adults. However, it is no known if weight loss in combination with MMBI will provide additive or synergistic improvements in mobility limited older, obese Veterans. We hypothesize that our MMBI program in combination with a hypocaloric nutritional intervention (Nutrition) will be more effective than MMBI alone in improving muscle quality, physical function and economy of gait. In addition, we hypothesize that the Nutrition + MMBI will be more effective than MMBI alone at improving self- reported measures of function and disability. Objective: We propose a randomized clinical trial in 120 older (age > 60 yr) community-dwelling obese (BMI >30 kg/m2), Veterans with mobility limitations who use walking assistive devices in which we will: Specific aim 1: Compare the effects of a 6-month MMBI intervention alone to a 6-month combination Nutrition + MMBI on physical functioning and economy of gait. Specific aim 2: Compare the effects of the two interventions on body composition, muscle mass, strength and relative sarcopenia. Specific aim 3: Assess the effects of the two interventions at baseline, 6, 12 and 24 months on their self- reported measures of function and disability using the Late-Life Function and Disability Instrument (LLFDI). Methods: Veterans enrolled into the study will have baseline testing at the Baltimore GRECC and VAMHCS Human Performance Laboratory consisting of 1) performance-based outcome measures include VO2peak, gait speed (gait rite), chair stands, lateral mobility and balance (four square step test, figure eight), SPPB, handgrip strength (dynamometry), and economy of gait (portable VO2 measurement during 6 minute walk) and functional status (ADL, IADLs); 2) lower extremity strength testing, 3) total body DXA scan, and a CT scan of the abdomen, hips and thighs for determination of lower extremity and core muscle composition; and 4) biomarkers. After completion of baseline testing, the Veterans will be randomized to one of the two interventions. Nutrition classes will be led by a GRECC dietitian. The goal is for subjects to lose 10% of their weight over the first 6 months with gradual weight loss after that. The MMBI will consist of a group dynamic balance class, a supervised obstacle course, and lower extremity and core strengthening. After 3-, 6-, 12-, and 24-months, subjects will repeat the assessments that they had at baseline. Impact: Few exercise rehabilitation studies target older, obese Veterans who use walking assistive device and indeed individuals who use walking assistive devices are often excluded from the studies. This research directly benefits Veterans as it may lead to more effective interventions that improve mobility, reduce fall risk, and reduce injury-related hospitalization and death in older Veterans with mobility limitations. This nutritional and multimodal balance intervention is readily exportable to the community and with additional resources could be widely implemented at other VAs as part of clinical care.