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Development of an approach for identifying overnutrition among older adults in community health care settings: - an opinion paper

Open AccessPublished:December 20, 2022DOI:https://doi.org/10.1016/j.nutos.2022.12.008

      Summary

      Background

      Along with demographic changes, a larger number of older adults may encounter health risks related to overweight and obesity. According to the obesity paradox, it is still uncertain whether nutritional interventions aiming at weight loss in older adults has favorable or adverse effects on health.

      Aims

      We aim to propose an approach that can be applied in community health care settings for identifying overnutrition among older adults with overweight or obesity in order to find those who may benefit from a nutritional intervention aimed at controlling body weight and maintaining or increasing physical function and quality of life. A second aim is to substantiate the proposed approach with results from the scientific literature on nutritional interventions.

      Methods

      The approach was developed in a stepwise, followed by a narrative literature review.

      Results

      The approach proposed for risk screening of older adults includes BMI ≥ 25 kg/m2, minimum one physical function criterion (muscle strength or physical performance) or one metabolic criterion (presence of non-communicable disease (NCDs)). Appropriate criteria, assessment tools and cut-off values adapted to older adults in community care settings are proposed for both. A total of 10 intervention studies (13 papers) identified in the narrative literature search supports that nutritional interventions including exercise are effective for older adults with overnutrition (BMI ≥ 25) and concurrently low physical function and/or NCDs.

      Conclusion

      An approach was proposed including screening for BMI ≥ 25, functional and NCD criterion. The approach confirmed by a narrative literature review, revealed a high heterogeneity of nutritional intervention studies in overweight and obese adults in community health care settings.

      Keywords

      Abbreviations

      ADL
      Activities of Daily Living
      BC
      Body composition
      BDD
      Balance Deficit Diet
      BIA
      Bioelectrical Impedance Analysis
      BMD
      Bone Mass Density
      BMI
      Body Mass Index
      BW
      Body weight
      DBW
      Desirable Body Weight
      CR
      Caloric Restriction
      DEMMI
      De Morton Mobility Index
      DRM
      Disease Related Malnutrition
      DXA
      Dual-energy X-ray Absorptiometry
      ESPEN
      European Society for Clinical Nutrition and Metabolism
      EWGSOP
      European Working Group on Sarcopenia in Older People
      EX
      Exercise
      FFQ
      Food Frequency Questionnaire
      HE
      Healthy Eating advice
      HGI
      High Glycemic Index
      HPI
      High Protein Intake
      GS
      grip strength
      IBC
      Individual Behavioral Counseling
      IL-6
      InterLeucin-6
      ILCD
      Intensive Low Calorie Diet
      IPAQ-SF
      International Physical Activity Questionnaire – Short Form
      LCD
      Low Calorie Diet
      LE
      Low Extremity
      LGI
      Low Glycemic Index
      MGF
      MechanoGrowth Factor
      MM
      Muscle Mass
      MNA
      Mini Nutritional Assessment
      MRI
      Magnetic Resonance Imaging
      MUST
      Malnutrition Universal Screening Tool
      6MWT
      6-Minute Walk Test
      NCD
      Non-Communicable Disease
      NCEP ATP III
      National Cholesterol Education Program's Adult Treatment Panel III
      NPI
      Normal Protein Intake
      NRS-2002
      Nutritional Risk Screening
      OS
      Obesity Sarcopenia
      PF
      Physical Function
      PPT
      modified Physical Performance Test
      QoL
      Quality of Life
      SAT
      abdominal subcutaneous adipose tissue
      SD
      Standard Deviations
      SPPB
      Short Physical Performance Battery
      RT
      Randomized Trial
      RCT
      Randomized Controlled Trial
      1-RM
      one-Repetition Maximum
      T2D
      Type 2 diabetes
      TEE
      Total Energy Expenditure
      TLR-4
      Toll-Like Receptor-4
      TNF-α
      Tumor Necrosis Factor α
      TUG
      Timed Up and Go
      UE
      Upper Extremity
      VAT
      Visceral Adipose Tissue
      VLCD
      Very Low Calorie Diet
      VO2max
      max/peak aerobic power
      WC
      Waist Circumference
      WHO
      World Health Organisation
      WL
      Weight Loss
      WS
      Weight Stable

      Introduction

      The world's population is becoming increasingly older and concurrently more overweight and obese []. Overweight and obesity (Overnutrition) is defined as “abnormal or excessive fat accumulation that may impair health” [
      • Cederholm T.
      • Barrazzoni R.
      • Austin P.
      • Ballmer Y.P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ] and is classified by body mass index (BMI) [
      • Cederholm T.
      • Barrazzoni R.
      • Austin P.
      • Ballmer Y.P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ]. Overnutrition is associated with decreased physical function i.e. low muscle strength and functional ability to perform physical tasks [
      • Starr K.N.P.
      • Mcdonald S.R.
      • Bales C.W.
      • Starr K.P.
      Obesity and physical frailty in older adults: a scoping review of intervention trials NIH public access.
      ,
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Jensen G.L.
      • Hsiao P.Y.
      Obesity in older adults: Relationship to functional limitation.
      ] as well as increased risk of non-communicable diseases (NCD) [
      • Starr K.N.P.
      • Mcdonald S.R.
      • Bales C.W.
      • Starr K.P.
      Obesity and physical frailty in older adults: a scoping review of intervention trials NIH public access.
      ,
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Yu Y.
      Reexamining the declining effect of age on mortality differentials associated with excess body mass: Evidence of cohort distortions in the United States.
      ,
      • Hunter D.J.
      • Reddy K.S.
      Noncommunicable Diseases.
      ] which together is associated with obesity sarcopenia [
      • Batsis J.A.
      • Villareal D.T.
      Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies HHS Public Access.
      ,
      • World Health Organization
      World report on ageing and health.
      ], all considered important aspects to prevent according to the WHO definition of healthy ageing [
      • World Health Organization
      World report on ageing and health.
      ]. Community health care requires effective interventions to overcome these problems [
      • Dimilia P.R.
      • Mittman A.C.
      • Batsis J.A.
      Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity.
      ].
      The ‘obesity paradox’, refers to the hypothesis that in some older adults, a high BMI at least up to 30 kg/m2 [
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ,
      • Mathus-Vliegen E.M.
      Obesity and the Elderly.
      ,
      • Bosello O.
      • Vanzo A.
      ] may be protective and associated with decreased morbidity and mortality [
      • Oreopoulos A.
      • Kalantar-Zadeh K.
      • Sharma A.M.
      • Fonarow G.C.
      The Obesity Paradox in the Elderly: Potential Mechanisms and Clinical Implications.
      ]. However, for other older adults, BMI ≥ 25 has been shown to promote inflammation and reduce muscle mass [
      • Zamboni M.
      • Mazzali G.
      • Fantin F.
      • Rossi A.
      • Di Francesco V.
      ,
      • Kalinkovich A.
      • Livshits G.
      Sarcopenic obesity or obese sarcopenia: A cross talk between age-associated adipose tissue and skeletal muscle inflammation as a main mechanism of the pathogenesis.
      ], leading to an increased risk of morbidity and mortality [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Bray G.A.
      • Macdiarmid J.
      The epidemic of obesity.
      ,

      EE Calle, MJ Thun, J Petrelli, C Rodriguez,, CW Heath Jr. Body-Mass index and Mortality in a prospective cohort of U.S. adults. N Engl J Med Vol. 341. p. 1097–1105. Available from: https://doi.org/10.1056/NEJM199910073411501.

      ].
      Ageing alone is associated with increased fat mass, decreased muscle mass [
      • Nair S.
      Aging muscle.
      ] and increased levels of inflammation [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Mathus-Vliegen E.M.
      Obesity and the Elderly.
      ,
      • Stenholm S.
      • Harris T.B.
      • Rantanen T.
      • Visser M.
      • Kritchevsky S.B.
      • Ferrucci L.
      Sarcopenic obesity: Definition, cause and consequences.
      ]. In combination with overnutrition, reduced muscle mass and NCD-related inflammation may synergistically worsen each of these conditions [
      • Goisser S.
      • Kemmler W.
      • Porzel S.
      • Volkert D.
      • Sieber C.C.
      • Bollheimer L.C.
      • et al.
      ].
      Interventions with nutrition-induced weight loss and exercise have in some studies [
      • Dimilia P.R.
      • Mittman A.C.
      • Batsis J.A.
      Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity.
      ,
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ,
      • Goisser S.
      • Kemmler W.
      • Porzel S.
      • Volkert D.
      • Sieber C.C.
      • Bollheimer L.C.
      • et al.
      ,
      • Locher J.L.
      • Goldsby T.U.
      • Goss A.M.
      • Kilgore M.L.
      • Gower B.
      • Ard J.D.
      Calorie Restriction in Overweight Older Adults: Do Benefits Exceed Potential Risks? HHS Public Access.
      ,
      • Theodorakopoulos C.
      • Jones J.
      • Bannerman E.
      • Greig C.A.
      ,
      • Liao C.-D.
      • Tsauo J.-Y.
      • Wu Y.-T.
      • Cheng C.-P.
      • Chen H.-C.
      • Huang Y.-C.
      • et al.
      Effects of protein supplementation combined with resistance exercise on body composition and physical function in older adults: a systematic review and meta-analysis.
      ,
      • Bales C.W.
      • Starr K.N.P.
      Obesity interventions for older adults: Diet as a determinant of physical function.
      ,
      • Jiang B.C.
      • Villareal D.T.
      Therapeutic and lifestyle approaches to obesity in older persons.
      ,
      • Waters D.L.
      • Ward A.L.
      • Villareal D.T.
      Weight loss in obese adults 65 years and older: A review of the controversy.
      ,
      • Haywood C.
      • Sumithran P.
      ] been effective in increasing physical function, although concerns remain whether weight loss may increase unintentional adverse effects such as loss of muscle mass [
      • Goisser S.
      • Kemmler W.
      • Porzel S.
      • Volkert D.
      • Sieber C.C.
      • Bollheimer L.C.
      • et al.
      ] with potentially detrimental effects on Quality of Life (QoL).
      Malnutrition defined as “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” [
      • Sobotka L.
      • Forbes A.
      ] among older adults has received intensive attention, compared with overnutrition, although this is also classified as a nutrition-related condition [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ]. Nevertheless, overnutrition classified by BMI ≥ 25 [
      • Cederholm T.
      • Barrazzoni R.
      • Austin P.
      • Ballmer Y.P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ] is hardly ever a part of the criteria in screening models [
      • Rubenstein L.Z.
      • Harker J.O.
      • Salva A.
      • Guigoz Y.
      • Vellas B.
      Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini-Nutritional Assessment (MNA-SF).
      ,
      • Kondrup J.
      • Ramussen H.H.
      • Hamberg O.
      • Stanga Z.
      • Camilo M.
      • Richardson R.
      • et al.
      Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials.
      ,
      Ernaeringsscreening -vurdering og dokumentation hos voksne.
      ] when identifying older adults who may benefit from nutritional interventions [
      • Dimilia P.R.
      • Mittman A.C.
      • Batsis J.A.
      Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity.
      ,
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ,
      • Goisser S.
      • Kemmler W.
      • Porzel S.
      • Volkert D.
      • Sieber C.C.
      • Bollheimer L.C.
      • et al.
      ,
      • Locher J.L.
      • Goldsby T.U.
      • Goss A.M.
      • Kilgore M.L.
      • Gower B.
      • Ard J.D.
      Calorie Restriction in Overweight Older Adults: Do Benefits Exceed Potential Risks? HHS Public Access.
      ,
      • Theodorakopoulos C.
      • Jones J.
      • Bannerman E.
      • Greig C.A.
      ,
      • Liao C.-D.
      • Tsauo J.-Y.
      • Wu Y.-T.
      • Cheng C.-P.
      • Chen H.-C.
      • Huang Y.-C.
      • et al.
      Effects of protein supplementation combined with resistance exercise on body composition and physical function in older adults: a systematic review and meta-analysis.
      ,
      • Bales C.W.
      • Starr K.N.P.
      Obesity interventions for older adults: Diet as a determinant of physical function.
      ,
      • Jiang B.C.
      • Villareal D.T.
      Therapeutic and lifestyle approaches to obesity in older persons.
      ,
      • Waters D.L.
      • Ward A.L.
      • Villareal D.T.
      Weight loss in obese adults 65 years and older: A review of the controversy.
      ,
      • Haywood C.
      • Sumithran P.
      ]. Due to high prevalence of overnutrition, an approach focusing on overnutrition may be a valuable next step in conceptualizing a strategic framework for public health action targeted at the community health care closest to the older adults. However, an approach must also consider other criteria, including metabolic and functional criteria, as is the case for GLIM criteria for the diagnosis of malnutrition [
      • Kondrup J.
      • Ramussen H.H.
      • Hamberg O.
      • Stanga Z.
      • Camilo M.
      • Richardson R.
      • et al.
      Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials.
      ,
      • Cederholm T.
      • Jensen G.L.
      • Correia M.I.T.D.
      • Gonzalez M.C.
      • Fukushima R.
      • Higashiguchi T.
      • et al.
      GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.
      ,
      • Moreland S.
      Nutrition screening and counseling in adults with lung cancer: a systematic review of the evidence.
      ].
      The aim is to propose an approach in community care settings for identifying overnutrition among older adults who may benefit from an intervention aimed at controlling body weight and maintaining or increasing physical function and QoL. The approach will be substantiated with results from the scientific literature.

      Methods

      The methods used are divided into two parts

      Part 1: Proposal for an approach for identifying overnutrition in older adults in community care settings

      Initially, the relevance of assessing BMI was investigated, based on existing literature and including a mapping of the relevance of physical function. This was followed by considerations in the literature of the significance of NCD in relation to overnutrition. A classification of different groups of overnutrition was established on the basis of the results and considerations of the importance of NCD and of physical function. By combining this information, an approach was proposed. As a next step, an extensive examination of existing approaches and tools used in screening and assessment of sarcopenia, malnutrition or frailty was conducted to determine relevant criteria. Both the approach and the selected criteria were aimed at representing measures that should be readily available and easy to use and understand for health care professionals in a community care setting.

      Part 2: Substantiation of the approach to identify overnutrition among older adults who may benefit from a nutritional intervention

      Substantiation of the approach was conducted by reviewing the literature on randomized nutritional interventions targeted at older adults with overnutrition. The relevant literature was identified by a literature search using Cochrane Library, PubMed, and CINAHL from January 2006 to June 2020 with pre-defined inclusion and exclusion criteria and search terms according to the Cochrane recommendations [
      • van Tulder M.
      • Furlan A.
      • Bombardier C.
      • Bouter L.
      Updated Method Guidelines for Systematic Reviews in the Cochrane Collaboration Back Review Group.
      ] as described in Table 1.
      Table 1Search terms and inclusion and exclusion criteria for identification of randomised studies on nutritional interventions in older overweight and obese adults.
      'Overweight’ OR ‘obesity’ OR ‘obese'AND‘Geriatric’ OR ‘elderly’ OR ‘ageing’ OR ‘older’AND‘Nutritional intervention’ OR ‘dietary intervention’ OR ‘dietary intake’
      Inclusion criteriaEnglish language, age ≥ 65 years, BMI≥ 25, randomized trial including dietary interventions.
      Exclusion criteriaSingle makers of vitamin and/or mineral supplementation intake and/or novel agents e.g. coffee.
      Selection of relevant studies against the background of the inclusion criteria was independently confirmed by at least two of the authors, and all authors participated in the analysis and interpretation of findings for each topic. Data were collected and organized into three groups according to the approach.

      Results

      Part 1: Proposal for an approach for identifying overnutrition in older adults in community care settings

      The relevance of using BMI as a tool to classify older adults with overnutrition

      Identifying and assessing overnutrition in older adults is not a straightforward process. BMI is an easy screening tool that correlates with the percentage of fat in young and middle-aged adults [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ] but not necessarily in older adults, who usually have a larger proportion of fat mass compared with younger adults with the same BMI [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ]. In addition, age-related loss of height due to the compression of vertebral bodies and kyphosis can alter the relation between BMI and percentage of fat [
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ,
      • Villareal D.T.
      • Apovian C.M.
      • Kushner R.F.
      • Klein S.
      Obesity in older adults: Technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.
      ,
      • Heiat A.
      • Vaccarino V.
      • Krumholz H.M.
      An evidence-based assessment of federal guidelines for overweight and obesity as they apply to elderly persons.
      ,
      • Sahyoun N.R.
      • Maynard L.M.
      • Zhang X.L.
      • Serdula M.K.
      Factors associated with errors in self-reported height and weight in older adults.
      ]. Accordingly, age-related changes in body composition using BMI in older adults tend to underestimate fatness, whereas loss of height will tend to overestimate fatness [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Villareal D.T.
      • Apovian C.M.
      • Kushner R.F.
      • Klein S.
      Obesity in older adults: Technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.
      ]. In summary, BMI may classify some older adults without excess fat mass as overnutrition and fail to classify others who have excess fat mass [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ,
      • Villareal D.T.
      • Apovian C.M.
      • Kushner R.F.
      • Klein S.
      Obesity in older adults: Technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.
      ]. This will potentially bias the prevalence of overnutrition in older adults.
      Besides BMI, other tools for assessing Overnutrition are available [
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ] eg. Waist Circumference (WC), percentages of fat, or assessing body composition by Bioelectrical Impedance Analysis (BIA) or Dual-energy X-ray Absorptiometry (DXA). However, these tools are also inadequate in terms of evidence-based cut-off values adapted to older adults and not feasible in practice [
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ].
      While BMI does not entirely predict the adverse effect of obesity in older adults, BMI is easy to determine and is available in community health care and clinical practice and is therefore still considered to be the most valid and commonly used criterion to classify overnutrition [
      • Dorner T.E.
      • Rieder A.
      Obesity paradox in elderly patients with cardiovascular diseases.
      ]. The European Society for Clinical Nutrition and Metabolism (ESPEN) and the World Health Organisation (WHO) define overnutrition in older adults ˃ 65 years as abnormal or excessive fat accumulation that may impair health and is determined by BMI [
      • Cederholm T.
      • Barrazzoni R.
      • Austin P.
      • Ballmer Y.P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ,
      • York David
      (American association for the study of obesity), Lenfandt, Claude (national heart L and BI. The practical guide: identification, evaluation, and treatment of overweight.
      ] using the same cut-off values as in younger people [
      • Cederholm T.
      • Barrazzoni R.
      • Austin P.
      • Ballmer Y.P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ,
      • York David
      (American association for the study of obesity), Lenfandt, Claude (national heart L and BI. The practical guide: identification, evaluation, and treatment of overweight.
      ,]. We therefore consider BMI to be the most appropriate tool for assessing overnutrition in older adults with the same cut-off points suggested by ESPEN and WHO, even though we acknowledge the limitation in this definition [
      • Sahyoun N.R.
      • Maynard L.M.
      • Zhang X.L.
      • Serdula M.K.
      Factors associated with errors in self-reported height and weight in older adults.
      ].
      BMI is also used in other screening tools like Nutrition Risk Screening (NRS)-2002, Mini Nutritional Assessment –Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST) applied to older adults [
      • Cederholm T.
      • Jensen G.L.
      • Correia M.I.T.D.
      • Gonzalez M.C.
      • Fukushima R.
      • Higashiguchi T.
      • et al.
      GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.
      ,
      • Kondrup J.
      • Allison S.P.
      • Elia M.
      • Vellas B.
      • Plauth M.
      ESPEN guidelines for nutrition screening 2002.
      ,
      • Bourdel-Marchasson I.
      • Blanc-Bisson C.
      • Lade Doussau A.
      • Germain C.
      • Dé J.-F.
      • Blanc R.
      • et al.
      Nutritional Advice in Older Patients at Risk of Malnutrition during Treatment for Chemotherapy: A Two-Year Randomized Controlled Trial.
      ,
      • Stratton R.J.
      • Hackston A.
      • Longmore D.
      • Dixon R.
      • Price S.
      • Stroud M.
      • et al.
      Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults.
      ], but only targeting low BMI. High BMI and weight gain may be overlooked, and is therefore a criterion in the approach.

      The significance of physical function in relation to overnutrition

      A decline in physical function caused by late-life overnutrition surpasses the decline that is associated with ‘normal’ ageing alone [
      • Jensen G.L.
      • Friedmann J.M.
      Obesity is associated with functional decline in community-dwelling rural older persons.
      ]. Several studies have shown that overnutrition in older adults is associated with decreased muscle strength and physical performance [
      • Starr K.N.P.
      • Mcdonald S.R.
      • Bales C.W.
      • Starr K.P.
      Obesity and physical frailty in older adults: a scoping review of intervention trials NIH public access.
      ,
      • Jensen G.L.
      • Friedmann J.M.
      Obesity is associated with functional decline in community-dwelling rural older persons.
      ].
      Several studies [
      • Brady A.O.
      • Straight C.R.
      • Schmidt M.D.
      • Evans E.M.
      Impact of body mass index on the relationship between muscle quality and physical function in older women.
      ,
      • Kong H.H.
      • Won Won C.
      • Kim W.
      Effect of sarcopenic obesity on deterioration of physical function in the elderly.
      ,
      • Sardinha L.B.
      • Cyrino E.S.
      • Santos L dos
      • Ekelund U.
      • Santos D.A.
      Fitness but not weight status is associated with projected physical independence in older adults.
      ,
      • Puzianowska-Kuznicka M.
      • Kuryłowicz A.
      • Walkiewicz D.
      • Borkowska J.
      • Owczarz M.
      • Olszanecka-Glinianowicz M.
      • et al.
      Obesity Paradox in Caucasian Seniors: Results of the PolSenior Study.
      ] have investigated the association between overnutrition and physical function in community dwelling older adults. Some studies found that a BMI˂30 was associated with an improved physical function [
      • Puzianowska-Kuznicka M.
      • Kuryłowicz A.
      • Walkiewicz D.
      • Borkowska J.
      • Owczarz M.
      • Olszanecka-Glinianowicz M.
      • et al.
      Obesity Paradox in Caucasian Seniors: Results of the PolSenior Study.
      ], while other studies found that BMI and WC were not associated with physical function [
      • Sardinha L.B.
      • Cyrino E.S.
      • Santos L dos
      • Ekelund U.
      • Santos D.A.
      Fitness but not weight status is associated with projected physical independence in older adults.
      ,
      • Puzianowska-Kuznicka M.
      • Kuryłowicz A.
      • Walkiewicz D.
      • Borkowska J.
      • Owczarz M.
      • Olszanecka-Glinianowicz M.
      • et al.
      Obesity Paradox in Caucasian Seniors: Results of the PolSenior Study.
      ]. However, it has also been described that declined muscle quality was associated with a decline in physical function [
      • Brady A.O.
      • Straight C.R.
      • Schmidt M.D.
      • Evans E.M.
      Impact of body mass index on the relationship between muscle quality and physical function in older women.
      ,
      • Sardinha L.B.
      • Cyrino E.S.
      • Santos L dos
      • Ekelund U.
      • Santos D.A.
      Fitness but not weight status is associated with projected physical independence in older adults.
      ] and that the obesity sarcopenia affected physical function more negatively than obesity or sarcopenia alone [
      • Kong H.H.
      • Won Won C.
      • Kim W.
      Effect of sarcopenic obesity on deterioration of physical function in the elderly.
      ]. In summary, the studies indicate that physical function is impacted by the level of muscle mass, muscle quality and not by BMI alone.
      A recent cross-sectional study (n=295) found that community-dwelling older adults with low muscle mass but without poor physical performance had fewer disabilities with obesity compared to older adults with low muscle mass and physical function combined with other conditions (e.g. type 2 diabetes (T2D) and coronary disease) [
      • Chao Y.P.
      • Chen W.L.
      • Peng T.C.
      • Wu L.W.
      • Liaw F.Y.
      • Kao T.W.
      Examining the association between muscle mass, muscle function, and fat indexes in an elderly population.
      ]. Other studies verify the use of physical function as a prognostic indicator for disablement, frailty, nursing homes admission, hospitalization and mortality [
      • Buckinx F.
      • Aubertin-Leheudre M.
      Relevance to assess and preserve muscle strength in aging field.
      ,
      • Zoico E.
      • Di Francesco V.
      • Guralnik J.M.J.
      • Mazzali G.
      • Bortolani A.
      • Guariento S.
      • et al.
      Physical disability and muscular strength in relation to obesity and different body composition indexes in a sample of healthy elderly women.
      ,
      • Morley J.E.
      • Vellas B.
      • Abellan van Kan G.
      • Anker S.D.
      • Bauer J.M.
      • Bernabei R.
      • et al.
      Frailty consensus: A call to action.
      ,
      • Billot M.
      • Calvani R.
      • Urtamo A.
      • Sánchez-Sánchez J.L.
      • Ciccolari-Micaldi C.
      • Chang M.
      • et al.
      Preserving mobility in older adults with physical frailty and sarcopenia: Opportunities, challenges, and recommendations for physical activity interventions.
      ]. This supports that an approach for overnutrition in older adults including an assessment of physical function may provide a more meaningful approach than assessing overnutrition by BMIalone. On this basis, physical function is therefore included in the approach. In the community care setting, the selected physical function criteria include assessment of both muscle strength and physical performance.

      The significance of NCD in relation to overnutrition in older adults

      It is well established that excess fat mass in overnutrition in older adults contributes to a number of NCDs. NCDs are common among older adults, as a result of the metabolic changes associated with ageing, the accumulation of fat mass with a pro-inflammatory cascade of events such as intramuscular fat infiltration and insulin resistance occur [
      • Batsis J.A.
      • Villareal D.T.
      Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies HHS Public Access.
      ]. This negative interrelationship between adipose and muscle tissue [
      • Srikanthan P.
      • Karlamangla A.S.
      Muscle mass index as a predictor of longevity in older adults.
      ] is likely to be intensified by the presence of obesity-related NCDs such as cardiovascular disease [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Jahangir E.
      • De Schutter A.
      • Lavie C.J.
      Low weight and overweightness in older adults: risk and clinical management.
      ,
      • Amarya S.
      • Singh K.
      • Sabharwal M.
      Health consequences of obesity in the elderly.
      ], T2D [
      • Amarya S.
      • Singh K.
      • Sabharwal M.
      Health consequences of obesity in the elderly.
      ,
      • Nair K.S.
      Aging muscle.
      ] and chronic respiratory disease [
      • Mathus-Vliegen E.M.
      Obesity and the Elderly.
      ,
      • Villareal D.T.
      • Apovian C.M.
      • Kushner R.F.
      • Klein S.
      Obesity in older adults: Technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society.
      ].
      Most of these NCDs are associated with chronic or reoccurring inflammation of a mild to moderate degree [
      • Cederholm T.
      • Jensen G.L.
      • Correia M.I.T.D.
      • Gonzalez M.C.
      • Fukushima R.
      • Higashiguchi T.
      • et al.
      GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.
      ]. The inflammatory processes enhance the catabolism of muscle mass and catalyze the development of sarcopenia, especially at advanced age [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ,
      • Fielding R.A.
      • Vellas B.
      • Evans W.J.
      • Bhasin S.
      • Morley J.E.
      • Newman A.B.
      • et al.
      Sarcopenia: An Undiagnosed Condition in Older Adults. Current Consensus Definition: Prevalence, Etiology, and Consequences. International Working Group on Sarcopenia.
      ,
      • Beyer I.
      • Mets T.
      • Bautmans I.
      Chronic low-grade inflammation and age-related sarcopenia.
      ]. Overnutrition and chronic NCDs are an underlying cause of disability in older adults [
      • Fried L.P.
      • Guralnik J.M.
      Disability in older adults: Evidence regarding significance, etiology, and risk.
      ].
      Ageing in combination with overnutrition is considered a risk factor for morbidities (e.g. NCDs) and low-level inflammation [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ,
      • Mathus-Vliegen E.M.
      Obesity and the Elderly.
      ,
      • Stenholm S.
      • Harris T.B.
      • Rantanen T.
      • Visser M.
      • Kritchevsky S.B.
      • Ferrucci L.
      Sarcopenic obesity: Definition, cause and consequences.
      ], and current validated screening models and criterion aimed at identifying malnutrition, e.g. GLIM criteria, Nutritional Risk Screening 2002 (NRS-2002), Mini Nutritional Assessment Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST) include the presence of acute disease or injury and chronic disease [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ,
      • Cederholm T.
      • Jensen G.L.
      • Correia M.I.T.D.
      • Gonzalez M.C.
      • Fukushima R.
      • Higashiguchi T.
      • et al.
      GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.
      ,
      • Power L.
      • de van der Schueren M.A.E.
      • Leij-Halfwerk S.
      • Bauer J.
      • Clarke M.
      • Visser M.
      • et al.
      Development and application of a scoring system to rate malnutrition screening tools used in older adults in community and healthcare settings – A MaNuEL study.
      ]. If NCDs related to both overnutrition and age are included as a metabolic criterion, this will potentially create an accurate identification of overnutrition older adults in need of an intervention. Therefore, NCDs related to overnutrition are included in the approach.

      Classification of different categories of overnutrition

      Overnutrition and malnutrition are generally classified as two different clinical nutritional concepts, however ESPEN raises a concern regarding malnutrition among overnutrition persons with disease, injury or high energy poor quality diets [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ]. Excess fat mass may contribute to the formation of malnutrition by causing low-grade inflammation [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ]. However, it is unclear how the present diagnostic criteria (e.g. low BMI and weight loss) from ESPEN identify a possible concomitant presence of these conditions in older adults with overnutrition. Furthermore, the above-mentioned studies [
      • Brady A.O.
      • Straight C.R.
      • Schmidt M.D.
      • Evans E.M.
      Impact of body mass index on the relationship between muscle quality and physical function in older women.
      ,
      • Kong H.H.
      • Won Won C.
      • Kim W.
      Effect of sarcopenic obesity on deterioration of physical function in the elderly.
      ,
      • Sardinha L.B.
      • Cyrino E.S.
      • Santos L dos
      • Ekelund U.
      • Santos D.A.
      Fitness but not weight status is associated with projected physical independence in older adults.
      ,
      • Puzianowska-Kuznicka M.
      • Kuryłowicz A.
      • Walkiewicz D.
      • Borkowska J.
      • Owczarz M.
      • Olszanecka-Glinianowicz M.
      • et al.
      Obesity Paradox in Caucasian Seniors: Results of the PolSenior Study.
      ] underline the need for addressing physical function in these older adults when evaluating their nutritional status. overnutritionThe concept that overnutrition may hold a health risk especially in older adults with low physical function, i.e., muscle strength or physical performance or who have NCD combined with low physical function is the understanding that underlies the present proposed approach to identify overnutrition.

      Proposal for an approach for identifying overnutrition in community care settings among older adults who may benefit from nutritional interventions

      Against the background of the various factors described above and inspired by the classification of malnutrition and the GLIM criteria by Cederholm et al. [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ,
      • Cederholm T.
      • Jensen G.L.
      • Correia M.I.T.D.
      • Gonzalez M.C.
      • Fukushima R.
      • Higashiguchi T.
      • et al.
      GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.
      ], three different potential subgroups of older adults with overnutrition assessed as a high BMI (≥25 kg/m2) are suggested in our proposed approach: 1) overnutrition without NCD and with normal physical function, 2) overnutrition with NCD or low physical function, and 3) overnutrition with NCD and low physical function (Fig. 1).
      Fig. 1
      Fig. 1Classification of overnutrition relevant for identifying overnutrition among older adults who may benefit from nutritional interventions.

      Assessment criteria for the approach

      The assessment criteria for the approach and appropriate cut-off values are shown in Table 2 and discussed below. The physical function criteria include tests, tools and cut-off values for assessing muscle strength and physical performance recommended by the European Working Group on Sarcopenia in Older People (EWGSOP) [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ]. NCD criteria include disease burden including intermediates (BP, serum-lipids) assessed from medical records.
      Table 2Assessment criteria to be used for the approach for identifying older adults with overnutrition who may benefit from a nutritional intervention.
      OvernutritionPhysical function tests and criteriaNCD assessment criteria
      BMIANDLow muscle strengthORLow physical performanceAND/ORPresence of NCDs
      ≥ 25 kg/m2

      Body weight (kg) and height (m)
      Grip strength

      <20 kg for women and <27 kg for men [
      • Dodds R.M.
      • Syddall H.E.
      • Cooper R.
      • Benzeval M.
      • Deary I.J.
      • Dennison E.M.
      • et al.
      Grip Strength across the Life Course: Normative Data from Twelve British Studies.
      ]

      OR

      Chair stand test (chair rise test) five repetitions ˃ 11.4 sec (60–69 years), 12.6 s (70–79 years), and ˃14.8 sec. (80–89 years) [
      • Bohannon R.W.
      Reference values for the five-repetition sit-to-stand test: A Descriptive meta-analysis of data from elders.
      ]
      Gait speed <0.8 m/s [
      • Cruz-Jentoft A.J.
      • Baeyens J.P.
      • Bauer J.M.
      • Boirie Y.
      • Cederholm T.
      • Landi F.
      • et al.
      Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.
      ] or <1.0 m/s [
      • Fielding R.A.
      • Vellas B.
      • Evans W.J.
      • Bhasin S.
      • Morley J.E.
      • Newman A.B.
      • et al.
      Sarcopenia: An Undiagnosed Condition in Older Adults. Current Consensus Definition: Prevalence, Etiology, and Consequences. International Working Group on Sarcopenia.
      ]

      OR

      Short physical performance battery (SPPB)

      (≤8 point score) [
      • Guralnik J.M.
      • Ferrucci L.
      • Pieper C.F.
      • Leveille S.G.
      • Markides K.S.
      • Ostir G.V.
      • et al.
      Lower Extremity Function and Subsequent Disability: Consistency Across Studies, Predictive Models, and Value of Gait Speed Alone Compared With the Short Physical Performance Battery.
      ]

      OR

      Timed up-and-go test (TUG) (≥20 s) [
      • Bischoff H.A.
      Identifying a cut-off point for normal mobility: a comparison of the timed “up and go” test in community-dwelling and institutionalised elderly women.
      ]

      OR

      400-m walk (Completion time ˃6 min) [
      • Newman A.B.
      • Simonsick E.M.
      • Naydeck B.L.
      • Boudreau R.M.
      • Kritchevsky S.B.
      • Nevitt M.C.
      • et al.
      Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability.
      ]
      Yes/no

      Presence of cardiovascular disease, chronic respiratory disease and/or type 2-diabetes [
      • WHO
      ICD-10 Version:2019. World Health Organization.
      ] or hypertension [
      • Atasoy S.
      • Johar H.
      • Peters A.
      • Ladwig K.H.
      Association of hypertension cut-off values with 10-year cardiovascular mortality and clinical consequences: a real-world perspective from the prospective MONICA/KORA study.
      ,
      • Jellinger P.S.
      • Handelsman Y.
      • Rosenblit P.D.
      • Bloomgarden Z.T.
      • Fonseca V.A.
      • Garber A.J.
      • et al.
      American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease.
      ], hyperglycemia [
      • Atasoy S.
      • Johar H.
      • Peters A.
      • Ladwig K.H.
      Association of hypertension cut-off values with 10-year cardiovascular mortality and clinical consequences: a real-world perspective from the prospective MONICA/KORA study.
      ,
      • Jellinger P.S.
      • Handelsman Y.
      • Rosenblit P.D.
      • Bloomgarden Z.T.
      • Fonseca V.A.
      • Garber A.J.
      • et al.
      American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease.
      ] or hyperlipidemia [
      • Jellinger P.S.
      • Handelsman Y.
      • Rosenblit P.D.
      • Bloomgarden Z.T.
      • Fonseca V.A.
      • Garber A.J.
      • et al.
      American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease.
      ].

      Overnutrition: assessment of BMI

      The basic anthropometric data of body weight and height are essential for each risk screening, and calculating the BMI is the first step in approach. Weighing should be carried out in the morning before breakfast [
      • Spencer E.A.
      • Appleby P.N.
      • Davey G.K.
      • Key T.J.
      Validity of self-reported height and weight in 4808 EPIC–Oxford participants.
      ]. Due to loss of stature or vertebral compression, height can be difficult to measure precisely in older adults [
      • Sahyoun N.R.
      • Maynard L.M.
      • Zhang X.L.
      • Serdula M.K.
      Factors associated with errors in self-reported height and weight in older adults.
      ]. Height can also be measured in recumbent position [
      • Frid H.
      • Thors Adolfsson E.
      • Rosenblad A.
      • Nydahl M.
      Agreement between different methods of measuring height in elderly patients.
      ,
      • Luft V.C.
      • Beghetto M.G.
      • Castro S.M.J.
      • de Mello E.D.
      Validation of a New Method Developed to Measure the Height of Adult Patients in Bed.
      ] with minimal trouble to the older person. BMI is calculated as body weight (in kg) divided by the square of height (in m) [
      • York David
      (American association for the study of obesity), Lenfandt, Claude (national heart L and BI. The practical guide: identification, evaluation, and treatment of overweight.
      ].
      Based on the BMI, [
      • York David
      (American association for the study of obesity), Lenfandt, Claude (national heart L and BI. The practical guide: identification, evaluation, and treatment of overweight.
      ] overweight is defined as BMI ≥ 25 and <30 kg/m2 and obesity as BMI ≥ 30 kg/m2, aligned with WHO and ESPEN guidelines [
      • York David
      (American association for the study of obesity), Lenfandt, Claude (national heart L and BI. The practical guide: identification, evaluation, and treatment of overweight.
      ,].

      Physical function criteria: assessing muscle strength

      Muscle strength can be defined as “the amount of force a muscle can produce with a single maximal effort” [
      • Beaudart C.
      • Rolland Y.
      • Cruz-Jentoft A.J.
      • Bauer J.M.
      • Sieber C.
      • Cooper C.
      • et al.
      Assessment of muscle function and physical performance in daily clinical practice: a position paper endorsed by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).
      ]. In the present approach, muscle strength is evaluated by grip strength or the chair stand test (five times sit-to-stand) as suggested by EWGSOP [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ]. Grip strength is a simple tool that represents the hand and arm muscles and can be substituted by lower limb measurement in case of hand impairment [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ] (Table 2). The chair stand test measures the duration of time the participant needs to rise five times from a seated position without using the arms, and represents the strength of leg muscles [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ]. A variation of this test is the timed chair stand test, which counts how many times a participant can rise from and sit down on the chair during a 30-second interval [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ].

      Physical function criteria: assessing physical performance

      Various tests can be used to measure physical function in community health care settings, either as measurements of muscle function or as physical performance.
      As for assessing muscle strength EWGSOP recommendations are used similar to GLIM criteria. Gait speed is recommended for predicting and evaluating physical function related to sarcopenia [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ]. Additionally, the Short Physical Performance Battery (SPPB) is recommended and includes a balance test, habitual gait speed and the five-repetition chair stand test. [
      • Billot M.
      • Calvani R.
      • Urtamo A.
      • Sánchez-Sánchez J.L.
      • Ciccolari-Micaldi C.
      • Chang M.
      • et al.
      Preserving mobility in older adults with physical frailty and sarcopenia: Opportunities, challenges, and recommendations for physical activity interventions.
      ,
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ]. Timed Up and Go (TUG) is an assessment tool to determine mobility and includes timing rising from a chair, walking three meters, turning around a physical mark and walking back to the chair and sitting down [
      • Billot M.
      • Calvani R.
      • Urtamo A.
      • Sánchez-Sánchez J.L.
      • Ciccolari-Micaldi C.
      • Chang M.
      • et al.
      Preserving mobility in older adults with physical frailty and sarcopenia: Opportunities, challenges, and recommendations for physical activity interventions.
      ]. The 400-m walk test assesses mobility over a long distance, and participants are instructed to walk at a normal pace. The SPPB, TUG and 400-m walk are also recommended as assessment tools by EGWSOP to determine physical function [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ]. It is not necessary to implement all assessments – just one can be selected.

      NCD criteria: assessing the presence of NCD

      NCD information should be derived from medical/health care records and include cardiovascular diseases, chronic respiratory disease, T2Dand cancer [
      • Fried L.P.
      • Guralnik J.M.
      Disability in older adults: Evidence regarding significance, etiology, and risk.
      ].
      The key metabolic changes that increase the risk of NCDs are also included such as hypertension, hyperglycemia and hyperlipidemia.
      The presence of the diseases (Yes/No) will potentially identify older adults with adverse effects of overnutrition.
      Based on the above, the assessment criteria for the approach and appropriate cut-off values are shown in Table 2.
      When older adults with BMI ≥ 25 kg/m2 is classified according to the approach (Fig. 1), the next steps in the nutrition care process should followed according to ESPEN guidelines [
      • Cederholm T.
      • Barazzoni R.
      • Austin P.
      • Ballmer P.
      • Biolo G.
      • Bischoff S.C.
      • et al.
      ESPEN guidelines on definitions and terminology of clinical nutrition.
      ].

      Part 2:Nutritional interventions among older adults with overnutrition that are effective in improving or maintaining physical function and quality of life

      To validate the approach, a number of nutritional interventions were reviewed in order to determine whether the approach would identify older adults with Overnutrition in need of a nutritional intervention better than BMI itself. Table 3, Table 4 summarize the 10 intervention trials (described in 13 papers) that met our inclusion criteria [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ,
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. Details of the studies are shown in supplementary files.
      Table 3Nutritional interventions targeting older adults aged ≥ 65 and with a BMI ≥ 25 with NCD or low physical function.
      First author (year) and countryStudy design, sample size and durationStudy populationPhysical function assessment criteriaNCD assessment criteriaInterventionsOutcome measuresKey findings
      Ard (2016) USA [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ]
      RT, n = 28 Duration: 6 monthsCommunity dwelling Males and females

      70.3 yrs, Obese (BMI ≈ 41.5 kg/m2)
      NoT2D, hypertension and hyperlipidemiaWL + EX + IBC (n=14)

      WS + EX + IBC (n=14)

      No Control group
      BW, BC (DXA), physical performance (SPPB) and adverse event frequency.No changes (P ˃ 0.5) in physical function.
      Ard (2018) USA [
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ]
      RCT, n=164 Duration: 52 weeksCommunity dwelling Males and females

      70.3 ± 4.7 yrs

      Obese (BMI 30–40 kg/m2)
      NoT2D, hypertension, hyperlipidemiaWS + EX, (n=55)

      WL + EX, (n=55)

      EX, (n = 54)

      No control group
      BW, (VAT by MRI), SAT (DXA), BMD (DXA), Physical performance: 6MWT, SPPB, hand GS, knee extension strength and chair sit and reach test). QoL (SF-36v2) and Impact of Weight on Quality of Life-Lite.No changes (P ˃ 0.5) in physical function.

      WL group did not have P ˃ 0.5) loss of VAT or LM compared with EX at 12 months, despite a loss of BF and BW compared to the WS and EX groups.

      QoL improved in all groups.
      Beavers (2019) USA [
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ]
      RCT, n = 96, Duration: 6 monthsCommunity dwelling Males and females

      70.3 ± 3.7 yrs

      Obese (BMI 35.4 ± 3.3 kg/m2)
      Self-reported mobility disabilityNoWL, (n = 47)

      WS, (n = 49)

      No control group
      BW, self-reported meal replacement, 24-h urinary nitrogen level (urine samples), height, physical performance gait speed (400-m walk) and BC (DXA).No changes (P ˃ 0.5) in physical function.

      At 6 months, total body mass was reduced (P < 0.5) in the WL group compared with the WS group with 87% of total mass lost as fat. No change in lean mass.
      Frimel (2008) USA [
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ]
      RT, n = 30 Duration: 6 monthsCommunity dwelling Male and females

      70 ± 5 yrs

      Overnutrition (BMI 37 ± 5 kg/m2)
      Frailty meeting at least two of three of the criteria for mild to moderate physical frailtyNoneWL + IBC, n = 15)

      WL + IBC + EX, n = 15

      No control group
      BC (DXA), muscle strength

      (1-RM). The volume of UE and LE EX training
      WL+IBC+EX group increased UE and LE strength in response to exercise (17–43%), whereas the WL+ IBC group maintained strength.

      Both groups had similar (P > 0.05) decreases in weight, but the WL+IBC+EX group lost less FFM and LM (P < 0.05).
      Kelly (2011) USA [
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ]
      RT, n = 28 Duration: 12 weeksCommunity dwelling Males and females

      66 ± 1 yr

      Obese (BMI 34.2 ± 0.7 kg/m2)
      NoInsulin resistance (prediabetic)Low glycemic index diet + EX, (LGI, n = 13)

      High glycemic index diet + EX, (HGI, n = 15)

      No control group
      BC (DXA), oral glucose response, and inflammation (TNFα and IL-6).Both interventions decreased (P ˂ 0.05), BMI, fasting plasma glucose, and insulin. Markers of inflammation were lower (P = 0.02) in the LGI than in HGI.
      Muscariello (2016) Italy [
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ]
      RT, n = 104, Duration: 3 monthsOutpatients Females

      ≈66 yrs

      Obese (BMI ≈ 32 kg/m2)
      Sarcopenia defined according to the MM index.NoWL+NPI (0.8 g/kg/d of protein), (n = 50)

      WL+HPI (1.2 g/kg/d of protein), (n = 54)

      No control group
      BW, WC, BC (BIA), handgrip strength, dietary intake (FFQ) and physical activity (questionnaire IPAQ-SF)No change in muscle strength or physical activity

      Reductions in BMI in both groups; P ˂ 0.01.

      The MM index improved in both NPI and HPI groups, P ˂ 0.01 vs baseline.
      Nicklas (2018) USA [
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ]
      RT, n = 180 Duration: 20 weeksCommunity dwelling Male and females

      69.2 ± 3.5 yrs

      Obese (BMI ≈ 34.5 kg/m2)
      NoT2D, hypertension, hyperlipidemiaEX, (n = 44)

      WL (LCD), + EX (n=58)

      WL (VLCD) + EX, (n=53)

      No control group
      Peak aerobic capacity (VO2 peak) (treadmill exercise test). BC (DXA), lipid and glucose (blood samples). Physical performance (SPPB), (400-m walk). Self-reported disability (19-item questionnaire) Fatigue (Medical Outcome Study 36-item short-form measure)VO2 peak increased in all groups. No effects on physical function.

      LCD and VLCD groups had improvements in fatigue and disability compared to EX group.
      OvernutritionBC: Body composition; BF, Body Fat; BIA, Bioelectrical Impedance Analysis; BMD, Bone Mass Density; BMI, Body Mass Index; BW: Body weight; DBW, Desirable Body Weight; DXA, Dual-energy X-ray Absorptiometry; EX, Exercise; 1-RM, one-Repetition Maximum; FFQ, Food Frequency Questionnaire; GS, grip strength; HGI, High Glycemic Index; HPI, High Protein Intake; IBC, Individual Behavioral Counseling; IL-6, interleukin-6; IPAQ-SF, International Physical Activity Questionnaire – Short Form; LCD, Low Calorie Diet; LE, Low Extremity; LGI, Low Glycemic Index; LM, Lean Mass; MM, Muscle Mass; 6MWT, 6-Minute Walk Test; MRI, Magnetic Resonance Imaging; NPI, Normal Protein Intake; Overnutrition, Overweight and Obese; QoL, Quality of Life; RT, Randomized Trial; RCT, Randomized Controlled Trial; SAT, abdominal subcutaneous adipose tissue; SPPB, Short physical performance battery; TNF-α, Tumor Necrosis Factor α; T2D, Type 2 Diabetes; UE, Upper Extremity; VAT, Visceral Adipose Tissue; VLCD, Very Low Calorie Diet; VO2max, max/peak aerobic power; WC, Waist Circumference; WL, Weight Loss; WS, Weight Stable.
      Table 4Nutritional interventions targeting older adults aged ≥ 65 and with a BMI ≥ 25 with NCD and low physical function
      First author (year) and countryStudy design, sample size and durationStudy populationPhysical function assessment criteriaNCD assessment criteriaInterventionsOutcome measuresKey findings
      Haywood (2018) Australia [
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ]
      RT, n = 117 Duration: 12 weeksCommunity dwelling

      Male and females

      70 yrs

      Obese (BMI 40 kg/m2)
      Low/moderate functionT2D, hypertension and hyperlipidemiaHE + EX, (n = 36)

      WL (LCD) + EX (n = 40)

      WL (VLCD) + EX (n = 41)

      No control group
      Physical function (DEMMI and 6MWT), BC (DXA) bone mineral density (DXA), blood pressure, glucose monitoring and nutritional parameters.Physical function improved in all groups. All groups lost weight. VLCD group had significant reduction in FM, LM and BMD, but increased relative LM.
      Villareal (2006a) USA [
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ]
      RT, n = 27 Duration: 26 weeksCommunity dwelling

      Males and females

      ≈70 yrs

      Obese (BMI ≈ 39 kg/m2)
      Mild to moderate frailtyThe number of chronic diseases was 1.6 ± 0.8 (mean ±SD) in the control group and 2.0 ±0.7) (mean ±SD) in the intervention group.WL +EX (n = 17)

      Control group (n = 10)
      Physical function (PPT score, VO2 max, and Functional Status Questionnaire score), BC (DXA), Health-Related Quality-of-Life Assessment (The Medical Outcomes

      Survey 36-Item Short-Form Health Survey (SF-36))
      The PPT score (P =0.001), VO2 max (P–= 0.02), and Functional Status Questionnaire score (P = 0.02) improved in WL group compared with control group.

      WL group also improved strength, walking speed, obstacle course, 1-leg limb stance time, and health survey physical subscale scores (all P ˂ 0.05).

      The WL group lost 8.4%±5.6% of body weight, whereas weight did not change in the control group (P ˂ 0.001). Likewise, WL group lost FM but contained LM, unlike the control group.

      The WL group had improvements in QoL compared to the control group, though not significant.
      Villareal (2006b) USA [
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]

      Same study as 54
      RCT n = 27 Duration: 26 weeksOutpatients,

      Males and females

      ∼ 70 yrs

      Obese (BMI 39± 5 kg/m2)
      Mild to moderate frailtyMetabolic syndromeWL + EX (n = 17)

      Control group (n=10)
      WC, blood pressure, serum lipids, fatty acids and inflammatory markers, oral glucose intolerance test, metabolic syndrome criteria and BC (DXA)Changes in weight loss, WC, plasma glucose, serum triacylglycerols, and systolic and diastolic blood pressure were different between WL group and control group (P˂ 0.05 for all).

      The number of subjects with the metabolic syndrome decreased by 59% in WL group but did not change significantly in the control group (P ˂ 0.05).
      Villareal (2008) USA [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ]

      Same study as 54
      RCT, n = 27, Duration: 52 weeksCommunity dwelling

      Males and females

      70±5 yrs,

      Obese (BMI 39 ± 5 kg/m2)
      Mild to moderate frailty

      40% had sarcopenia
      Metabolic syndromeWL + EX (n = 17)

      Control group (n = 10)
      BW and BMD and BMC of the lumbar spine, proximal femur, and total body (DXA). Skeletal muscle mRNAs for TLR-4, MGF, TNFα, and IL-6 were also assessed.Relative improvements in strength, assessed by 1-RM, were detected for both upper body and lower body and all muscle groups (all P ˂ 0.05).

      Compared with the control group, WL group had greater changes in BMD, bone markers, and hormones.
      Villareal (2011) USA [
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ]
      RCT, n = 107

      Duration: 1 year
      Community dwelling Males and females

      ≈ 70 yr,

      Obese (BMI ≈37 kg/m2)
      Physical frailtyChronic disease and routine medicationsWL (n = 26)

      EX (n=26)

      WL+EX (n = 28)

      Control group, no treatment, (n = 27)
      Physical function (PPT), frailty, BC (DXA and MRI), BMD (MRI), and QoL (The Medical Outcomes 36-Item Short-Form Health

      Survey (SF-36))
      Physical function increased in all groups except the control group.

      BW decreased in WL group and in the WL+EX group, but did not decrease in the EX or control group

      QoL increased in all three groups
      ADL, Activities of Daily Living; BC, Body Composition; BIA, Bioelectrical Impedance Analysis; BMD, Bone Mass Density; BMI, Body Mass Index; BW, Body Weight; DBW, Desirable Body Weight; DEMMI, De Morton Mobility Index; DXA, Dual-energy X-ray Absorptiometry; EX, Exercise; HE, Healthy Eating advice; IL-6, InterLeukin-6; IPAQ-SF, International Physical Activity Questionnaire – Short Form; LCD, Low Calorie Diet; MGF, MechanoGrowth Factor; MM, Muscle Mass; MRI, Magnetic Resonance Imaging; 6MWT, 6-Minute Walk Test; NCEP ATP III, National Cholesterol Education Program's Adult Treatment Panel III; 1-RM, one-Repetition Maximum; Overnutrition, Overweight and Obese; PF, Physical function; PPT, modified Physical Performance Test; RT, Randomized Trial; RCT, Randomized Controlled Trial; SD, Standard Deviations; TLR-4, Toll-Like Receptor-4; TNF-α, Tumor Necrosis Factor α; T2D, Type 2 Diabetes; VAT, Visceral Adipose Tissue; VLCD, Very Low Calorie Diet; VO2max, max/peak aerobic power; WC, Waist Circumference; QoL, Quality of Life.

      Nutritional interventions targeting older adults with overnutrition without NCD and with normal physical function

      No trials within the pre-defined inclusion and exclusion criteria and search terms (Table 1) were found, and it is, therefore, unclear whether an intervention benefits older adults only with a BMI ≥ 25 and without NCD and with normal physical functionality.

      Nutritional interventions targeting older adults with overnutrition and either NCD or low physical function

      Seven studies were identified investigating nutritional interventions targeting older adults (age ≥ 65) with a BMI ≥ 25 and also NCDs or low physical function [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ] (Table 3 and supplementary files). Three of the studies included participants with a low physical function in relation to mobility disabilities and mild to moderate physical frailty and difficulty in or in need of assistance with activities of daily living [
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ] Additionally, the four other studies investigated older adults (age ≥ 65) with a BMI ≥ 25 and NCD [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ].
      Two trials by Ard et al. [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ] found no effects on physical function and no significant difference between groups in lean mass was found, although the intervention groups intendedly lost body weight and fat mass [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ], however quality of life (QoL) improved in all groups [
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ]. The studies investigated the effect of low energy diets combined with physical training in obese community dwelling older males and females suffering from T2D, hypertension and hyperlipidemia [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ]. A larger randomized trial from Nicklas et al. investigated the effects of exercise (EX) alone or EX with low calorie diet (LCD) or EX with very LCD (VLCD) on several metabolic parameters [
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ]. VO2 max increased in all groups, and there was a significant treatment effect, although no effect on physical function measures was found [
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ],oth groups had significant improvement in self-reported fatigue and disability compared to the EX group [
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ].
      In the study by Beavers et al., a weight loss intervention had no effects on physical function in the weight loss (WL) group compared to the weight stable (WS) group, although the WL group lost body weight and fat mass [
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ].
      Frimel et al. included community dwelling older adults with frailty and intervened either with WL alone or with WL and EX [
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ]. In this trial, loss of lean mass was prevented in the upper extremities, but not in the lower extremities. Both groups lost body weight, but the WL + EX group lost less lean mass and improved strength compared to the WL group (P < 0.05) [
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ]. The paper suggested that this improvement may be due to the effects of a decrease in muscle fat infiltration and inflammation associated with the loss of weight and body fat [
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ].
      Kelly et al. recruited community dwelling older adults with obesity and with insulin resistance [
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ] for an intervention containing either a low glycemic index (LGI of 40) diet and EX or high glycemic index (HGI of 80) diet and EX [
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ]. Both interventions decreased BMI (P ˂ 0.001), fasting plasma glucose and insulin (both P ˂ 0.05), although markers of inflammation were lower in the LGI compared to the HGI (P ˂ 0.05).
      Muscariello et al. reported no changes in physical function, although significant reductions in BMI were found in both intervention groups receiving either normal or high protein WL diets [
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ].
      In summary, all interventions aimed at inducing weight loss in the participating groups of older adults with either NCD and/or low physical function were successful. The combination of energy restriction and exercise showed the most significant results in relation to body weight [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ] and limited the loss of muscle mass [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ]. Although changes in body composition were achieved, significant improvements in physical function were observed only in one study [
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ] where exercise combined with a nutritional intervention reduced muscle mass loss during weight loss and increased muscle strength in frail obese older adults [
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ].

      Nutritional interventions targeting overnutrition older adults with both NCD and low physical function

      Three studies investigating nutritional interventions targeted at older adults aged ≥65 and with a BMI ≥ 25 in combination with NCD and low physical function are reported in six articles [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ,
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ,
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ] as described in Table 4.
      Haywood et al. reported improved physical function independent of intervention (EX+HE vs. EX+LCD vs. EX+VLCD) [
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ]. Weight was reduced in the EX+LCD and the EX+VLCD groups, while the EX+VLCD group had significant reductions in fat mass and lean mass but an increase in relative lean mass [
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ].
      Three papers by Villareal et al. (two in 2006 and one in 2008) reported the same cohort with an intervention consisting of WL and EX, compared to a control group [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. Energy deficiency was ≈750 kcal/day supplemented with a daily multivitamin tablet [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. Physical function improved significantly in modified physical performance test (PPT), max/peak aerobic power (VO2 max) test and functional status in the WL+EX group compared to the control group, and changes in body composition, decrease in body weight and fat mass decreased significantly in the intervention group [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. All cardiovascular risk factors improved significantly in the WL+EX group, and the number of subjects with the metabolic syndrome decreased by 59% in the WL + EX group [
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. In addition, an increase in bone turnover in response to weight loss was seen, but the clinical significance of the decrease in bone mass density was not clear as all participants had high baseline scores and there was no evidence of osteoporosis following the weight loss [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ]. It was suggested that weight loss reduced the mechanical stress on the hip without negatively altering the spine or wrist [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ].
      As in the other RCTs by Villareal et al. [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ], a fourth paper by Villareal et al. (2011) found changes in body composition and physical function, whereas WL was only achieved in the WLand WLt+EX groups and not in the EX or control group. Physical function and QoL improved significantly in all groups except for the control group [
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ].
      A follow-up study of the one-year lifestyle RCT by Villareal et al. (2011) [
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ] is reported by Waters et al. [
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ]. This shows that, except for the self-reported functional status and health-related QoL, which achieved the highest scores at 12 months, all measures remained improved relative to baseline at 30 months [
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ].
      In summary, the largest weight loss was seen in groups receiving calorie restrictions (WL) and EX combined [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ,
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ,
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. The combination of diet-induced WL and EX limited the loss of muscle mass [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ,
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ,
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ]. Unlike the trials described in Table 3 [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ], these studies report intervention effects on physical function or function [
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ,
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ,
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ] and on QoL [
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults.
      ,
      • Waters D.L.
      • Vawter R.
      • Qualls C.
      • Chode S.
      • Armamento-Villareal R.
      • Villareal D.T.
      Long-term maintenance of weight loss after lifestyle intervention in frail, obese older adults.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ]. [
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ] These studies also cover a range of complex nutrition and exercise interventions, though not as diverse as those in Table 3 [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ]. Only one study had no control group [
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ].
      The results in Table 4 show that older adults with overnutrition and NCD and low physical function may gain positive effects from nutrition and EX interventions on physical function, body composition and QoL. Additionally, the studies report other beneficial effects on metabolic syndrome. The results of these trials also show that there is no difference in outcomes of physical function or QoL, regardless of whether the interventions include a weight stable or a weight loss intervention combined with exercise. No serious adverse effects was found in any of the intervention studies (Table 3, Table 4).

      Discussion

      The present opinion paper proposes a novel approach that combines a measure of BMI with a physical function criterion and a NCD criteria for identifying older adults with overnutrition who may benefit from a nutritional intervention. The novelty of the present approach is that in addition to BMI, the presence of overnutrition is combined with the presence of NCD and low physical function i.e. low muscle strength and physical performance.
      The approach was developed for use in a community health care setting, and the criteria were defined by reliable tests available in community health care settings. Aligned with the EWGSOP consensus, muscle strength and physical function are criteria for risk screening of reduced muscle mass. The purpose of the approach is not to diagnose sarcopenia, but to use the framework provided by EWGSOP to identify overnutrition older adults in need of a nutritional intervention. Presumably some older adult have low physical function without sarcopenia, and they are also in need of a nutritional intervention.
      The cut-off values used in the approach are based on current knowledge and might be inadequate, especially for the BMI.
      Limitations of using BMI as a measure alone is that BMI does not take body composition and fat distribution into account. Therefore the use of BMI alone is associated with certain limitations that may alter the relation between overnutrition and mortality, which partly explains the obesity paradox. Nevertheless, a BMI ≥25 is included and referred to as a high BMI in the approach, despite the ongoing debate concerning the cut-off values for older adults [
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ,
      • Heiat A.
      • Vaccarino V.
      • Krumholz H.M.
      An evidence-based assessment of federal guidelines for overweight and obesity as they apply to elderly persons.
      ,
      • Elia M.
      Obesity in the Elderly.
      ,
      • Bales C.W.
      • Buhr G.
      Is Obesity Bad for Older Persons? A Systematic Review of the Pros and Cons of Weight Reduction in Later Life.
      ,
      • Decaria J.E.
      • Sharp C.
      • Petrella R.J.
      Scoping review report: Obesity in older adults.
      ].
      Muscle strength and physical performance are considered accurate indicators for reduced physical function, at least when the objective is not to try to identify sarcopenia or obesity sarcopenia. Assessing muscle strength and physical performance is a key step in identifying older adults with overnutrition who might benefit from an intervention. The absence of these parameters is a limitation in existing validated assessment tools (NRS-2002, MNA -SF and MUST [
      • Rubenstein L.Z.
      • Harker J.O.
      • Salva A.
      • Guigoz Y.
      • Vellas B.
      Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini-Nutritional Assessment (MNA-SF).
      ,
      • Kondrup J.
      • Ramussen H.H.
      • Hamberg O.
      • Stanga Z.
      • Camilo M.
      • Richardson R.
      • et al.
      Nutritional risk screening (NRS 2002): A new method based on an analysis of controlled clinical trials.
      ,
      • Power L.
      • de van der Schueren M.A.E.
      • Leij-Halfwerk S.
      • Bauer J.
      • Clarke M.
      • Visser M.
      • et al.
      Development and application of a scoring system to rate malnutrition screening tools used in older adults in community and healthcare settings – A MaNuEL study.
      ]).
      Muscle strength and physical function can be measured in various ways, but the present opinion paper chooses to focus on tests included in the EWGSOP consensus [
      • Cruz-Jentoft A.J.
      • Bahat G.
      • Bauer J.
      • Boirie Y.
      • Bruyère O.
      • Cederholm T.
      • et al.
      ].
      Regarding co-morbidities and inflammation, NCD associated with overnutrition includes cardiovascular disease [
      • Kalish V.B.
      Obesity in older adults. Vol.43, Primary Care - Clinics in Office Practice.
      ], chronic respiratory disease, diabetes and cancer [
      • Amarya S.
      • Singh K.
      • Sabharwal M.
      Health consequences of obesity in the elderly.
      ,
      • Nair K.S.
      Aging muscle.
      ] Recognition of a disease and inflammation is, a widely accepted criterion in current screening tools such as NRS-2002 [
      • Kondrup J.
      • Allison S.P.
      • Elia M.
      • Vellas B.
      • Plauth M.
      ESPEN guidelines for nutrition screening 2002.
      ] and MNA-SF [
      • Rubenstein L.Z.
      • Harker J.O.
      • Salva A.
      • Guigoz Y.
      • Vellas B.
      Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini-Nutritional Assessment (MNA-SF).
      ]. However, mild to moderate inflammation requires laboratory indicators such as serum C-reactive protein, TNF-α, interleukins, albumin and pre-albumin [
      • Cederholm T.
      • Jensen G.L.
      • Correia M.I.T.D.
      • Gonzalez M.C.
      • Fukushima R.
      • Higashiguchi T.
      • et al.
      GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.
      ,
      • Pawelec G.
      • Goldeck D.
      • Derhovanessian E.
      Inflammation, ageing and chronic disease.
      ] and is not necessarily obtained in community health care settings, and therefore the present approach focuses on the presence of NCD as a determinant for inflammation. Obesity-related comorbidities such as osteoarthritis may also be relevant to include, and may be a short coming to this approach.
      To validate the approach, a number of nutritional intervention trials included in the literature search were reviewed. Our literature search to identify relevant intervention studies in the particular target group and settings revealed that interventions have, to a large extent, been performed in the target group of older overweight or obese subjects with either NCD or low physical function at baseline.
      No studies were identified in older overnutrition without disease and with normal physical function, which probably illustrates the “obesity paradox” in real life where it is uncertain whether or not overnutrition alone is beneficial for physical function. It remains unclear whether this group of older adults would benefit from a nutritional intervention or perhaps some of these individuals appeared in the study control groups. Besides, ethical considerations may speak against intervening a healthy group of older adults.
      Seven studies targeted older adults (age ≥ 65) with a BMI ≥ 25 and NCD or low physical function [
      • Ard J.D.
      • Cook M.
      • Rushing J.
      • Frain A.
      • Beavers K.
      • Miller G.
      • et al.
      Impact on weight and physical function of intensive medical weight loss in older adults with stage II and III obesity.
      ,
      • Ard J.D.
      • Gower B.
      • Hunter G.
      • Ritchie C.S.
      • Roth D.L.
      • Goss A.
      • et al.
      Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.
      ,
      • Beavers K.M.
      • Nesbit B.A.
      • Kiel J.R.
      • Sheedy J.L.
      • Arterburn L.M.
      • Collins A.E.
      • et al.
      Effect of an Energy-Restricted, Nutritionally Complete, Higher Protein Meal Plan on Body Composition and Mobility in Older Adults With Obesity: A Randomized Controlled Trial.
      ,
      • Frimel T.N.
      • Sinacore D.R.
      • Villareal D.T.
      Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults.
      ,
      • Kelly K.R.
      • Haus J.M.
      • Solomon T.P.J.
      • Patrick-Melin A.J.
      • Cook M.
      • Rocco M.
      • et al.
      A Low-Glycemic Index Diet and Exercise Intervention Reduces TNFα in Isolated Mononuclear Cells of Older, Obese Adults.
      ,
      • Muscariello E.
      • Nasti G.
      • Siervo M.
      • Di Maro M.
      • Lapi D.
      • D’Addio G.
      • et al.
      Dietary protein intake in sarcopenic obese older women.
      ,
      • Nicklas B.J.
      • Brinkley T.E.
      • Houston D.K.
      • Lyles M.F.
      • Hugenschmidt C.E.
      • Beavers K.M.
      • et al.
      Effects of Caloric Restriction on Cardiorespiratory Fitness, Fatigue, and Disability Responses to Aerobic Exercise in Older Adults With Obesity: A Randomized Controlled Trial.
      ] (Table 3). The studies were very heterogeneous, with a broad range of complex nutritional and exercise interventions. None of the studies included a control group, which is a major limitation. However, all interventions had positive effects on WL and body composition, and the studies generally indicate that identifying this group of overnutrition older adults, as suggested in the approach, offers a beneficial tool to the community care setting. Overall, these studies reported that the combination of diet-induced WL and EX resulted in the most significant WL, while still limiting the loss of muscle mass.
      Three studies (six papers) were identified targeting older adults aged ≥ 65 with a BMI ≥ 25 and NCD and low physical function [
      • Waters D.L.
      • Ward A.L.
      • Villareal D.T.
      Weight loss in obese adults 65 years and older: A review of the controversy.
      ,
      • Villareal D.T.
      • Shah K.
      • Banks M.R.
      • Sinacore D.R.
      • Klein S.
      Effect of Weight Loss and Exercise Therapy on Bone Metabolism and Mass in Obese Older Adults: A One-Year Randomized Controlled Trial.
      ,
      • Haywood C.J.
      • Prendergast L.A.
      • Purcell K.
      • Le Fevre L.
      • Lim W.K.
      • Galea M.
      • et al.
      Very Low Calorie Diets for Weight Loss in Obese Older Adults—A Randomized Trial.
      ,
      • Villareal D.T.
      • Banks M.
      • Sinacore D.R.
      • Siener C.
      • Klein S.
      Effect of weight loss and exercise on frailty in obese older adults.
      ,
      • Villareal D.T.
      • Miller B.V.
      • Banks M.
      • Fontana L.
      • Sinacore D.R.
      • Klein S.
      Effect of lifestyle intervention on metabolic coronary heart disease risk factors in obese older adults.
      ,
      • Villareal D.T.
      • Chode S.
      • Parimi N.
      • Sinacore D.R.
      • Hilton T.
      • Armamento-Villareal R.
      • et al.
      Weight loss, exercise, or both and physical function in obese older adults.
      ] (Table 4). Overall, the results of the interventions, which included nutritional and EX interventions, were positive in terms of body composition and WL. These studies included control groups, which strengthens the conclusion on the effects of the interventions. The studies covered a range of complex nutritional and EX interventions, and they reported positive effects of the nutritional interventions on physical function or function and on QoL. Although only a few studies were available, and since they had a control group, compared to the studies on overnutrition with either NCD or low physical function, the overall results confirm that older adults in community health care settings with overnutrition and NCD and low physical function gain positive effects from nutritional interventions on physical function, body composition and QoL.
      Even though the included trials and a large number of reviews [
      • Dimilia P.R.
      • Mittman A.C.
      • Batsis J.A.
      Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity.
      ,
      • Goisser S.
      • Kemmler W.
      • Porzel S.
      • Volkert D.
      • Sieber C.C.
      • Bollheimer L.C.
      • et al.
      ,
      • Theodorakopoulos C.
      • Jones J.
      • Bannerman E.
      • Greig C.A.
      ,
      • Bales C.W.
      • Starr K.N.P.
      Obesity interventions for older adults: Diet as a determinant of physical function.
      ,
      • Jiang B.C.
      • Villareal D.T.
      Therapeutic and lifestyle approaches to obesity in older persons.
      ,
      • Martínez-Amat A.
      • Aibar-Almazán A.
      • Fábrega-Cuadros R.
      • Cruz-Díaz D.
      • Jiménez-García J.D.
      • Pérez-López F.R.
      • et al.
      Exercise alone or combined with dietary supplements for sarcopenic obesity in community-dwelling older people: a systematic review of randomized controlled trials.
      ,
      • Liao C.-D.
      • Tsauo J.-Y.
      • Wu Y.-T.
      • Cheng C.-P.
      • Chen H.-C.
      • Huang Y.-C.
      • et al.
      Effects of protein supplementation combined with resistance exercise on body composition and physical function in older adults: a systematic review and meta-analysis.
      ,
      • Yin Y.H.
      • Liu J.Y.W.
      • Välimäki M.
      Effectiveness of non-pharmacological interventions on the management of sarcopenic obesity: A systematic review and meta-analysis.
      ,
      • Bouchonville M.F.
      • Villareal D.T.
      Sarcopenic obesity: How do we treat it?.
      ] suggest interventions that combine nutrition and exercise, more research in this particular target group and specific community health care setting is needed. Lack of scientific evidence in this field is a major barrier to any actions that might be taken in this area. It seems like both groups with older adults with either NCD or low physical function or older adults with both NCD and low physical function, gain positive effects from a nutritional intervention. However, knowledge on which nutritional intervention is safe and beneficial for the different needs of older adults with overnutrition is lacking [
      • Cetin Derrick C.
      • Gaelle N.
      Obesity in the elderly: More complicated than you think.
      ]. Assessing overnutrition, not only by BMI classification but also by considering overnutrition combined with low physical function and/or related to disease and inflammation (Fig. 1) may enlighten the obesity paradox and partly explain why excess fat mass appears to be protective in some older adults and related to morbidity, mortality and disabilities in others.
      Lack of evidence in this field is largely due to the absence of consensus on definitions and cut-off points and terms, making it hard to compare results of the different studies [
      • Goisser S.
      • Kemmler W.
      • Porzel S.
      • Volkert D.
      • Sieber C.C.
      • Bollheimer L.C.
      • et al.
      ]. However, it may also be explained by the inclusion and exclusion criteria used in past research. To overcome some of these confounding factors and hopefully enhance our understanding of who will benefit from the most nutritional interventions and not merely who is overnutrition, the approach presented in this paper may prove to be a valuable assessment tool. Clearly, the approach requires validation to be further tested and qualified and adjustments made if necessary. However, when applying the approach retrospectively to recent trials carried out including older adults with overnutrition, the criteria of the approach seem to be promising.

      Conclusion

      For identification in community health care settings of older adults with overnutrition who may benefit from nutritional interventions, we propose an approach using a BMI of ≥ 25 kg/m2 and at least one physical functional criterion (muscle strength or physical performance) or one metabolic criterion (NCDs) as inclusion criteria. We also propose cut-off values adapted to older adults in community care settings. The proposed approach was supported by a narrative literature review, that suggested that interventions combining nutrition and exercise interventions had positive effects on physical function and quality of life, especially on older adults with functional limitations and NCDs.
      The narrative literature review also revealed a high heterogeneity of nutritional intervention studies in older adults with overnutrition in community health care settings and more research in this particular target group and specific community health care setting is needed.

      Statement of authorship

      Tenna Christoffersen: Conceptualization, Methodology, Investigation, Writing – Original draft, Writing – Review & Editing. Anne Marie Beck: Conceptualization, Methodology, Investigation, Writing – Original draft, Writing – Review & Editing. Inge Tetens: Conceptualization, Methodology, Investigation, Writing – Original draft, Writing – Review & Editing. Anja Weirsøe Dynesen: Conceptualization, Methodology, Project administration, Investigation, Writing – Original draft, Writing – Review & Editing. Margit Dall Aaslyng: Supervision, Writing – Review & Editing.

      Conflict of Interest Statement and Funding sources

      The authors declare no conflict of interest.

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