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Risky Business – A Geriatric Education Day

Ottawa, May 5th, 2014.

Obesity Reduction in Older Adults:


Does Exercise Modality Matter?

Robert Ross
PhD, FACSM, FAHA
School of Kinesiology and Health Studies
Medicine, Division of Endocrinology and Metabolism
Queen’s University
Kingston, Ontario, Canada
Faculty/Presenter Disclosure

• Faculty: Robert Ross

• Relationships with commercial interests:


– Grants/Research Support: CIHR
– Speakers Bureau/Honoraria: Canadian Sugar Institute,
Therathecnologies
– Consulting Fees: University of Copenhagen
Bias declaration is that:

Body weight is not a good


primary outcome for strategies
designed to manage obesity
and related health risks.
Adults
Health Risk

Public interpretation for


obesity management?
Weight Loss is required
No weight loss is a failure

23-25 High
Body Mass Index
Optimal Weight Loss Recommendations

Adults
Health Risk

Clinically significant weight loss = greater than 5%

Less than 3% = weight maintenance

Body Mass Index


Does Successful Obesity Management Require
Weight Loss?

Adults
Obesity Management – Desired Outcomes
Health Risk

Decrease total adiposity

Decrease abdominal adiposity

Maintain/increase lean mass


Decrease functional limitation
Improve Cardiorespiratory Fitness
Decrease cardiometabolic risk factors

Body Mass Index


Obese Elderly: The Merging of Two Epidemic Trends

Abdominal /
Visceral Fat

Upper
Body Health Risk

Lower
Body
Skeletal Muscle
Subcutaneous Fat
Issues with aging
62 year old 80 year old
Abdominal Abdominal
Subcutaneous Subcutaneous
3.3 kg 2.9 kg

Visceral Fat Visceral Fat


3.8 kg 6.8 kg

Leg muscle Leg muscle


17.5 kg 10.3 kg

7.5 mg/kg/min Insulin Sensitivity 3.4 mg/kg/min

Functional Fitness 30% less


Issues with aging

 Aging
population
Issue #1 Issue #2

 Abdominal  Muscle
obesity mass

Insulin resistance  Mobility and function


 Metabolic Risk
Preventing and Treating Skeletal Muscle Loss
Exercise Modality

Skeletal Muscle in Athletes and


Sedentary Controls by Age

20

15

10

0
Young Old Old Old
Sedentary Sedentary Aerobic Strength

H. Klitgard et al., Acta Phsyiol Scand 1990;140:41-54


Preventing and Treating Sarcopenia
Muscle Hypertrophy in Response to a
Laboratory-Based Strength Training Program

80 •Resistance ; Nautilus
•8 exercises
75
13%
•To volitional fatigue
14%
70 8%
8% baseline
65 week 6
60 week 12

55

50
Right Leg Left Leg

W.R. Frontera et al., J Appl Physiol 1988;64:1308-44


Decreasing Health Risk and Improving Functional
Capacity in Older Adults

Which modality of exercise is optimal?

Aerobic Resistance
Exercise AE + RE
Exercise
 Abd fat  Abd fat  Abd fat
 Muscle  Muscle  Muscle

Which modality is optimal for decreasing abdominal obesity,


insulin resistance and increasing functional capacity?
Effects of Exercise Modality on Insulin
Resistance and Functional Capacity in Aging: A
Randomized Controlled Trial
Treatment Groups
1. Control (N=28)

Random 2. Resistance Exercise (N=36)


Allocation
3. Aerobic Exercise (N=37)

4. Resistance and Aerobic (N= 35)

Abdominally Obese Men and Women (Age ~68yrs) : 6 month


exercise intervention, without caloric restriction.

Davidson et al. Arch Intern Med 169(2): 122-131, 2009.


Recruit
Testing Protocol
VO2max VO2max VO2max
Consent FFT FFT FFT FFT
MRI MRI
Clamp Clamp

6-month intervention
Dietary run-in OGTT
period
(3-4 wks)

C: Normal lifestyle RE: Weights AE: Treadmill RAE: Weights 3x/wk +


3x/wk 5x/wk Treadmill 3x/wk
Visceral Fat, Skeletal Muscle,
and Insulin Resistance
Magnetic Resonance Imaging

Hyperinsulinemic Euglycemic Clamp


Anthropometrics

• Height
• Weight
• Skinfolds
– 7-site
• Circumferences
– Abdominal
– Appendicular
Cardiorespiratory and functional fitness
Functional fitness tests
Maximal graded Chair stands
exercise test (VO2max) Arm curls
2-minute step
8-foot up and go
Effects of Exercise Modality on
Cardiorespiratory Fitness in Older Men and Women

*
Percent Change (%)

150 Minutes
* 90 Minutes
walking / wk walking / wk

Control Resistance Aerobic Aerobic and


Exercise Exercise Resistance
Exercise
Effect of Fatness (BMI) and Fitness on
Cardiovascular Disease (CVD) Mortality
Wei M et al. JAMA 1999; 282:1547-53
RR of CVD Mortality

4.5

3
Fit
Unfit
1.5

0
Normal Weight Overweight Obese

“Fit” – top 80 percent – 30 minutes per day of physical activity


Metabolic Syndrome, Fitness, and Mortality
Katzmarzyk et al. Arch Intern Med 2004;164: 1092-7.

CVD Mortality Among 19,223 Men from the Aerobics Center


Longitudinal Study: 10 Years of Follow-up
Unfit Fit
CVD death rate per 10 000 man-y

25

20

15

10

0
Healthy Metabolic Syndrome

“Fit” – top 80 percent ~ 30 minutes per day of physical


Effects of Exercise Modality on Body Weight and
Waist Circumference in Older Men and Women

Control Resistance Aerobic Aerobic and


1 Exercise Exercise Resistance
Exercise
0
Percent Change

-1

-2

-3
* *†
-4 *†

-5 *†
*

-6 Body Weight Waist Circumference


Effects of Exercise Modality on Visceral Fat, Total
Fat and Skeletal Muscle in Older Men and Women

5 *‡ *‡
Percent Change (%)

0 Skeletal Muscle

Visceral Fat
-5
Abdominal Fat

Total Fat
-10 *†
* * *†
*
-15 *

-20 Control Resistance Aerobic Aerobic and


Exercise Exercise Resistance
Exercise
Exercise Modality on Skeletal Muscle Mass
in Older Adults
Diff from Control (p<0.05)
* Diff from AE (p<0.05)
+
Change in Skeletal Muscle (kg)

*+
1 *+

-1

Control RE AE RE + AE
-2

Davidson et al. Arch Intern Med 169(2): 122-131, 2009.


Effects of Exercise Modality on Insulin Sensitivity
in Older Men and Women
*
60 †
Insulin Sensitivity (%)

50
Percent Change in

40 *

30
20
10
0
Control Resistance Aerobic Resistance and
Exercise Exercise Aerobic
Exercise
Effects of Exercise Modality on Functional
Limitation in Older Men and Women

*‡
30
Percent Change (%)

20 *

10

0
Control Resistance Aerobic Resistance and
Exercise Exercise Aerobic
Exercise
Effects of Exercise Modality on Insulin
Resistance and Functional Capacity in Aging: A
Randomized Controlled Trial

Davidson et al. Arch Intern Med 169(2): 122-131, 2009.


Decrease Abdominal Fat and Increase Skeletal Muscle
Associated with Improvement in Functional Capacity

60
Functional Capacity
% Improvement in

50
40
30
High
20
Mid
10
Low Muscle Gain
0 (kg)
High Mid Low
Abdominal Fat Loss (kg)
Principal Finding
150 minutes of weekly exercise

Reduction of abdominal and visceral fat

Increase in skeletal muscle mass

Improvement in insulin resistance

Improvement in cardiorespiratory fitness

Balanced diet, exercise, no weight loss

Davidson et al. Arch Intern Med 169(2): 122-131, 2009.


SUMMARY
AHA and ACSM advocate that regular physical activity is essential for
healthy aging. That older adults engage in both exercise modalities to
reduce the risk factors for chronic disease and disability.

MSSE 39:(8) 1435-1445, 2007.


Canada’s Physical Activity Guides

Canadian Society for Exercise Physiology ; www.csep.ca


Rethink your Treatment Targets
For management of obesity and related health risk,
we must look beyond weight loss as the only
indicator of therapeutic/treatment success.

Physical Activity /
Exercise

Healthy Eating
Habits
For Reducing Obesity and Related Health Risk,
Exercise Without (minimal) Weight Loss is Not a Failure
Ross et al. Ann Intern Med (2001) ; Ross et al. Obesity Research (2004)
Waist Circumference Reduction

Obese Men and Women


8
Winner!
6
Decrease in abdominal and visceral Fat
4
Decrease waist circumference
2 BENEFITS Increase in skeletal muscle mass

0 Control Weight No Weight


Increase cardiorespiratory fitness
Loss Loss
Decrease blood pressure
Exercise

No Change
in BMI
Importance of Self-Monitoring – Role for Pedometers

Accumulate 15-30 minutes per day

2000 extra steps / day


Acknowledgement
Research Funding

Canadian Institutes of Health Research (CIHR)


Institute of Nutrition, Metabolism and Diabetes

Thank You