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The Journal of Nutrition, Health & Aging©Volume 8, Number 2, 2004

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Introduction

The proportion of the Chilean population over 60 years ofage is increasing rapidly. Presently, 10.5% of the nationalpopulation is over 60. Based on the Chilean Census, by 2025,the percent will increase to 16% (1). Three major reasons forthe increase are a decline in absolute mortality rates, arelatively recent decline in the number of births which hasshifted the mean age of the population toward the elderly, andan extension of life expectancy.

Elders are more prone to nutritional deficiencies, which inturn cause significant functionally adverse consequences. Themain reasons for their deficiencies are social isolation, poverty,an increased prevalence of gastrointestinal disturbances,changes in metabolic and synthetic function, alterations innutrient requirements and alterations in taste sensation. AChilean survey showed that mean protein intake was 54 g/dayin poor male elders and 57 g/day in females. This intake isbelow the recommendation for healthy young adults. Likewise,intake of most micronutrients were below recommended dailyallowances also (2) .

Among lifestyle factors, the lack of physical exercise is oneof the most important predictors of disability in the elderly (3).Therefore, an important adjunct to a good provision of nutrientsto improve muscle mass and function, should be muscletraining. Strength training of lower limbs in frail eldersimproves muscle function, size and mobility and reduces gait

instability (4,5). However, the long term beneficial effects of aphysical activity program for the elderly, can be hampered by alack of compliance to the exercise protocols. A 18 monthsexercise intervention in community dwelling older personsshowed an attrition rate of 36% (6). The lack of compliance canalso limit the possible beneficial effects of a long termnutritional supplementation program in this age group.

In May 1999, the Chilean government started to provide aspecially devised food supplement to 70,000 free-livingsubjects of 70 years old or older, in the metropolitan area ofSantiago. For economical reasons, not all elders were benefitedwith this nutritional supplement and only some publicoutpatient clinics were randomly chosen to participate in thisprogram. All elders attending the benefited clinics, irrespectiveof their nutritional status or economical condition, were eligibleto receive the nutritional product.

Nutritional supplementation and training could eventuallyhave additive effects on outcomes such as muscle strength andfunctionality. Moreover, the feasibility of implementing longterm training programs at the primary care level, using simpledevices and limited resources, has not been explored.Therefore, the aim of this study was to assess the effects of aone year controlled trial of nutritional supplementation andresistance exercise training on muscle strength in a group ofhealthy free living Chilean elderly subjects.

NUTRITIONAL SUPPLEMENTATION AND TRAINING IN THE ELDERLY

EFFECTS OF NUTRITIONAL SUPPLEMENTATION AND RESISTANCETRAINING ON MUSCLE STRENGTH IN FREE LIVING ELDERS.

RESULTS OF ONE YEAR FOLLOW

D. BUNOUT1,2, G. BARRERA1, P. DE LA MAZA1, M. AVENDAÑO1, V. GATTAS1, M. PETERMANN1, S. HIRSCH1

1. Institute of Nutrition and Food Technology (INTA) and 2. Faculty of Medicine, University of Chile. Mailing address: Daniel Bunout, INTA, University of Chile, PO Box 138-11,

Santiago, Chile, Fax: 56 (2) 2214030, E mail: [email protected]

Abstract: Purpose: To assess the effects of a one year nutritional supplementation and resistance trainingprogram on muscle strength and walking capacity in the elderly. Material and methods: Elderly subjects fromtwo outpatient clinics received a nutritional supplement, that provided 400 Kcal, 15 g/protein and 50% ofvitamin DRVs per day. Half the subjects receiving and not receiving the supplement were randomly assigned to aresistance exercise training program with two sessions per week. Every six months, body composition usingDEXA, limb muscle strength, maximal inspiratory and expiratory pressures and walking capacity were assessed.Results: One hundred forty nine subjects were considered eligible and 101 (31 supplemented and trained, 28supplemented, 16 trained and 26 without supplementation nor training) completed the year of follow up. Overallcompliance with the supplement was 48 ± 22 % and trained subjects attended 56 ± 21% of programmed sessions.No changes in fat free mass were observed in any of the groups, but fat mass increased from 22.5 ± 7.3 to 23.2 ±7.3 kg in all groups (p < 0.001). Upper and lower limb strength and walking capacity increased significantly intrained subjects whether supplemented or not. Maximal inspiratory pressure and right hand grip strengthincreased only in the supplemented and trained group. Conclusions: Resistance training improved musclestrength and walking capacity. .

Key words: Nutritional supplementation, elderly, resistance training, muscle strength.

Material and methods

The study population was selected from a group of healthy,non institutionalized elderly subjects, ascribed to three publicoutpatient clinics. These subjects are regularly controlled atthese clinics in a preventive geriatric program. We consideredeligible subjects aged 70 years or older, that were assigned tothree public outpatient clinics, two that were providing anutritional product delivered by the Government, (prepared as asoup or porridge and given as two daily snacks, composition intable 1) and one that was not delivering the supplement.Supplemented and non supplemented individuals wererandomly assigned to a resistance exercise training program orto a non training group, using a computer generated randomnumber list. Randomization was stratified by gender and age.Thus four groups of subjects were finally generated:supplemented and trained (SE), supplemented and non trained(SN), non supplemented and trained (NE) and nonsupplemented non trained (NN). We excluded all subjects withchronic debilitating diseases such as cancer, chronic infections,severe organ failure and diabetes mellitus. We also excludedsubjects that were not able to go to the clinic by their ownmeans and individuals with a minimental state examinationscore (7) of less than 20.

Table 1Nutritional composition of the product delivered to the Elderly

PER 100 g PER SERVING

Energy (Kcal) 400 200Protein (g) 13 6.5Saturated fat (g) 1.6 0.8Monounsaturated fat (g) 5.4 2.7Polyunsaturated fat (g) 4 2Cholesterol (g) 0 0Carbohydrates (g) 62.3 31.2Total fiber (g) 6.2 3.1Sodium (mg) 280 140Vitamins/minerals (%DRV*) 10 to 25 %

* DRV = Daily reference values

Subjects assigned to resistance exercise training were invitedto attend bi-weekly training sessions of one hour each. Trainingconsisted in a period of warming up and three levels of chairstands (five sets of 10 repetitions; levels included sitting andfake sitting with and without the use of arm supports), threelevels of modified squats (five sets of 10 repetitions; levelsincluded squats without therabands or with therabands toincrease gravitational force), three levels of step ups in a stair(ten sets of 10 repetitions; levels included one step, two stepsand two steps without using the hand rails) and six sets of 15repetitions of arm pull-ups using rubber bands that are colorcoded to confer progressive resistance (Thera-Bands, TheHygienic Corporation, Akron, OH, USA).. Quality of exercise

was visually determined by the range of movements and theabsence of substitution by other muscles. To determine whichcolor or rubber band should be used initially, 12 to 15repetitions of good quality exercise, until fatigue, were carriedout. In each exercise, subjects made three series of 10repetitions with the rubber bands. Respiratory muscle trainingwas done using threshold valves (Threshold inspiratory muscletrainer, HealthScan Products INC, Cedar Grove, NJ, USA)calibrated at 30% of maximal inspiratory pressure of eachindividual; three periods of 5 min each, separated by 3 min restwere carried out in each exercise session. Subjects were alsoengaged in walking periods of 15 min before and afterresistance training. Exercise was supervised by a specializedcoach according to the progression of each subject and basedon the Borg scale (8). Once the subject considered that aspecific exercise was light or very light (a score of eight or lessin the Borg scale), a higher level of difficulty was indicated orthe color of the rubber band changed. Attendance to eachtraining session was recorded to assess compliance with theexercise program. The percentage of programmed sessions thatthe subject attended was calculated.

The follow up of these subjects started simultaneously withthe start of the nutritional supplementation program of thegovernment in May 1999. All individuals were subjected to fullassessments at the baseline period, six and twelve months offollow up, that included:

1. Clinical evaluation by a physician. Besides medicalassessment, the following instruments were applied: Katzactivities of daily living (maximum score 6), instrumentalactivities of daily living (maximum score 8), minimental stateexamination (maximum score 30), abbreviated geriatricdepression scale (worst score 15) (9) and the mini nutritionalassessment (maximum score 30. The cutoff nutritional risk isbelow 23.5 points ) (10).

2. Body composition was measured by dual energy X rayabsorptiometry (DEXA) in a Lunar DPX-L double beamdensitometer (Lunar Corporation, Madison, Wisconsin, USA,System 7660, Software 1.3z). Interassay variability of themethod is approximately 1% (11).

3. Hand grip strength was measured using a hand gripdynamometer (Therapeutic Instruments, Clifton NJ, USA) inboth hands.

4. Bilateral quadriceps and biceps isometric strength, weremeasured using a Nicholas Manual Muscle Tester (Model01160, Lafayette Instrument Company, Lafayette, IN, USA)according to the instructions provided by the manufacturer (12).

5. Maximal inspiratory and expiratory pressures weremeasured with a Collins Digital Pulmonary Manometer(Warren E Collins Inc Braintree MA, USA), according to theinstructions provided by the manufacturer. All measurementswere made at residual volume.

6. Endurance was measured as the distance that subjectscould walk at a constant pace in a flat surface during 12minutes.

THE JOURNAL OF NUTRITION, HEALTH & AGING©


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The nutritional product was delivered monthly and thesubjects were instructed to take the supplement between meals.Every month, all subjects were contacted personally or bytelephone, asking for compliance with the nutritional product(servings per day) and for the presence of adverse events. Incase of problems, subjects were booked to attend a specialclinic, available for all study subjects. A hot line was availablefor queries and subjects could attend the clinic if they felt theneed to do so. If a subject was admitted to a hospital, themedical record was reviewed, with authorization of treatingphysician. If a subject died, the exact cause of death wasrecorded. Non compliant subjects were visited at their housesand every effort was made to maintain them in the program.

Statistical analysisAs this was an open study, testers were not blinded to group

assignment. To avoid interobserver errors, all muscle strengthmeasurements were made by the same investigator. All patientrecords and laboratory results were kept in Fox Pro® databases.The national ID number (unique to each person) was used asthe main identifier. Statistical analysis was done using Statisticafor Windows® version 4.5 (StatSoft Inc, 1993) . Results areexpressed as mean ± standard deviations or as median and 95%confidence intervals for variables with a skewed distribution.Comparisons of basal data between study groups was doneusing one way ANOVA. Comparisons of the evolution ofparameters during the year of follow up, within and betweengroups, were done using ANOVA for repeated measures.Gender and depression scores were considered as covariates inthe analysis. Post hoc comparisons between groups, when thetwo way interaction yielded significant changes, was doneusing the Newman Keuls test.

This study was approved by INTA´s ethics committee andall subjects signed an informed consent before entry into thestudy.

Results

Eighty four subjects receiving the nutritional supplement and65 non supplemented individuals were considered eligible forthe study. Subject flow is shown in figure 1.

The basal demographic, anthropometric and laboratoryvalues of the 101 followed individuals are depicted in table 2and 2a. The NE group had a higher depression score than therest of the groups. All other parameters did not differ betweengroups. Mean body mass index was 27.4 ± 4.6 kg/m2. Sixsubjects (1 SE, 2 SN, 2 NE, 1 NN) had a Mini NutritionalAssessment score below 23.5 and none had a score below 17(table 2). At baseline, 51 subjects (16 SE, 11 SN, 8 NE, 16 NN)were hypertensive (21 received angiotensin converting enzymeinhibitors, 18 received calcium channel blockers, four receivedbeta blockers, three received diuretics and 5 were treated withnon pharmacological measures) and six subjects (1 SE, 3 SN, 1NE, 1 NN) had clinically relevant osteoarthritis.

Figure 1Subject flow during the year of follow up.

During the year of follow up, all supplemented subjectsconsumed the nutritional product. The compliance was 48.1 ±21.7% of the suggested dose (two servings of 50 g per day,range 15 to 100%). trained subjects attended 56.1 ± 21 % ofprogrammed training sessions. During the second semester offollow up, there was a significantly lower attendance thanduring the first semester (47 ± 29.1 and 63.9 ± 18.8 % ofsessions respectively, p = 0.02).

Among geriatric assessment scores, during the year therewas a significant reduction of the activities of daily livingscore, from 5.9 ± 0.4 to 5.8 ± 0.5 points in all groups (p <0.003), but no differences between groups. No changes wereobserved in mini mental, instrumental activities of daily living,depression and mini nutritional assessment scores.

During the year of follow up, 27 episodes of falls (7 in SE, 8in SN, 6 in NE and 6 in NN individuals) and 85 episodes ofinfections, mostly upper respiratory infections (29 in SE, 20 inSN, 17 in NE and 19 in NN individuals), were recorded.

No changes in weight, mid arm, calf or hip circumferencewere observed. Waist circumference increased in all groupsform 98.8 ± 10.5 to 99.8 ± 10.8 cm, with no differencesbetween groups (p< 0.001).



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Walking capacity and all muscle strength measures, exceptleft hand grip strength and maximal expiratory pressure,improved more in trained groups than in non trained groups.The increases in right hand grip strength and maximalinspiratory pressure were significantly higher in the SE group,compared to all other groups (Table 3). No association betweenthe changes in muscle strength and baseline nutritional status ofthe subjects was observed. There was a positive correlationbetween the change in walking capacity at one year and thechange in right quadriceps strength (Spearman r = 0.33 p =

0.026) in the trained groups. This correlation was not observedin the non trained groups. No other associations with musclestrength were observed.

When comparing subjects with a high and low compliancewith the nutritional supplement, no differences in outcomeswere observed. However, subjects that attended to 66% or moreexercise sessions had a greater increase in upper and lower limbstrength than subjects that attended to a lower proportion ofsessions (table 4).



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Supplement + exercise Supplement Exercise No intervention ANOVA(21 female/10 male) (16 female/12 male) (12 female/4 male) (17 female/16 male) p

Demographic data and assessment scales:Age (years) 74.0 ± 3.6 74.7 ± 3.8 74.4 ± 3.27 73.7 ± 3.6 0.74Minimental score 26.1 ± 3.0 26.1 ± 3.2 25.6 ± 3.44 25.4 ± 2.9 0.33Activities of daily living score 5.8 ± 0.5 5.8 ± 0.4 5.9 ± 0.34 5.9 ± 0.2 0.332Instrumental activities of daily living score 7.6 ± 1.1 7.9 ± 0.5 7.8 ± 0.54 7.82 ± 0.6 0.639Depression score 4.2 ± 3.4 2.4 ± 1.9 5.2 ± 3.41 3.6 ± 3.1 0.018Mini nutritional assessment score 26.8 ± 1.9 27.3 ± 2.2 26.7 ± 2.31 27.5 ± 1.8 0.46

Anthropometric measures:Weight (Kg) 66.2 ± 11.9 61.9 ± 11.2 62.2 ± 10.11 68.7 ± 12 0.113Height (cm) 155.7 ± 9.1 153.8 ± 9.1 151.5 ± 8.76 154.1 ± 10.3 0.531Arm circumference (cm) 29.1 ± 3.2 28.0 ± 2.6 28.3 ± 2.23 30.0 ± 3.4 0.08Calf circumference (cm) 34.4 ± 3.1 33.5 ± 3.0 33.4 ± 3.07 34.7 ± 3.0 0.31Waist circumference (cm) 99.6 ± 10.5 95.6 ± 9.6 98.9 ± 8.54 101.2 ± 12.0 0.25Hip circumference (cm) 98.8 ± 7.7 96.9 ± 7.1 98.4 ± 6.66 101.4 ± 9.5 0.22

Blood pressure:Systolic (mm Hg) 144.4 ± 15.6 153.9 ± 23.6 159.4 ± 31.08 158.6 ± 23.5 0.07Diastolic (mm Hg) 80.5 ± 9.8 82.1 ± 12.3 84.1 ± 11.86 83.4 ± 11.8 0.7

Supplement + exercise Supplement Exercise No intervention ANOVA(21 female/10 male) (16 female/12 male) (12 female/4 male) (17 female/16 male) P

Muscle strength:Right hand grip (Kg) 22.2 ± 9.0 25.0 ± 7.8 22.7 ± 9.4 25.8 ± 8.8 0.375Left hand grip (Kg) 21.5 ± 8.5 23.6 ± 7.6 20.4 ± 7.7 24.9 ± 8.9 0.264Right quadriceps (Kg) 14.6 ± 7.6 15.0 ± 8.4 14.5 ± 6.3 16.8 ± 5.5 0.610Left quadriceps (Kg) 15.2 ± 10.5 14.8 ± 7.5 13.9 ± 6.4 16.6 ± 5.7 0.7Right biceps (Kg) 9.8 ± 5.1 10.1 ± 6.4 9.7 ± 6.1 11.3 ± 6.7 0.776Left biceps (Kg) 10.6 ± 5.8 10.5 ± 6.6 10.3 ± 5.4 12.1 ± 6.4 0.808Maximal insp pressure (cm H2O) 53.6 ± 17.5 53.6 ± 26.0 52.9 ± 20.5 54.3 ± 18.3 0.997Maximal exp pressure (cm H2O) 62.5 ± 22.1 62.0 ± 25.3 64.1 ± 30.4 62.4 ± 18.5 0.993Walking capacity (m) 869.5 ± 188.3 847.0 ± 165.5 878.9 ± 194.7 913.5 ± 156.3 0.58

Body composition (DEXA):Fat mass (kg) 23.3 ± 7.8 20.6 ± 6.6 21.4 ± 6.2 24.1 ± 7.9 0.277Fat free mass (kg) 40.7 ± 9.5 39.5 ± 8.3 38.2 ± 7.4 41.8 ± 8.5 0.578

Table 2Baseline features of study subjects

Table 2 aBaseline features of study subjects

Double beam x ray absorptiometry, disclosed no changes infat free mass in any of the four groups during the study. Fatmass increased in all groups from 22.5 ± 7.3 to 23.2 ± 7.3 kg(p=0.002), without differences between groups. No differencesin body composition changes, were observed between exercisecompliance groups.

If the seven patients in the NE group that refused to exercise,are considered as controls in an intention to treat analysisinstead of treating them as dropouts, results do not changesubstantially.

Discussion

The results of this one year follow up study show that aresistance exercise program can improve muscle strength.

Subjects enrolled in this study were healthy, except for thepresence of chronic diseases such as osteoarthritis or high bloodpressure. Only six subjects were at risk for malnutrition,according to the Mini Nutritional Assessment and none wasclassified as malnourished according to this score.

The training program was designed using simple andinexpensive means, considering that such program should becarried out in a setting of public primary care clinics. Theadvantage of such type of training is that it can be massivelyapplied. The drawback is that the use of rubber bands or stairs,does not allow a strict calculation of the work load that is beingused and thus to perform an accurate planning of theprogression in work load. Measurements of muscle strength,using the Nicholas Manual Muscle tester have a good intraratercorrelation (0.97 to 0.99) and a correlation with an isokineticdynamometer (Cybex II) that range from 0.72 to 0.76 for kneeextensors and from 0.64 to 0.65 for elbow flexors (13).

A specific training of respiratory muscles was alsoperformed, using respiratory resistance valves. The aim oftraining these muscles was to decrease the eventual morbidityassociated to respiratory infections and exercise capacity.Previous studies have shown that training respiratory musclesdecrease the incidence of respiratory complications inhospitalized malnourished patients (14, 15).



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Table 3Changes in respiratory and extremity muscle strength during the study period

Supplemented plus Supplemented Exercise No Anova §Exercise (n= 31) (n =28) (n=16) Intervention (n=26)

Right hand grip At 6 months 1.5 (0.1 2.9) ¶ 0.0 (-1.2 1.2) 1.0 (-0.5 2.5) 0.0 (-1.3 1.3) p=0.031Strength (kg) At 12 months 1.0 (-0.6 2.6) 0.0 (-1.5 1.5) 0.0 (-3.7 3.7) 0.0 (-1.3 1.3)

Left hand grip At 6 months 1.0 (-0.6 2.6) 0.0 (-8.4 8.4) 2.0 (-1.1 5.1) 1.0 (-0.1 2.1) p=0.70Strength (kg) At 12 months 1.0 (-0.4 2.4) 0.0 (-1.7 1.7) 2.0 (-0.3 4.3) 0.0 (-1.4 1.4)

Right quadriceps At 6 months 7.3 (5.4 9.2) 0.9 (-4.1 5.8) 7.9 (6.1 9.6) -1.0 (-3.0 1.0) p< 0.001Strength (kg) At 12 months 10.6 (8.7 12.4) 3.0 (1.0 5.0) 10.2 (7.5 12.8) 1.5 (-0.5 3.6)

Left quadriceps At 6 months 9.5 (6.1 13.0) 2.3 (0.6 4.1) 9.8 (7.9 11.7) -2.0 (-4.4 0.5) p<0.001Strength (kg) At 12 months 11.5 (8.0 15.1) 3.7 (2.0 5.5) 8.6 (6.6 10.6) 1.4 (-0.8 3.5)

Right biceps At 6 months 10.1 (8.7 11.5) 5.7 (3.9 7.5) 10.9 (8.4 13.4) 5.3 (4.0 6.7) p<0.001Strength (kg) At 12 months 10.8 (7.9 13.6) 7.3 (5.7 8.9) 11.3 (8.9 13.7) 7.5 (6.0 9.1)

Left biceps At 6 months 9.5 (8.1 10.9) 4.9 (2.9 6.8) 10.7 (9.1 12.4) 4.2 (2.3 6.1) p<0.001Strength (kg) At 12 months 9.0 (7.2 10.9) 6.5 (4.9 8.0) 8.2 (5.9 10.4) 6.0 (4.3 7.6)

Maximal insp. At 6 months 5.5 (0.6 10.4) -0.5 (-6.8 5.8) 6.5 (-3.1 16.1) -1.5 (-9.2 6.2) p=0.024Pressure (cm H2O) At 12 months 3.0 (-1.9 7.9) 1.0 (-3.5 5.5) 4.0 (-3.9 11.9) 3.5 (-1.6 8.6)

Maximal exp. At 6 months 0.0 (-4.8 4.8) -6.5 (-13.9 0.9) -7.5 (-16.9 1.9) -6.0 (-16.0 4.0) p=0.399Pressure (cm H2O) At 12 months -1.0 (-8.6 6.6) 0.5 (-5.0 6.0) -6.0 (-15.1 3.1) -1.0 (-6.8 4.8)

Walking capacity At 6 months 70.0 (4.2 135.8) -51.0 (-100.7 -1.3) 40.0 (-55.7 135.7)-147.0 (-219.2 -74.8) p< 0.001(m) At 12 months 132.0 (68.4 195.6) -23.5 (-71.4 24.4) 28.0 (-123.0 179.0)-219.0 (-305.0 -133.0)

¶ = Results are expressed as the median change from baseline and its 95% confidence intervals ; § = Anova for repeated series, two way interactions. The lines connect the groups that aresignificantly different (Newman Keuls post hoc comparisons)

The training sessions in this study, added an extra amount ofexercise equivalent to 180 minutes per week. The safety ofresistance training and subsequent increase in muscle strengthin the elderly has been previously reported by several authors(5, 16). The compliance with exercise sessions wasapproximately 50%. This figure is comparable with the attritionrates in long term exercise programs, reported elsewhere (6).Trained subjects had a significant increase in all the musculargroups tested. Walking capacity also increased. There was aclear association between attendance to training sessions andgain in strength. However, apparently there is no threshold inthe amount of weekly sessions to obtain beneficial results fromexercise, and subjects exercising once a week can also obtainpositive results (17). Other studies in the elderly, using similartype of low intensity, high volume exercise, have demonstratedthe positive effects of this intervention on the activities of dailyliving (18). Therefore its is not imperative to design highintensity training sessions, amenable for lesions and accidents,to obtain positive results in the elderly. The non significantchanges in muscle strength observed in non trained subjects

could be due to the learning effect caused by the repeated useof the muscle tester.

DEXA is a reliable method to measure body composition. Inour experience, the mean differences for the estimation of bodyfat in adults, when comparing DEXA with deuterium dilution,are less than 2% (19). The increase in fat mass observed in thisstudy is not surprising. The elderly loose fat free mass, despitethe maintenance of a stable body weight due to a gain in fatmass. A 0.18 to 0.65 kg/year reduction in fat free mass and asimilar gain of fat mass has been reported (20, 21). Exerciseincreased muscle strength without changes in fat free measuredby DEXA, although many studies have reported that trainingincreases this compartment (22). However most authors havereported local increases in muscle cross sectional area,measured by magnetic resonance imaging (23, 24). Therefore,apart from the possibility of a lack of sensitivity of DEXA todetect the exercise induced changes, our results could indicatethat training also improves the metabolic efficiency of musclesand muscle quality per mass unit, as reported previously inexperimental animals and humans (25, 26). Moreover,



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Table 4Effects of compliance with exercise session on changes in muscle strength

Subjects attending Subjects attending Subjects attending Anova §to less than 33% of to 33 to 66% of to more than 66%

sessions sessions of sessions

Right hand grip 6 months 1.5 (-2.8 5.8) ¶ 1.5 (0.1 2.9) 1.0 (-0.1 2.1) p = 0.29Strength (kg) 12 months 0.0 (-7.9 7.9) 0.5 (-1.1 2.1) 0.5 (-1.4 2.4)

Left hand grip 6 months 2.0 (-2.8 6.8) 1.0 (-0.4 2.4) 1.0 (-1.4 3.4) p = 0.23Strength (kg) 12 months 2.0 (-2.5 6.5) 1.0 (-0.5 2.5) 2.0 (0.2 3.8)

Right quadriceps 6 months 6.9 (3.0 10.9) 7.2 (5.9 8.5) 11.0 (8.6 13.5) p < 0.001Strength (kg) 12 months 1.3 (-2.3 5.0) 10.2 (8.2 12.1) 11.9 (10.1 13.7)

Left quadriceps 6 months 5.2 (-7.8 18.2) 8.0 (6.8 9.2) 10.5 (7.9 13.1) p < 0.001Strength (kg) 12 months 5.6 (-7.9 19.1) 9.1 (7.4 10.8) 11.7 (9.9 13.5)

Right biceps 6 months 7.1 (3.7 10.4) 10.8 (8.7 12.8) 10.6 (9.0 12.3) p = 0.044Strength (kg) 12 months 3.8 (0.7 6.8) 11.4 (9.4 13.3) 11.6 (7.6 15.6)

Left biceps 6 months 4.6 (1.0 8.1) 10.2 (9.0 11.4) 10.0 (8.5 11.5) p = 0.03Strength (kg) 12 months 1.3 (-2.8 5.4) 8.9 (7.2 10.5) 10.0 (7.9 12.1)

MIP † 6 months 11.5 (0.0 23.0) 4.5 (-2.6 11.6) 5.5 (-1.7 12.7) p = 0.56(cm H2O) 12 months -2.5 (-11.6 6.6) 4.0 (-3.1 11.1) 4.5 (-2.0 11.0)

MEP ‡ 6 months -3.0 (-17.2 11.2) -0.5 (-8.7 7.7) -3.0 (-8.1 2.1) p< 0.83(cm H2O) 12 months -13.0 (-24.6 -1.4) -0.5 (-11.6 10.6) 0.0 (-8.0 8.0)

Walking 6 months 94.0 (-77.4 265.4) 17.0 (-74.9 108.9) 86.0 (25.1 146.9) p = 0.17Capacity (m) 12 months -12.0 (-173.7 149.7) 19.0 (-109.3 147.3) 186.0 (133.3 238.7)

† MIP = maximal inspiratory pressure. ‡ MEP = maximal expiratory pressure; ¶ = Results are expressed as the median change from baseline and its 95% confidence intervals; § = Anovafor repeated series, two way interactions. The lines connect the groups that are significantly different (Newman Keuls post hoc comparisons)

metabolic studies have shown that training may improvemuscle leucine turnover without a concomitant increase inwhole body turnover in the elderly (27). Therefore, it ispossible that changes in limb fat free mass were undetected.Muscle strength is clearly related to functional capacity in theelderly and as long as strength is increased, we can expectbetter walking capacity and limb performance (28, 29, 30).

Hand grip was not trained, but its measurement was includedsince it has been used as a prognostic nutritional indicator inhospitalized patients (31). This parameter and maximalinspiratory pressure improved only in supplemented and trainedsubjects. Although the amount of extra protein provided by thesupplemented was relatively low (7 g per day, considering thecompliance), this may indicate that, at least for respiratorymuscles, there is an additive effect of nutritionalsupplementation and exercise. Since hand grip was not trained,the improvement observed in the supplemented and trainedgroup can be associated with the nutritional supplementation.It has been reported that when elderly subjects are trained andconsume an omnivorous diet, there is a greater gain in strengththan when a lactoovovegetarian diet is eaten (32). Likewise, ifyoung adults are supplemented with aminoacids after a bout ofheavy resistance exercise, net muscle protein synthesis isinduced (33). In the case of respiratory muscles, other authorshave shown a clear cut effect of nutritional repletion on theperformance of these muscles (34, 35). Castañeda et al havealso showed the importance of an adequate provision ofproteins on changes in muscle mass and composition (36). Thefailure to find an significant additive effect of nutritionalsupplementation on the strength of some muscle groups in thisstudy, could be also due to a lack of power of the sample size .Therefore, considering the additive effects of exercise andnutrition on inspiratory muscles, exercise should always beprescribed with an adequate nutrient provision in the elderly.

The feasibility of a long term training program and the useof simple exercises that do not require expensive devices aretwo issues that have not been assessed thoroughly. This workshows that its is possible to carry out such programs withcompliance rates similar to other chronic disease treatmentprograms such as hypertension, diabetes or dyslipidemias (37,38, 39). In spite of the relatively low compliance, positiveeffects were obtained with the exercise program.

Considering the beneficial effects of exercise on strengthand walking, training programs should be offered at primaryhealth care clinics. Exercise training can be done with verylow resources and self care practices can be used, preparingexercise monitors in the community. The cost effectiveness ofa community based long term exercise training in NewZealand, was calculated. The program was cost effective andresulted in a reduction of injuries, only in subjects aged 80years or more (40, 41). Probably, elders of less than 80 yearswill experience the benefits of training, later in life.

In summary a one year resistance training and nutritionalsupplementation program increased respiratory, upper and

lower extremity muscle strength.

Financing: Bristol Myers Squibb grant

References

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