Background Obesity exacerbates the age-related decline in insulin sensitivity and is associated with risk for cardiometabolic syndrome in older adults; however, the appropriate treatment for obese older adults is controversial. Objective To determine the independent and combined effects of weight loss and exercise on cardiometabolic risk factors in obese older adults. Design One-hundred-seven obese (BMI≥30 kg/m2) older (≥65 yrs) adults with physical frailty were randomized to control group, diet group, exercise group, and diet-exercise group for 1 year. Outcomes for this study included change in insulin sensitivity index (ISI), glucose tolerance, central obesity, adipocytokines, and cardiometabolic syndrome. Results Although similar increases in ISI occurred in the diet-exercise and diet groups at 6 months, the ISI improved more in the diet-exercise than in the diet group at 12 months (2.4 vs. 1.2; between-group difference, 1.2; 95% CI, 0.2-2.1); no changes in ISI occurred in both exercise and control groups. The diet-exercise and diet groups had similar improvements in insulin area under the curve (AUC) (−2.9 and −2.9 ×103mg.min/dl), glucose AUC (−1.4 and −2.2×103mg.min/dl), visceral fat (−787 and −561 cm3), tumor-necrosis factor (−17.0 and −12.8 pg/mL), adiponectin (5.0 and 4.0 ng/mL), waist circumference (−8.2 and −8.4 cm), triglyceride (−30.7 and −24.3 g/dL), and systolic/diastolic BP (−15.9 and −13.1/−4.9 and −6.7 mmHg), while no changes in these parameters occurred in both exercise and control groups. The cardiometabolic syndrome prevalence decreased by 40% in the diet-exercise and by 15% in the diet group. Body weight decreased similarly in the diet-exercise and diet groups (−8.6 and −9.7kg) but not in the exercise and control groups. Conclusions In frail, obese older adults, lifestyle interventions associated with weight loss improve insulin sensitivity and other cardiometabolic risk factors, but continued improvement in insulin sensitivity is only achieved when exercise training is added to weight loss.

Purpose of review The increasing prevalence of sarcopenic obesity in older adults has heightened interest in identifying the most effective treatment. This review highlights recent progress in management with an emphasis on lifestyle interventions and pharmacologic therapy aimed at reversing sarcopenic obesity. Recent findings While weight loss and exercise independently reverse sarcopenic obesity, they act synergistically in combination to improve body composition and physical function beyond which is observed with either intervention alone. Optimizing protein intake appears to have beneficial effects on net muscle protein accretion in older adults. Myostatin inhibition is associated with favorable changes in body composition in animal studies, though experience in humans is relatively limited. Testosterone and growth hormone offer improvements in body composition but the benefits must be weighed against potential risks of therapy. GHRH-analog therapy shows promise but further studies are needed in older adults. Summary At present, lifestyle interventions incorporating both diet-induced weight loss and regular exercise appear to be the optimal treatment for sarcopenic obesity. Maintenance of adequate protein intake is also advisable. Ongoing studies will determine whether pharmacologic therapy such as myostatin inhibitors or GHRH-analogs have a role in the treatment of sarcopenic obesity.

No abstract

Worldwide increases in diabetes prevalence in the face of limited medical resources have prompted international interest in innovative healthcare delivery models. Project ECHO (Extension for Community Healthcare Outcomes) is a "telementoring" program which has been shown to increase capacity for complex disease management in medically underserved regions. In contrast to a traditional telemedicine model which might connect a specialist with one patient, the ECHO model allows for multiple patients to benefit simultaneously by building new expertise. We recently applied the ECHO model to improve health outcomes of patients with complex diabetes (Endo ECHO) living in rural New Mexico. We describe the design of the Endo ECHO intervention and a 4-year, prospective program evaluation assessing health outcomes, utilization patterns, and cost-effectiveness. The Endo ECHO evaluation will demonstrate whether and to what extent this intervention improves outcomes for patients with complex diabetes living in rural New Mexico, and will serve as proof-of-concept for academic medical centers wishing to replicate the model in underserved regions around the world.

No abstract

No abstract

Osteoporosis is a common condition with serious consequences because of fractures. Despite availability of treatments to reduce fracture risk, there is a large osteoporosis treatment gap that has reached crisis proportions. There are too few specialists to provide services for patients who need them. Bone Health Extension for Community Health Care Outcomes (TeleECHO) is a strategy using real-time ongoing videoconferencing technology to mentor health care professionals in rural and underserved communities to achieve an advanced level of knowledge for the care of patients with skeletal diseases. Over the first 21 months of weekly Bone Health TeleECHO programs, there were 263 registered health care professionals in the United States and several other countries, with 221 attending at least 1 online clinic and typically 35 to 40 attendees at each session at the end of the reported period. Assessment of self-confidence in 20 domains of osteoporosis care showed substantial improvement with the ECHO intervention (P = 0.005). Bone Health TeleECHO can contribute to mitigating the crisis in osteoporosis care by leveraging scarce resources, providing motivated practitioners with skills to provide better skeletal health care, closer to home, with greater convenience, and lower cost than referral to a specialty center. Bone Health TeleECHO can be replicated in any location worldwide to reach anyone with Internet access, allowing access in local time zones and languages. The ECHO model of learning can be applied to other aspects of bone care, including the education of fracture liaison service coordinators, residents and fellows, and physicians with an interest in rare bone diseases.

No abstract