J Nutr Health Aging

NUTRIENT INTAKE DURING DIET-INDUCED WEIGHT LOSS AND EXERCISE INTERVENTIONS IN A RANDOMIZED TRIAL IN OLDER OVERWEIGHT AND OBESE ADULTS G.D. MILLER1, D.P. BEAVERS2, D. HAMM1, S.L. MIHALKO1, S.P. MESSIER1 1. Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC. 27109-7868; 2. Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157. Corresponding author: Gary D. Miller, PhD, Box 7868 Reynolda Station, Department Health and Exercise Science, Wake Forest University, Winston-Salem, NC 27109-7868, [email protected]; 336-758-1901; 336-758-4680 (fax)

Abstract: Objectives: Dietary restriction in obese older adults undergoing weight loss may exacerbate nutrient deficiencies common in this group; the nutritional health of older adults is a factor in their quality of life, disability, and mortality. This study examined the effect of an 18-month weight loss program based in social cognitive theory incorporating partial meal replacements, on nutrient intake in older overweight and obese adults. Design: The following analysis is from the Intensive Diet and Exercise for Arthritis (IDEA) trial, a single-blind, randomized controlled trial. Individuals were randomized into one of three 18-month interventions: exercise (E); intensive diet-induced weight loss (D); or intensive diet-induced weight loss plus exercise (D+E). Setting: The study setting was at a university research facility. Participants: Overweight and obese older adults (n=388; BMI=33.7±3.8 kg/m2; 65.8±6.1 years) were recruited. Interventions: The D and D+E interventions (group mean goal of ≥10% loss by 18-months) utilized partial meal replacements (2 meal replacement shakes/ day for 6-months). Exercise training for E and D+E was 3 days/week, 60 minutes/day. Measurements: Three day food records were collected at baseline, 6-months, and 18-months and analyzed for total energy and macro- and micronutrient intake. Comparisons of dietary intake among treatment groups were performed at 6 and 18 months using mixed linear models. Results: Weight loss at 18-months was 11.3±8.3% (D), 10.3±6.8% (D+E), and 1.2±4.2% (E). Meal replacements were used by more than 60% (6-months) and 50% (18-months) of D and D+E participants, compared to ≤15% for E. Both D and D+E consumed less energy and fat, and more carbohydrates and selected micronutrients than E during follow-up. More than 50% of all participants consumed less than the recommended intake of particular vitamins and minerals. Conclusions: The diet intervention improved intakes of several nutrients. However, inadequate intake of several vitamins and minerals of concern for older adults suggests they need further guidance to assure adequate intake. Key words: : Diet, macronutrients, micronutrients, partial meal replacements.

Introduction

influence health conditions associated with aging (4, 9), dietary manipulation of specific nutrients and non-nutrients, as well as promoting certain dietary patterns, such as the Mediterranean Diet or the Dietary Approaches to Stop Hypertension (DASH) has been suggested to improve health indices linked to a number of health conditions associated with aging (4, 9). Intuitively, dietary restriction would potentially lower intake of both macro- and micronutrients. Consequently, this may lead to compromised nutritional health in older adults as protein, vitamin D, vitamin B12, folate, calcium, fiber, and fluids have been targeted as nutrients of potential concern in this cohort (10, 11). Furthermore, older adults have a higher risk for nutritional deficiencies compared to young adults based on physiological, psychological, and socioeconomic differences (5). Notably, these nutritional deficiencies may worsen the loss in lean mass and bone that accompanies weight loss (12, 13). Our earlier work demonstrated that intakes of vitamin E, vitamin C, folate, magnesium, and zinc were less than the age and gender adjusted estimated average requirement in more than 25% of weight stable older obese adults (14). Interestingly, in comparison to a weight stable group, those undergoing a calorie restricted diet using partial meal replacements had higher intakes of nearly all micronutrients

More than 22% of the world population is projected to be over the age of 65 by the year 2050 (1). Furthermore, obesity continues to be a health issue in our society with estimates that over 40% of 65-74 year olds are considered obese (2). Independently, obesity and aging have health risks that lead to serious public health implications, including osteoarthritis, impaired physical function (3), and cognitive decline (4). However, there is a reluctance of some clinicians to promote weight loss in overweight and obese older adults, which stems from the observations that intentional weight loss may promote sarcopenia, bone loss, nutrient deficiencies, and low lean body mass (5, 6). Interestingly, older adults appear to be at a lower mortality risk than younger adults for the same BMI level, further promoting apprehension in advising weight loss in this older cohort (3). Importantly, the nutritional status of older people is a factor in their quality of life, disability, morbidity, and mortality (7). Furthermore, overweight and obesity were associated with elders who were in poor health with chronic diseases, were physically inactive, and had poor diet quality with high fat and soda intake and low levels for vegetables and fruits (8). As evidence suggests that diet components Received June 28, 2016 Accepted for publication August 18, 2016

1

J Nutr Health Aging

NUTRIENTS, WEIGHT LOSS, OLDER ADULTS while consuming less energy. Our findings are in agreement with others who found higher intakes of selected nutrients in weight loss programs using partial meal replacements (15–17). Using a longer follow-up period and 3-day food records in an exclusively in older adult cohort, this study investigated the detailed characterization of diet composition in older overweight and obese adults undergoing an 18-month weight loss intervention based in social cognitive theory that utilized partial meal replacements and nutrition education.

process are described elsewhere (19).

Intervention Design Eligible individuals were randomized into one of three, 18 month, study groups: intensive diet-induced weight loss only (D); exercise-only (E); or intensive diet-induced weight loss plus exercise (D+E). Individuals in the dietary interventions (D and D+E groups) were placed on an energy restricted diet. Initial diet plans included an energy-intake deficit of 800 to 1000 kcal/day Methods depending on the individual’s anticipated energy expenditure with a minimum of 1100 kcal/day for women and 1200 kcal/ The following analysis is from the Intensive Diet and day for men. A calorie distribution goal was set as follows: Exercise for Arthritis (IDEA) trial, a single-blind, randomized 45-60% from carbohydrates; 15-20% from protein; and <30% controlled trial conducted at Wake Forest University from July from fat. 2006 to April 2011. Study staff involved in assessing outcomes Participants in D and D+E consumed up to two meal were blinded to the intervention assignment. The primary replacements per day with a third meal consisting of REMHFWLYH RI ,'($ ZDV WR GHWHUPLQH LI D • UHGXFWLRQ LQ approximately 500-750 kcal. Participants were provided for body weight through means of diet, with or without exercise, 6-months with the ‘Lean Shake’ meal replacements from GNC would improve mechanistic (knee joint loads, inflammation) consisting of 180 calories/serving. The nutritional breakdown and clinical outcomes (pain, function, mobility, health-related of the meal replacement can be found in Table 1. For the third quality of life) in older adults with knee osteoarthritis (OA). meal of the day, dietary interventionists gave participants a Details of the results of the primary outcomes are presented in weekly menu guide with recipes that consisted of meals that an earlier publication (18). All procedures followed were in were high in fruits and vegetables, low in fat, and contained accordance with the ethical stands of Wake Forest University 2100-3100 kjoules (500-750 kcals) per meal. Participants and Wake Forest Baptist Health. The study was approved by could also consume snacks such as fruits, vegetables, and the Institutional Review Board of Wake Forest Baptist Health meal replacement bars all equaling approximately 420-500 and all participants provided informed consent. kjoules (100-120 kcals) per serving. Interventionists monitored weight weekly and adjusted daily caloric intake based on each Participants individual’s rate of weight change. Participants attended three The study population was 454 overweight and obese, older group sessions and 1 individual session each month for the community-dwelling adults with knee pain and radiographic first six months of the study. For months 7 to 18 they attended knee OA. Eligibility criteria included: Body mass index (BMI) biweekly group sessions and 1 individual session every two = 27 – 41 kg/m2 •  \HDUV RI DJH UDGLRJUDSKLF HYLGHQFH months. Participants were asked to monitor their own diet of mild to moderate tibiofemoral OA or tibiofemoral + by completing daily logs of their food and beverage intake. patellofemoral OA in at least one knee, defined as a Kellgren- Further details of the dietary intervention has been described Lawrence grade of II or III; and pain on most days due to knee elsewhere (19). The exercise training consisted of 60 minutes of exercise OA. Details of the recruitment strategy and of the screening Table 1 Nutrient content in 1 serving of meal replacement (GNC Lean Shake®) (180 kcals) Nutrient

Amount

% Daily Value

Nutrient

% Daily Value

Saturated Fat (g)

0.5

3%

Vit. C

60%

Cholesterol (mg)

5

Total Fat (g)

Trans Fat (g)

Sodium (mg)

Potassium (mg) Carbs (g)

Fiber (g)

Protein (g)

2

3%

Vit. A

50%

Biotin

Vit. E

20%

Magnesium

20%

20%

Selenium

20%

20%

Manganese

30

32%

5LERÁDYLQ

9

NA

Vit. B-6

NA

Iodine

50%

10%

8

20%

Calcium

250

8%

Vit. B-12

Folic Acid

NA

280

% Daily Value

20%

0

2%

Nutrient

Iron

Thiamin Niacin

2

20% 20%

20%

Zinc

Copper

20%

20%

20%

20%

20%

J Nutr Health Aging

THE JOURNAL OF NUTRITION, HEALTH & AGING© 3 days a week. The program consisted of aerobic walking (15 minutes), strength training (20 minutes), another aerobic phase (15 minutes), and cool-down (10 minutes). During the first 6-months, participants reported to the exercise facility. Following a 2-week transition phase, an option was provided to either remain in the facility program, change to a home-based program, or combine the facility and home-based programs.

and 18 months were estimated using mixed linear models fitting randomization arm, visit, and arm by visit interaction, adjusted for baseline BMI, calories consumed, and baseline values of the outcome variable. The models assume a firstorder autoregressive covariance structure. The percentages of randomization groups achieving age- and genderspecific reference values were estimated using time-specific proportions and comparisons were based on chi-square tests for independence. The estimated associations between change in macronutrients vs. change in micronutrients from baseline were produced using a mixed linear regression model averaged over 6 and 18 months, adjusted for randomization group, visit, baseline BMI, and gender. Overall group comparisons were assumed significant at the 0.05 level of significance, and individual visit-specific pairwise mean comparisons were deemed significant at a Bonferroni-adjusted 0.0167 level. All comparisons were performed using SAS v9.4 (SAS Institute, Cary, NC). Results

Measurements Participants reported to the study facilities at Wake Forest University and Wake Forest School of Medicine for testing at baseline, 6-months, and 18-months. Demographic characteristics were determined only at baseline. Height and weight were measured and BMI was calculated at each testing visit. Dietary intake, which was the primary outcome measure, was assessed using a 3-day food record at each testing visit. The food records were analyzed for nutrient intake using the Minnesota Nutrition Data System (NDS). Individuals reported food and beverage intake using portion size estimates using 2D food-portion visual aids from NDS. Partial meal replacement use was quantified by viewing each day’s food records for all participants at each time point and identifying the number of meal replacements used during the 3 day recording period. Meal replacements counted included the GNC® Lean Shake provided as well as similar products from other sources. Research staff collecting dietary data were not involved in delivering the study intervention.

Demographic and descriptive information for the overall study population as well as for each intervention group by gender are presented in Table 2. There were no differences among groups for any of these variables. The overall mean age was 66 years with an initial weight and BMI of 93 kg and 33.7 kg/m2, respectively. Almost 80% of the individuals were obese with the remaining 20% classified as overweight. Over 70% were female and more than eight in ten were white. Nearly 10% of the cohort had cardiovascular disease with hypertension present in two-thirds of participants. Weight loss (% from baseline) at 6-months was 9.2±6.1% for D, 9.4±6.8% for D+E, and 1.2±4.2% for E. Weight loss at 18-months was 11.3±8.3% for D, 10.3±9.3% for D+E, and 1.1±4.3% for E.

Data Analysis Descriptive characteristics were used to summarize baseline data, including means and standard deviations for continuous variables and counts and percentages for discrete variables. Group-specific changes in weight were estimated using crude mean changes from baseline at 6 and 18 month assessment visits. The randomization effects for nutrient intake at 6

Table 2 Descriptive characteristics of study participants by group at baseline

Age, mean yrs (SD)

Body Weight, kg (SD)

BMI, kg/m2 (SD)

Gender- female, n (%)

Race- white, n (%)

Comorbid Illnesses (%)

Cardiovascular Disease

Osteoporosis

Diabetes

Hypertension

Obesity

Total (n = 388)

Exercise (n=126)

Diet (n = 132)

Diet + Exercise (n =130)

93.2±15.0

92.5±14.7

93.6±15.5

93.6±14.7

65.8±6.1

33.7 ±3.8

273 (70.4%)

333 (85.8%) 9.4

9.0

12.9

62.2

79.4

65.5±6.1

33.5±3.7

90 (71.4%)

66.1±6.3

33.7±3.8

92 (69.7%)

110 (87.3%)

114 (86.4%)

7.3

12.2

12.0

16.4

7.3

62.4

78.6

3

8.7

61.7

79.6

65.8±6.0

33.8±3.8

91 (70.0%)

109 (83.8%) 8.1

11.2

10.2

62.5

80.0

J Nutr Health Aging

NUTRIENTS, WEIGHT LOSS, OLDER ADULTS Table 3 3URWHLQOLSLGVDQGÀEHULQWDNHDWEDVHOLQHDQGPRQWKV%DVHOLQHYDOXHVDUHXQDGMXVWHGPHDQVFROODSVHGDFURVVDOO groups. Means at 6- and 18-months are estimated means±SEM and are adjusted for baseline values, total caloric intake, baseline BMI, and gender Diet Component

Baseline

Protein (g/kg body weight)

0.8±0.0

Sat FA (g)

MUFA (g)

PUFA (g)

Trans FA (g)

Cholesterol (mg)

Total Fiber (g)

Soluble Fiber (g)

Insoluble Fiber (g)

24.0±0.6 28.7±0.6

17.2±0.4

4.3±0.1

279.3±8.2

20.9±0.4 7.0±0.1

13.9±0.3

6-months

Exercise

0.74±0.02a 18.9±0.5

a

22.7±0.7

14.6±0.6

3.1±0.2

18-months

6-months

19.4±0.6

17.2±0.6

0.75±0.02a a

23.4±0.4

14.6±0.6

2.7±0.2

0.79±0.02b b

20.8±0.7

12.9±0.6

2.9±0.2

Diet

Diet + Exercise

18-months

6-months

18-months

17.2±0.5

17.0±0.5

17.5±0.5b

0.85±0.02b b

22.1±0.7

12.9±0.6

2.3±0.2

0.85±0.02b b

20.8±0.6

13.3±0.5

2.6±0.2

0.80±0.02b

21.9±0.7

13.4±0.6

2.7±0.2

238.4±13.1

237.8±13.7

207.4±13.5

222.3±12.8

210.3±11.8

206.6±13.2

6.6±0.3

6.1±0.3

7.3±0.3

7.8±0.3

7.0±0.3

8.2±0.3a

19.3±0.7b 12.6±0.6b

18.9±0.8b b

12.7±0.6b

21.8±0.8a 14.5±0.6a

22.5±0.7a a

14.7±0.6a

22.1±0.7a 14.9±0.5a

23.5±0.7a 15.2±0.6a

Sat FA: saturated fatty acids; MUFA: monounsaturated fatty acids; PUFA: polyunsaturated fatty acids; Trans FA: trans fatty acids; Chol: cholesterol; Values with different superscripts at DVSHFLÀHGWLPHSHULRGDUHVLJQLÀFDQWO\GLIIHUHQWIURPHDFKRWKHULQJURXSFRPSDULVRQV

Figure 1 Energy (kjoules) intake at baseline, 6-months, and 18-months for each group. Values at baseline are unadjusted means. Values at 6- and 18-months are adjusted means with S.E.M

polyunsaturated, and trans) as well as for cholesterol and fiber by group at 6- and 18-months are shown in Table 3. Consistent with total fat intake, consumption of saturated fat was less for D and D+E than E at both 6- and 18-months. There was no intervention effect for the other fatty acids or cholesterol. Total fiber and insoluble fiber intake was also higher for D and D+E than E at 6- and 18-months. Furthermore, soluble fiber was higher at 18-months for D and D+E than E. Statistically significant differences were apparent among groups for selected vitamins and minerals at the two followup time points. These are noted in Table 4. The following vitamins showed significant differences between groups with D and D+E having higher intakes than E: vitamin C, vitamin E, thiamin, niacin, vitamin B6, and folate. Minerals that showed significant differences between groups at both 6- and 18-months were iron and magnesium, while zinc and copper were different at 6-months only and calcium was different at 18-months only. For these minerals, D and D+E had greater intakes than E. In that the dietary intervention for D and D+E focused on altering portion size and achieving a macronutrient intake that reflected the Dietary Guidelines, associations for the change in the intake of macronutrients with the change in the intake of selected vitamins and minerals were analyzed. In combining participants across all 3 groups, it was found that a greater change in the intake of carbohydrates, fats, and protein was associated with a greater change in the consumption of key vitamins and minerals. A greater change in intake of folate, vitamin B12, calcium, and magnesium were associated (p<0.05) with greater changes in carbohydrates, fats, and protein intake, and greater changes in vitamins A and C were associated (p<0.05) with greater change in the intake of carbohydrates, but not fat or protein.

Baseline dietary intake is presented in Figures 1 and 2 for total energy and macronutrients, and in Table 3 for other dietary components. These values are unadjusted means and are collapsed across the three groups. Participants consumed at baseline about 7500 kjoules (1800 kcals), with nearly 80 g of protein, 80 g of fat, and 220 g of carbohydrates. Comparisons among the three groups at the 6- and 18-month follow-up for total energy and macronutrient intake are shown in Figures 1 and 2. As expected based on the interventions, fewer kjoule (Figure 1), more carbohydrates (Figure 2a), and less fat (Figure 2b) were consumed by D and D+E than E at both 6-months and 18-months. However, there were no differences between groups in protein intake expressed in g/day (Figure 2c); when expressed per kg body weight, the D and D+E groups showed higher intakes than E at both 6- and 18-months (Table 3). Intake for nutrients potentially related to cardiometabolic risk, including specific fatty acids (saturated, monounsaturated, 4

J Nutr Health Aging

THE JOURNAL OF NUTRITION, HEALTH & AGING© Figure 2a-c Nutrient (g) intake (carbohydrates (Figure 2a), fats (Figure 2b), proteins (Figure 2c)) at baseline, 6-months, and 18-months for each group. Values at baseline are unadjusted means. Values at 6- and 18-months are adjusted means with S.E.M

As described in the methods, this included providing all participants in these groups with product for up to 2 meal replacements per day for the first 6-months of the study. At baseline, the dietary recalls showed that the number of participants (and % of participants in the group) using a meal replacement was n=11 (8.3%) for D, n=14 (10.8%) for D+E and n=10 (7.9%) for E. At 6-months the number and percent of participants using meal replacements was n=42 (60.0%) for D and 64 (67.4%) for D+E and n=10 (13.7%) for E (p<0.01 for group comparisons). At 18-months, the use of meal replacements had declined for D (n=38, 50.0%) and D+E (n=36, 50.7%), but they were still significantly higher than E (n=11, 15.7%). Reported usage of meal replacements included the product supplied to the participants as well as other products participants may have purchased that were meal replacements. Further analysis of the data indicated that the use of meal replacements during the 18-month follow-up was associated with statistically significantly greater change in the intakes of vitamins C and B12, folate, calcium, and magnesium.

a

b

Discussion Our primary aim was to examine the effect of an 18-month weight loss program that included caloric restriction and use of partial meal replacements with and without exercise training on nutrient intake in older overweight and obese adults with knee osteoarthritis. While the use of a partial meal replacement plan has been effective for promoting weight loss (14, 20), there are limited data indicating the effect this strategy has on the intake of both macro- and micronutrients (14, 16). The meal replacement chosen for this study contained 30-40% of the Daily Value for most vitamins and minerals, and thus it would be expected that its use would contribute to improving the nutrient density of the diet. Since 50% of individuals in both D and D+E reported consuming at least one meal replacement per day for the duration of the 18-month intervention, the additional vitamins and minerals found in the products likely added significantly to the diets. In that energy intake decreased in the dietary intervention groups, it would be expected that there would be parallel reductions in micronutrients. A number of the vitamins and minerals improved with weight loss, which points to the benefit of the meal replacements, as well as emphasis on consuming a higher quality diet with the energy restriction. These findings are in contrast to Gardner et al., who found an increased risk of inadequacy in micronutrients for individuals undergoing several commercial weight loss programs (21). It is well established that lifestyle changes through diet and physical activity in older adults lead to weight loss and improvement in morbidity, mortality, hormones, physical function, cognition and quality of life in older adults (4, 9). Compromised nutrient intake in older adults is a health concern as this affects disability, morbidity, and mortality (7). Older adults who restrict their dietary intake in an intentional weight

c

The percentage of individuals that had an intake less than the Estimated Average Requirement or Adequate Intake (vitamins D and K and calcium) is presented in Table 5. At baseline, the majority (>50%) of participants had an intake for most nutrients at the level of the Estimated Average Requirement or the Adequate Intake. The exceptions were for vitamins D and E, as well as calcium and magnesium. For these nutrients, fewer than one-half of the participants consumed less than the Estimated Average Requirement or Adequate Intake, demonstrating a low intake by the majority of participants. During follow-up, fewer participants in D and D+E groups had intakes below the Estimated Average Requirement or Adequate Intake for vitamins C and E, and magnesium and zinc at 18-months. The dietary intervention for D and D+E groups, by design, included the incorporation of partial meal replacements. 5

J Nutr Health Aging

NUTRIENTS, WEIGHT LOSS, OLDER ADULTS Table 4 Vitamins and Minerals Intakes at baseline, 6- and 18-months. Baseline values are unadjusted means collapsed across all 3 groups. Means at 6- and 18-months are estimated means±SEM and are adjusted for baseline values, total caloric intake, baseline BMI, and gender Nutrient

Baseline

Vitamin A (mcg)

8202±297

8293±804

Vitamin E (mg)

8.7±0.2

7.5±1.0

Vitamin D (mcg) Vitamin K (mg) Vitamin C (mg) Thiamin (mg)

5LERÁDYLQPJ

5.1±0.3

153.8±7.6 86.3±2.5 1.6±0.0 2.0±0.0

Exercise

6-months

18-months

4.1±0.4

4.6±0.4

b

148.4±18.6 76.5±6.1

b

1.4±0.1b 1.9±0.1

6-months

7469±846

9510±830

7.8±1.0

13.2±1.0

b

130.8±19.6 72.9±6.4

b

1.4±0.1b 1.8±0.1

Diet

4.4±0.4

a

18-months

4.7±0.4

4.9±0.4

13.1±1.0

13.6±0.9

4.9±0.4

a

159.2±18.2 a

1.9±0.1

18-months

8650±722

a

1.7±0.1a

6-months

9243±782

168.4±13.4 104.4±6.3

Diet + Exercise

104.6±6.0 1.6±0.1a 1.9±0.1

a

157.7±16.7 99.9±5.5

a

1.7±0.0a 1.0±0.1

9102±814 15.3±1.0a

164.4±18.9 90.9±6.2ab 1.7±0.1a 1.9±0.1

Niacin (mg)

22.2±0.4

20.8±0.9

19.9±1.0

24.2±1.0

24.0±0.9

25.8±0.8

25.6±0.9a

Folate (mcg)

404.2±7.8

377±17b

371±17b

437±17a

433±16a

441±15a

453±17a

Calcium (mg)

770.8±15.6

Vitamin B6 (mg) Vitamin B12 (mcg) Phosphorus (mg)

Magnesium (mg) Iron (mg)

Zinc (mg)

Copper (mg)

Selenium (mg)

Manganese (mg) Sodium (mg)

1.9±0.1 5.3±0.2

b

1.7±0.1b 4.5±0.4 714±30

b

1.7±0.1b 5.2±0.4

689±32

b

a

2.1±0.1a 4.8±0.4

332±11a

318±11a

1073±27

1067±27

15.1±0.3

13.1±0.6

13.4±0.7

1.2±0.0

1.0±0.1b

1.1±0.1

11.8±0.5

b

8.9±0.8b

110.1±2.1

94.8±3.1

2657.2±41.0

2876±78

3.6±0.1

3.2±0.1

252±12b

b

10.7±0.8

5.1±0.4

786±29ab

1074±26 248±11b

2.1±0.9a

747±31

1197.5±19.1 281.3±4.7

a

a

2.3±0.1a 5.3±0.4

801±27

2.2±0.1a 6.1±0.4

792±30a

1127±25

1126±24

1092±26

17.1±0.6

15.7±0.6

18.3±0.6

17.2±0.6a

1.2±0.1a

1.2±0.1

1.2±0.1a

1.2±0.1

a

12.8±0.8a

a

337±10a

a

12.0±0.8

14.4±0.7a

326±11a

12.7±0.8

95.7±3.2

92.0±3.2

95.7±3.0

95.8±2.8

98.3±3.1

2777±82

2735±80

2683±76

2814±70

2839±79

3.23±0.1

3.3±0.1

3.6±0.1

3.2±0.1

3.7±0.1

9DOXHVZLWKGLIIHUHQWVXSHUVFULSWVDWDVSHFLÀHGWLPHSHULRGDUHVLJQLÀFDQWO\GLIIHUHQWIURPHDFKRWKHULQJURXSFRPSDULVRQV

requirements should be increased to 1.0-1.2 g/kg body weight (23, 24). Furthermore, emerging evidence suggests that consumption of more protein during weight loss and with normal ageing has favorable outcomes on body composition and physical function (23, 25–27). Even though the protein intake for D and D+E was higher than E during the follow-up time points, it was still below the suggested intake of 1.0-1.2 g/ kg body weight. In addition to the significant group differences in macronutrient intakes, many vitamins and minerals were also different among groups. For the micronutrients, group differences were observed not only in absolute intakes, but also as compared to standard levels that represent dietary adequacy. Specifically, the proportion of participants in each group of the study that had an intake at a level that was at least the estimated average requirement or adequate intake of the DRI was calculated. This analysis provided further insight from our earlier work (14) by determining whether intakes are meeting the general intake recommendations for vitamins and minerals. Whereas the majority of participants at baseline

loss program may further reduce their already compromised intake of selected nutrients. Thus, it was important to determine the impact a sound weight loss strategy had on nutrient intake levels. Micronutrient intakes are frequently overlooked, which considering their roles in chronic and acute illnesses, they should be addressed and they are important for judging diet quality. As expected, total calorie intake was less in the D and D+E groups than in E which was due to a lower fat intake as carbohydrate intake was higher for D and D+E compared to E. Furthermore, the higher intake of protein expressed as kg body weight/day for D and D+E than for E at both 6- and 18-months is of interest based on the recent discussion in the literature on the appropriate intake of protein for older adults. Currently, the recommended level from the Dietary Reference Intakes is 0.8 g/kg, which has been suggested to be inadequate for the maintenance of muscle mass for adults ages 55-77 (22). Whereas the Dietary Reference Intake may be appropriate for establishing the minimum amount of protein required for short term homeostasis, a number of experts suggest protein 6

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THE JOURNAL OF NUTRITION, HEALTH & AGING© had intakes for vitamins D and E and calcium and magnesium below their respective estimated average requirement or adequate intake, during the follow-up, intakes for vitamin E and magnesium improved more for the D and D+E than for E. However, there was no improvement or group differences in calcium and vitamin D at 18-month follow-up. It is concerning that these intakes are lower than the age and gender specific recommendations of the Dietary Reference Intakes considering the multitude of physiologic processes attributed to vitamin D and calcium, such as bone and cardiovascular health, muscle function, immunity, cancer prevention, mental health, and cognition of older adults (28–31). The potential compromise in muscle function may be of particular interest in our cohort as reduction in knee extensor strength is positively associated with worsening of knee function in individuals with knee osteoarthritis (32). Substantial evidence suggests that underreporting of dietary intake is common, and appears to be more prominent in obese individuals, at least in young adults (33, 34). Although this has been shown in some studies in older adults (35), others report no relation between underreporting and BMI in this aging cohort (36, 37). Low reported intake may be due to deliberate deletions, failure of recall or actual low intake. Although underreporting is likely to be apparent in older adults as well as in younger individuals, the causes may be different (38), which include a higher activity level and use of more than four medications. Whereas the validity and value of self-reported dietary intake assessments has been questioned (39), a recent editorial by Davy and Estabrooks reiterated their value, with reference to their predictive validity (40). Dietary assessment for individuals include obtaining weights of food, gathering food records, recalling intake over a short period, and food frequency questionnaires, and their advantages and limitations have been extensively reviewed (41). The 3-day food records utilized in this study provide quantitative intake of nutrients, but require a burden to the study staff and participants. By providing written instructions and training participants on proper methods for recording their intake, such as writing items down in a timely manner, estimating portion sizes, and providing detailed information of the specific foods consumed, accuracy can increase accuracy (41, 42). As new innovative technologies are developed diet assessment may become less costly and more time effective (43). Thus, it is important to view results from self-reported dietary assessments with the knowledge and recognition of their limitations. In summary, these results demonstrate that participants randomized to a dietary induced weight loss program based in social cognitive theory incorporating partial meal replacements, with or without exercise training, have improved intake of selected macro- and micronutrients compared to an exerciseonly training group over an 18-month follow-up period. Compared to the exercise-only training group, those in the diet intervention consumed less energy and fat, and more protein, fiber, calcium, magnesium, iron, zinc, copper, vitamin

Table 5 Percentage of participants within a group meeting the Estimated Average Requirement or Adequate Intake using age DQGJHQGHUVSHFLÀFUHIHUHQFHYDOXHV9DOXHVDWHDFKWLPH period by group Nutrient Vitamin A 6-months 18-months Vitamin C 6-months 18-months Vitamin D 6-months

18-months Vitamin E 6-months 18-months Vitamin K 6-months 18-months Thiamin 6-months 18-months 5LERÁDYLQ 6-months 18-months Niacin 6-months 18-months Vitamin B6 6-months 18-months Folate 6-months 18-months Vitamin B12 6-months 18-months Calcium 6-months 18-months Copper 6-months 18-months Iron 6-months 18-months Magnesium 6-months 18-months Selenium 6-months 18-months Sodium 6-months 18-months Zinc 6-months 18-months

Baseline 96.4%

60.1%

6.7%

16.5%

59.3%

92.8%

98.2%

96.9%

77.3%

66.2%

90.5%

26.8%

92.3%

100.0%

43.8%

98.2%

99.5%

81.4%

Exercise

Diet

Diet + Exercise

94.5% 97.1%

97.1% 93.4%

97.9% 100.0%

56.2%b 54.3%

75.7%a 68.4%

73.7%ab 66.2%

5.5%

4.3%

6.3%

17.8%b 14.3%b

50.0%a 40.8%a

47.4%a 45.1%a

53.4% 57.1%

58.6% 67.1%

55.8% 62.0%

86.3% 92.9%

95.7% 89.5%

90.5% 97.2%

94.5% 94.3%

95.7% 97.4%

98.9% 98.6%

93.2% 92.9%

95.7% 94.7%

98.9% 98.6%

76.7% 71.4%

80.0% 78.9%

85.3% 88.7%

67.1% 71.4%

75.7% 72.4%

71.6% 77.5%

83.6% 92.9%

91.4% 92.1%

93.7% 88.7%

26.0% 20.0%

20.0% 28.9%

23.2% 28.2%

87.7% 94.3%

94.3% 90.8%

92.6% 91.5%

97.3% 98.6%

100.0% 100.0%

100.0% 100.0%

30.1%b 30.0%b

52.9%a 57.9%

57.9%a 54.9%a

97.3% 98.6%

92.9% 96.1%

97.9% 98.6%

98.6% 100.0%

95.7% 96.1%

97.9% 100.0%

60.3%b 75.7%

77.1%ab 85.5%

89.5%a 81.7%

7.1%

10.5%

9.9%

7

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NUTRIENTS, WEIGHT LOSS, OLDER ADULTS E, Vitamin C, thiamin, niacin, vitamin B6, and folate. Thus, there is less probability of inadequate nutrient intake in older adults using a dietary weight loss program that is similar to ours. Of clinical importance, a significant proportion of all study participants had intakes lower than recommended levels for several nutrients, including calcium, magnesium, vitamin D and vitamin E, at baseline and during follow-up. The practical application of these findings suggests that even with the improved intake for some nutrients, selected vitamins and minerals remained low in the diet of older adults, demonstrating further dietary guidance is needed in this cohort. Furthermore, this study occurred in a controlled environment and was part of a clinical trial which provided the meal replacement and structured exercise program in a central facility. Further testing of this intervention in a community-based study targeting older obese and overweight adults in a pragmatic trial is required to translate these findings to the community.

13. Zamboni M, Mazzali G. Obesity in the elderly: an emerging health issue. Int J Obes. 2012;36(9):1151-1152. doi:10.1038/ijo.2012.120. 14. Miller GD. Improved nutrient intake in older obese adults undergoing a structured diet and exercise intentional weight loss program. J Nutr Heal Aging. 2010;14(6):461-466. http://www.ncbi.nlm.nih.gov/pubmed/20617289. 15. Hamdy O, Zwiefelhofer D. Weight management using a meal replacement strategy in type 2 diabetes. Curr Diab Rep. 2010;10(2):159-164. doi:10.1007/s11892-010-01039. 16. Ashley JM, Herzog H, Clodfelter S, Bovee V, Schrage J, Pritsos C. Nutrient adequacy during weight loss interventions: a randomized study in women comparing the dietary intake in a meal replacement group with a traditional food group. Nutr J. 2007;6:12. doi:10.1186/1475-2891-6-12. 17. Truby H, Hiscutt R, Herriot AM, et al. Commercial weight loss diets meet nutrient requirements in free living adults over 8 weeks: a randomised controlled weight loss trial. Nutr J. 2008;7:25. doi:10.1186/1475-2891-7-25. 18. Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013;310(12):1263-1273. doi:10.1001/jama.2013.277669. 19. Messier SP, Legault C, Mihalko S, et al. The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale. BMCMusculoskeletDisord. 2009;10:93. doi:14712474-10-93 [pii];10.1186/1471-2474-10-93 [doi]. 20. Moran-Ramos S, Avila-Nava A, Tovar AR, Pedraza-Chaverri J, Lopez-Romero P, Torres N. Opuntia ficus indica (nopal) attenuates hepatic steatosis and oxidative stress in obese Zucker (fa/fa) rats. J Nutr. 2012;142(11):1956-1963. doi:10.3945/ jn.112.165563. 21. Gardner CD, Kim S, Bersamin A, et al. Micronutrient quality of weight-loss diets that focus on macronutrients: results from the A TO Z study. Am J Clin Nutr. 2010;92(2):304-312. doi:10.3945/ajcn.2010.29468. 22. Campbell WW, Trappe T a, Wolfe RR, Evans WJ. The recommended dietary allowance for protein may not be adequate for older people to maintain skeletal muscle. J Gerontol A Biol Sci Med Sci. 2001;56(6):M373-M380. 23. Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the prot-age study group. J Am Med Dir Assoc. 2013;14(8):542-559. doi:10.1016/j.jamda.2013.05.021. 24. Deutz NEP, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group. Clin Nutr. 2014. doi:10.1016/j.clnu.2014.04.007. 25. Mojtahedi MC, Thorpe MP, Karampinos DC, et al. The effects of a higher protein intake during energy restriction on changes in body composition and physical function in older women. J Gerontol A Biol Sci Med Sci. 2011;66(11):1218-1225. doi:10.1093/gerona/glr120. 26. Evans EM, Mojtahedi MC, Thorpe MP, Valentine RJ, Kris-Etherton PM, Layman DK. Effects of protein intake and gender on body composition changes: a randomized clinical weight loss trial. Nutr Metab (Lond). 2012;9(1):55. doi:10.1186/1743-70759-55. 27. Houston DK, Nicklas BJ, Ding J, Harris TB, Tylavsky F a, Newman AB. Dietary protein intake is associated with lean mass change in older , community-dwelling adults : the Health , Aging , and Body. Am J Clin Nutr. 2008;87(1):150-155. doi:87/1/150 [pii]. 28. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2010;58(7):1299-1310. doi:10.1111/j.15325415.2010.02949.x. 29. Lee JH, O’Keefe JH, Bell D, Hensrud DD, Holick MF. Vitamin D deficiency an important, common, and easily treatable cardiovascular risk factor? J Am Coll Cardiol. 2008;52(24):1949-1956. doi:10.1016/j.jacc.2008.08.050. 30. Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T, Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr. 2006;84(1):18-28. http://www.ncbi.nlm.nih.gov/ pubmed/16825677. Accessed August 17, 2015. 31. Cherniack EP, Troen BR, Florez HJ, Roos BA, Levis S. Some new food for thought: the role of vitamin D in the mental health of older adults. Curr Psychiatry Rep. 2009;11(1):12-19. http://www.ncbi.nlm.nih.gov/pubmed/19187703. Accessed September 1, 2015. 32. Ruhdorfer A, Wirth W, Eckstein F. Longitudinal change in thigh muscle strength prior and concurrent to a minimal clinically important worsening or improvement in knee function - Data from the Osteoarthritis Initiative. Arthritis Rheumatol (Hoboken, NJ). 2015. doi:10.1002/art.39484. 33. Klesges RC, Eck LH, Ray JW. Who underreports dietary intake in a dietary recall? Evidence from the Second National Health and Nutrition Examination Survey. J Consult Clin Psychol. 1995;63(3):438-444. http://www.ncbi.nlm.nih.gov/ pubmed/7608356. Accessed October 8, 2015. 34. Lichtman SW, Pisarska K, Berman ER, et al. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects. NEnglJMed. 1992;327(27):18931898. http://www.ncbi.nlm.nih.gov/pubmed/1454084. 35. Tomoyasu NJ, Toth MJ, Poehlman ET. Misreporting of total energy intake in older men and women. J Am Geriatr Soc. 1999;47(6):710-715. http://www.ncbi.nlm.nih.

Ethical Standards: This investigation complied with the current laws of the United States, where this study was performed. Sources of Support: Support for this study was provided by grants from the National Institutes of Arthritis and Musculoskeletal and Skin Diseases (R01AR052528-01); From the National Institute of Aging (P30AG21332); From the National Center of Research Resources (M01-RR00211); and General Nutrition Centers. Dr. Miller reports grants from National Institutes of Health, grants from General Nutrition Centers during the conduct of the study. Dr. Mihalko reports grants from National Institutes of Health, grants from General Nutrition Centers, during the conduct of the study. Dr. Hamm reports grants from National Institutes of Health, grants from General Nutrition Centers, during the conduct of the study. Dr. Beavers reports grants from National Institutes of Health, grants from General Nutrition Centers, during the conduct of the study. Dr. Messier reports grants from National Institutes of Health, grants from General Nutrition Centers, during the conduct of the study. Conflict of Interest: The authors present no conflicts of interest for this study.



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