**6. Implications for clinical practice**

This review adds current evidences of interdisciplinary approach practices which comprise effective nutrient and exercise intervention strategies for KOA populations who have potential risks of sarcopenic obesity. This review also provides references for clinical practitioners to develop efficient and effective interventions for such population to prevent sarcopenic obesity.

## **Acknowledgements**

*Background and Management of Muscular Atrophy*

elder patients from experiencing acute sarcopenia.

on postoperative function outcomes.

recently received a total joint arthroplasty.

**4.2 Protein supplement plus exercise training after surgery**

The previous observational study has indicated that low protein intake occurring in patients with OA may place themselves at high risks of sarcopenia [128]. Therefore, perioperative interventions including protein supplement may prevent elder patients from suffering acute sarcopenia and poor surgical outcome at early stage after total joint replacement (i.e., TKR or THR) [129–131]. Alito et al. employed 5-day protein-contained (23%) supplements (PS) before surgery for patients who were undergoing THR and the results demonstrated that comparing with the non-supplement control group, the PS group experienced significantly a lower level of C-reactive protein (mean 80.6 vs. 66.5 mg/L, *P* < 0.01) and a shorter length of hospital stay (median 6 vs. 3 days, *P* < 0.01) after THR [129]. Yang et al. used high-dose PS on the day before and after THR surgery and the results showed that, comparing to the standard-care group, the PS group had less proportion of patients who required an intravenous albumin (45.1% vs. 26.8%, *P* = 0.023) and experienced a shorter length of hospital stay (mean 5.1 vs. 3.9 days, *P* < 0.001) [130]. Bai et al. used an oral ingestion of hydrolyzed PS for 5 postoperative days after TKR and the results indicated that PS enhanced postoperative nutrition status in terms of greater changes in blood prealbumin (*P* < 0.03) compared to the regularnutrition group [131]. The previous results had indicated that diet interventions, especially the PS, before or after total joint replacement can enhance postoperative nutrient status and shorten length of acute inpatient stay which further prevent

On the basis that either perioperative diet interventions or early rehabilitation programs exerts benefits on surgical outcome, combination of both may provide additional effects on function recovery after TKR or THR. The evidences regarding effects of PS plus exercise for healthy, sarcopenic, and frail elder populations have been well established by previous systemic review and meta-analysis studies [61, 68, 132]. However, the elder population with OA as well as those who underwent total joint replacement are less targeted by previous systemic reviews investigating efficacy of PS plus exercise. Future studies are necessary to be warranted in order to identify whether PS plus exercise following TKR or THR exerts any effect

Liao et al. conducted a systemic review and meta-analysis study to investigate effects of diet intervention plus ET for elder people with OA [118]. Among the included trials in Liao's study, all of the included trials which reported muscle mass outcomes conducted a PS plus ET intervention for older patients who recently received a TKR or THR [118] and the results showed that during an overall followup duration, the PS plus ET group achieved significant effects on muscle mass gains (SMD = 0.81; 95%CI: 0.45–1.17, *P* < 0.0001) compared to the ET control groups, regardless of PS type. The results indicated that PS plus ET exhibited significant effects on muscle mass for older individuals with OA, especially for those who

This review provides evidence that DI incorporated with ET is effective for promoting gains in muscle mass and strength and enhancing performance in physical mobility for the elder adults with lower-extremity OA, compared to placebo, DI-alone or ET-alone controls. In addition, muscle mass gains have effects on strength gain and global function recovery. Furthermore, the results of this study showed that PS plus ET appears to be the optimal treatment strategy for

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**5. Conclusions**

This study was funded by grants from the Taipei Medical University-Shuang Ho Hospital, Ministry of Health and Welfare, Taiwan (grant no. 109TMU-SHH-13) and Taipei Medical University (grant no. IIT-1072-3).
