Fight against Obesity and Sedentary Lifestyle to Promote Health

#### **Chapter 5**

## Sarcopenic Obesity: Focus on the Asian Population

*Mukulesh Gupta and Tuhina Gupta*

#### **Abstract**

Sarcopenic obesity (SO) is a condition observed in older adults, marked by a simultaneous presence of low muscle mass and high body fat mass. The document highlights the complex interplay of aging, hormonal changes, pro-inflammatory pathways, myocellular mechanisms, and oxidative stress as contributors to SO. It discusses the need for a standardized definition, as various criteria have been proposed over the years. The prevalence of SO varies in different populations, and its screening involves assessing body mass index (BMI) or waist circumference along with validated questionnaires. The document emphasizes the importance of accurate diagnostic methods, including measuring muscle mass, strength, and physical performance. The adverse health consequences of SO include increased risk of disability, cardiometabolic abnormalities, fractures, depression, mortality, and reduced quality of life. Lastly, the management of SO involves a multifaceted approach that focuses on gaining muscle mass while losing fat mass, primarily through resistance training, essential amino acid supplementation, dietary protein intake, and other emerging treatments.

**Keywords:** sarcopenic obesity, short physical performance battery (SPPB), appendicular lean mass, myosteatosis (MS), myofibrosis (MF)

#### **1. Introduction**

Normal aging is linked with 1% muscle loss from 30 years of age, which tends to accelerate after 70 years of age. In young adults, lean muscle mass, comprising around 50% of their overall bodyweight, declines to approximately 25% by the time they reach 75–80 years of age. After the age of 40, the rate of muscle loss can be as high as 8% per decade, and it increases to about 15% per decade after the age of 70. Individuals with diabetes experience a more significant reduction in muscle mass compared to others.

Hormones like total testosterone, which improves muscle protein synthesis, decrease by 1% per year, and the levels of dehydroepiandrosterone sulfate, a precursor to testosterone, also reduce with aging. Hyperthyroidism and chronic illness are also linked with muscle loss and reduced physical functioning. Sarcopenia was officially acknowledged as a medical condition in 2016 and was given a specific code in the International Classification of Diseases, tenth revision (ICD-10).

With age, apart from the development and progression of sarcopenia, the occurrence and prevalence of obesity also rise due to unhealthy diet and sedentary lifestyle [1]. The combination of high muscle mass and low fat mass is generally considered as healthy while the reverse as unhealthy. In obese individuals, metabolic change due to sedentary lifestyle, adipose tissue derangement, comorbidities, and so on can result in similar situation. A novel body composition category called sarcopenic obesity (SO) has emerged in recent times, characterized by the simultaneous presence of obesity and sarcopenia, encompassing both muscle mass and function [2]. This condition, also known as sarcopenic obesity, is gaining recognition as a clinical entity due to its substantial impact on patient-centered outcomes. It has multifactorial etiology, and its prevalence increases with age. SO is gaining attention because it is associated with many other age-related diseases that present as altered intercellular communication, dysregulated nutrient sensing, and mitochondrial dysfunction. Older adults identified with low muscle to fat ratio (MFR) have been found to have poor functional performance and high cardiometabolic risk. Higher cholecystectomy incidence is seen to be associated with low muscle mass, low muscle strength, sarcopenia, and sarcopenic obesity. Preliminary results suggest that SO may be associated with telomere shortening and may represent an important risk factor for accelerated aging than sarcopenia and obesity alone. Four body composition phenotypes have been proposed in older populations: normal, sarcopenic, obese, and sarcopenic obese. SO affects around 5–6% of Indian adults annually. SO is more common in older adults than in young adults. Both sarcopenia and obesity may individually cause threat for adverse health outcomes. But when combined, these two conditions can cause health threats that can be synergistically amplified. Studies have shown that SO is a better predictor of physical disability than sarcopenia or obesity alone.

The management of Sarcopenic Obesity involves implementing effective dietary and exercise strategies to counteract the negative outcomes. Additionally, there are various potential and developing treatments for SO, such as pharmacological interventions (including testosterone supplementation, selective androgen receptor modulators, myostatin inhibitors, and anti-obesity drugs), electrical acupuncture, whole-body electro-myo-stimulation, and the use of A2B agonists.

*Conclusion: Sarcopenic obesity is emerging as a new and distinct category of obesity across the globe, which is clinically important. A theoretical methodological work (with a special focus on Asian population) aiming at providing practical-application guidelines is proposed.*

#### **2. Sarcopenic obesity (SO): an emerging challenge**

Sarcopenic obesity is a new category of obesity in older adults who have high adiposity with low muscle mass. With aging, a progressive increase in fat mass, which normally peaks at about age 65 years in men and later in women, is observed. Aging is also associated with body fat distribution changes, visceral abdominal fat increase, and subcutaneous abdominal fat decrease. Moreover, in the elderly, ectopic fat deposition within non-adipose tissue such as the skeletal and cardiac muscle, liver, and pancreas has been observed. This phenomenon occurs even without significant changes in body mass index (BMI) or body weight. However, sarcopenia may arise in individuals with obesity at any age. The presence of obesity can cause a decline in muscle mass and function on its own, primarily because of the detrimental effects of metabolic disorders associated with adipose tissue. These disorders include oxidative

stress, inflammation, insulin resistance, and a higher occurrence of chronic noncommunicable diseases.

#### **2.1 Definition**

BMI does not distinguish between fat mass and lean mass. In 2000, Baumgartner introduced the term of sarcopenic obesity (SO), a condition characterized by the coexistence of low muscle mass and a high body fat mass [3]. But it may underestimate sarcopenia in overweight and obese subjects, thus leading to an underdiagnosis of SO. Hence, more definitions of SO have been proposed.

In 2009, the European Working Group on Sarcopenia in Older People (EWGSOP) put forward a clinical definition of sarcopenia to facilitate its identification in older individuals. This definition suggested that sarcopenia should be diagnosed based on the simultaneous presence of two factors: low muscle mass and impaired muscle function, indicated by either low strength and/or low physical performance. The International Working Group on Sarcopenia proposed a similar definition in 2011, based on a low appendicular or whole-body fat-free mass combined with poor physical functioning [4]. In 2014, the Foundation for the National Institutes of Health Sarcopenia Project recommended defining sarcopenia using specific cut points for low lean mass (appendicular lean mass adjusted for BMI: 0.789 for men and 0.512 for women) and for muscle weakness (grip strength: 26 kg for men and 16 kg for women) [5]. However, to date, there is no universally accepted definition or classification for sarcopenia, or for sarcopenic obesity [6]. Studies have shown that SO is a better predictor of physical disability than sarcopenia or obesity alone. In 2022, European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) defined Sarcopenic obesity as the coexistence of obesity and sarcopenia (includes mass and function) [2].

#### **2.2 Etiology and pathogenesis of SO**

	- i.*Aging:* Many changes in body composition on aging due to lifestyle and reduced physical activity result in increased accumulation of fat, leading to SO phenotype.

#### **Figure 1.**

*Pathophysiology leading to Sarcopenic obesity.*

dysfunction. This leads to impaired myocyte satellite cells differentiation/ proliferation, leading to sarcopenia due to obesity.

v.*Oxidative stress:* Oxidative stress (OS) leads to an accumulation of ROS/RNS, accompanied by cellular damage. OS leads to infiltration of immune cells in the adipose tissue, leading to obesity and IR. OS also causes damage to the myocyte/satellite cells, leading to sarcopenia. Thus, OS can lead to sarcopenic obesity (**Figure 1**).

#### **3. Sarcopenia in Asian populations: a distinct entity**

Asian people have been seen to have lower muscle mass, weaker grip strength, slower gait speed, and greater body fat mass with central distribution; however, the intensity of age-associated muscle mass decline in the older Asian population remains comparatively unaltered, but the decline rate in muscle strength or physical performance with aging was more noteworthy. Additionally, Asian people showed greater elevation in fat mass and higher incidence of central obesity with aging, particularly in women.

#### **3.1 Prevalence of sarcopenic obesity**

The prevalence of sarcopenic obesity exhibits significant variation depending on the definitions used, assessment methods employed, and the specific

*Sarcopenic Obesity: Focus on the Asian Population DOI: http://dx.doi.org/10.5772/intechopen.112528*

populations under consideration.SO prevalence generally varies from 0 to 25% in older adults in different studies. The prevalence of sarcopenia in Indian population is approximately 39% [7]. A study conducted in Indian population in 2015 by ICMR concluded that the prevalence rate of obesity and central obesity varies from 11.8 to 31.3% and 16.9 to 36.3%, respectively [8]. SO affects around 5–6% of Indian adults annually.

#### **4. Screening**

It is based on concomitant presence of an elevated body mass index (BMI) or waist circumference (WC) with ethnicity specific cutoff points. Validated questionnaires, for example, SARC-F in older subjects [9]. The Asian Working Group for Sarcopenia (AWGS) recommends several preliminary screening methods for sarcopenia. These include measuring calf circumference (less than 34 cm in men and less than 33 cm in women), utilizing the SARC-F scale (≥4), or employing the SARC-Calf scale (≥11). During hospitalization, DXA or BIA can be used to enhance the accuracy of skeletal muscle mass (SMM) measurements (**Table 1**).

#### **5. Diagnosis and method of assessment**

According to the consensus of the Asian Working Group for Sarcopenia (AWGS) [11], the diagnosis of this ailment necessitates analysis of


#### **5.1 Body composition**


In fact, both Dual Energy X-ray Absorptiometry (DXA) and Bioelectrical impedance analysis (BIA), the body composition methods which are usually recommended for definition of sarcopenia, are not able to recognize either myosteatosis (MS) or myofibrosis (MF) and also do not take into account muscle function in terms of strength and performance, and it is important because both muscle strength and performance decline quicker than muscle mass with aging.

To accurately diagnose SO, quantitative assessment of SMM and fat mass (FM) is vital. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are considered as gold standard for accurate diagnosis of SMM and FM, but their use is limited due to high cost, limited availability, and radiation exposure in case of CT (**Table 2**).

```
SARC-F screen for sarcopenia: component question scoring
Strength: How much difficulty do you have in lifting and carrying 10 pounds?
• None 0
• Some 1
• A lot or unable 2
Assistance in walking: How much difficulty do you have walking across a room?
• None 0
• Some 1
• A lot, use aids, or unable 2
Rise from a chair: How much difficulty do you have transferring from a chair or bed?
• None 0
• Some 1
• A lot or unable without help 2
Climb stairs: How much difficulty do you have climbing a flight of 10 stairs?
• None 0
• Some 1
• A lot or unable 2
Falls: How many times have you fallen in the past year?
• None 0
• 1ess than 3 falls 1
• 4 or more falls 2
Data suggests that a SARC-F score of ≥4 best predicts the need for further, more comprehensive evaluation.
```
#### **Table 1.**

*Validity of SARC-F Score: The SARC-F scale has demonstrated internal consistency and validity in identifying individuals at risk of experiencing negative outcomes associated with sarcopenia in various studies, including AAH, BLSA, and NHANES [10].*

#### **5.2 Skeletal muscle functional parameters**


Muscle functional cutoff points need to be validated as reference values for sex, ethnicity, and age stratum. Moreover, studies suggest the necessity to adjust handgrip strength (HGS) to body mass.

*Sarcopenic Obesity: Focus on the Asian Population DOI: http://dx.doi.org/10.5772/intechopen.112528*


#### **Table 2.**

*Diagnosis techniques for Sarcopenic obesity.*

#### **5.3 Biomarkers for sarcopenia**

Several Biomarkers have been studied. Irisin, a myokine that is released by skeletal muscles, is a potential biomarker for sarcopenia. Low irisin levels (<9.49 ng/mL) in T2DM patients is an independent risk factor for SO.

#### **6. Staging**


#### **7. Adverse health consequences of SO**

#### **7.1 SO has been associated with major clinical implications**

Increased risk of disability, mobility limitations, and overall impaired physical capacity; elevated risk of cardiometabolic abnormalities such as insulin resistance, dyslipidaemia, hypertension, type 2 diabetes, and low-grade inflammation; increased risk of fractures; depression and compromised overall psychological health; poor outcomes in cancer; increased mortality risk; reduced health-related quality of life;

**Figure 2.**

*Sarcopenic obesity: causes and consequences (CVD: cardiovascular disease).*

and institutionalization and expanded healthcare costs. However, the cross-sectional design of related studies fails to provide solid information on causal relationships. This highlights the need for longitudinal studies to elucidate the real impact of SO on the onset and progression of specific diseases (**Figure 2**).

#### **8. Management of sarcopenic obesity**

Two approaches need to be pursued at the same time:

Gaining SMM while losing FM: The effects of any intervention should focus on changes in body composition and functional parameters and not be measured as changes of body weight alone. If the treatment strategy is limited to only weight loss interventions, there can be inevitable health risks for elderly individuals, mainly related to the concomitant loss of bone and skeletal muscle mass and exacerbation of osteosarcopenia [12].

Therefore, it is very important to focus on body fat loss and maintenance or accretion of muscle mass, so as to maintain strength, function, and resting metabolic rate (RMR). Combined therapy of nutrition along with exercise is the most accepted strategy for these goals [13].

#### **8.1 Resistance training**

Resistance training is one the most accepted training for older adults that can improve body composition without weight loss.

Fiatarone and colleagues showed that an eight-week training program of resistance training led to an increase in muscle mass in even frail, institutionalized 90-year-old men and women [14]. Weight training (resistance training) for three days *Sarcopenic Obesity: Focus on the Asian Population DOI: http://dx.doi.org/10.5772/intechopen.112528*

a week increases muscle mass, with a decrease in fat mass in healthy men and women aged 50–75 years, with body weight remaining unchanged [15].

Resistance training also induces changes in muscle fiber in healthy men and women aged 60 years or older.

Along with severe calorie restriction, resistance training is beneficial. Calorie restriction usually leads to a reduction in both fat and lean mass. Resistance exercise, when prescribed along with calorie restriction, can help prevent muscle loss. As a result, this can lead to a decrease in fat mass along with maintaining muscle mass.

#### **8.2 Essential amino acids (EAA) supplementation**

EAA supplementation along with resistance exercise can enhance muscle protein synthesis and can improve body composition by increasing lean mass, not fat mass [16]. In men and women aged 25–35 years, ingestion of essential amino acids before intense resistance exercise resulted in significant increase in muscle protein synthesis and an increase in lean mass [17]. Similarly, 12 weeks of resistance training with the consumption of protein supplement (17 g of essential amino acids) twice a day by healthy young men stimulated greater gain in lean mass compared with resistance training alone [18]. Administration of 15 g of essential amino acids to healthy middle-aged men, along with resistance training program, resulted in attenuation of loss of muscle and gains in fat.

#### **8.3 Dietary protein**

Even without resistance exercise, a high protein diet may itself provide an anabolic environment for promoting retention or accretion of muscles over time. A study conducted by Solerte and colleagues concluded that in older men and women aged 64–84 years with sarcopenia, oral supplementation with 16 g per day of essential amino acids was sufficient to increase lean mass in 8 months [19]. This effect persisted over time and resulted in a decrease in TNFα, which is found to be elevated in sarcopenic process. Protein supplementation also prevents muscle loss during calorie restriction, with minimal energy deficit. Higher consumption of high-quality protein (aiming for 1–1.2 g/kg/d or even higher intake 1.2–1.5 g/kg/d) than the current RDA might be advantageous for older adults and malnourished medical in patients [20]. It is also seen that when an individual consumes insufficient diet, the loss of protein can be lessened or even stopped by the addition of carbohydrates or fats to the food and is regarded as the "protein-sparing action" of carbohydrates and fats.

#### **8.4 Treatment strategies**

See **Table 3**.

#### **8.5 Newer emerging treatments**

Electrical acupuncture and whole-body electro-myo-stimulation, in conjunction with nutritional supplementation, are emerging and effective approaches to bring about alterations in body composition. Whole body vibration therapy has also found to be a safe and convenient technique to cause neuromuscular activation and simulate the contraction of skeletal muscle. A recent study has demonstrated that the adenosine A2B receptor (A2B) is highly expressed in muscle tissue and brown adipose tissue (BAT) and may be a target for SO.


**Table 3.** *Novel treatment strategies.*

#### **9. Unmet needs, challenges, and knowledge gaps**


#### **10. Conclusions and future directions**

The convergence of two conditions – a growing aging population and increasing obesity rates – has led to an increase in the prevalence of SO, which is defined as the concurrent presence of sarcopenia and obesity in the same individual. SO can lead to an increase in risk of disability, CV disorders, hospitalization, and impaired quality

#### *Sarcopenic Obesity: Focus on the Asian Population DOI: http://dx.doi.org/10.5772/intechopen.112528*

of life and mortality. Because of such negative effects of SO, its effective diagnosis, prevention, and treatment emerge as a top priority among researchers and clinicians.

Sarcopenic obesity (SO) carries significant implications for public health, as it is connected to frailty, falls, disability, and heightened risks of morbidity and mortality.

The thin fat Indian phenotype, characterized by higher body fat composition and lower muscle mass (sarcopenia), makes individuals of Asian Indian descent more susceptible to muscle loss and metabolic disorders. Compared to their white or African counterparts. The rising prevalence of this condition among younger populations is a cause for concern.

To further advance the current knowledge, the scientific community should try to establish a robust definition and a reliable assessment/diagnostic method, conduct more patient-centric trials, and, finally, obtain concluding evidences with the help of trials for dietary and resistance training interventions.

#### **Author details**

Mukulesh Gupta1 \* and Tuhina Gupta<sup>2</sup>

1 Udyan Health Care Pvt Ltd, Lucknow, UP, India

2 SGT Medical College and Hospital, Gurgaon, India

\*Address all correspondence to: drmukulesh@yahoo.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 6** Movement and Aging

*Emilia Patricia Zarco, Anne Gibbone and Hanna Matatyaho*

#### **Abstract**

Movement is a fundamental function of life. Human beings move through the act of breathing before they learn language and speak. Movement is central to all of life's processes: growth and development, energy production and utilization, and environmental adaptation. This chapter will explore the power of human movement and how it can be harnessed to address the challenges of aging. Movement in this chapter refers to physical activity and exercise. The challenge of aging for the future is not simply prolonging human life at any cost or by any means but rather extending self-sufficiency and quality of life. Aging adults need to keep on moving to keep their independence, self-care and improve their quality of life. The chapter will present current knowledge and new insights from contemporary research as we explore how physical activity and exercise can help address challenges of aging in these areas: musculoskeletal health, pain, immune system and brain health.

**Keywords:** movement, physical activity, exercise, health promotion, aging

#### **1. Introduction**

Movement comes from the word "movere" which means to move. It is the act or process of moving. In a broader perspective, it is change or development. This chapter will focus on physical activity and exercise as movement. The World Health Organization (WHO) defines physical activity as any bodily movement that is produced by the contraction of skeletal muscle and that increases energy expenditure above a basal level. It refers to all movements including during leisure time, for transport to get to and from places or as part of a person's work. The US Centers for Disease Control and Prevention (CDC) also defines exercise as a form of physical activity that involves planned, structured and repetitive bodily movement with the goal of improving or maintaining health or fitness. Although all exercise is physical activity, not all physical activity is exercise.

The challenge of aging for the future is not simply prolonging human life at any cost or by any means but rather extending self-sufficiency and quality of life [1]. Movement is critical to address the changes of aging that prevent self-sufficiency and affect quality of life. Physical activity is required for self-care and determines an individual's level of independence or self-sufficiency. This challenge is compounded by the fact that 1.4 billion adults (27.5% of the world's adult population) or more than 1 in 4 adults do not meet the recommended level of physical activity to improve and protect their health [2]. Furthermore, both men and women become less active as they get older despite clear evidence that being active benefits older adults in relation

to preventing falls, remaining independent, reducing isolation and maintaining social links to improve psychosocial health [2].

The cost of physical inactivity is not only chronic diseases and premature deaths but a large economic burden. The WHO global status report on physical activity in 2022 states that physical inactivity costs health care systems US\$ 27 billion a year due to preventable non-communicable diseases (NCDs). In the US, half of all American adults have one or more preventable chronic diseases like obesity, type 2 diabetes, heart disease, many types of cancer, depression, anxiety and dementia resulting in approximately \$117 billion in annual health care costs and about 10 percent of premature mortality [3]. Furthermore, WHO projects almost 500 million (499,208 million) new cases of preventable NCDs between the years 2020–2030 if there is no change in the current prevalence of physical inactivity. The burden of new cases is highest among lower income countries (41 percent), with the Western Pacific Region predicted to be hardest hit. Globally, hypertension (47% prevalence accounting 22% health care cost), depression (43% accounting 28% health care cost) leads new cases of preventable NCDs. Dementia will account for 21% of health care costs due to the nature of its management and duration for which it is needed.

To explore how movement through increasing physical activity levels and engaging in regular exercise will help address aging challenges, a narrative review of relating movement with the four areas of health were chosen as the focus of the literature search: musculoskeletal health, pain, immune system and brain health. From the authors' discussion, these are the health areas that movement will impact directly or indirectly and will influence the aging populations' independence, self-sufficiency and quality of life. A preliminary search to validate the idea of relating aging with the four areas was conducted in the ONEsearch database. The key words "aging" paired with each of the areas of focus: musculoskeletal health, pain, immune system and brain health was used, and only peer-reviewed articles were included. The inclusion and exclusion criteria were formulated and refined after the preliminary search. The inclusion criteria included the following: worldwide peer-reviewed articles from 2020 and onward, English publications only, all types of research (quantitative and qualitative primary and secondary studies and tertiary research) were considered, and no dissertation work was included.

The evidence about the health benefits of regular physical activity is well established supported by studies that examined the role of physical activity in health and disease. There is evidence that even lower intensity activities demonstrate cardiometabolic and health benefits in an aging population [4]. A systematic review [13] found that 2.5 hour/week (equivalent to 30 min daily of moderate intensity activity on 5 days a week) compared with no activity was associated with a reduction in mortality risk of 19%, while 7 hour/week of moderate activity compared with no activity reduced the mortality risk by 24%. [5]. These studies clearly emphasize the importance of avoiding inactivity to delay death from all causes.

As one ages, being self-sufficient and pain free are among the utmost desires in sustaining a high quality of life [6]. Knowledge and practices that have been proven to regulate those goals have and continue to lead directly to movement [1]. Movement is dynamic and changes throughout the lifespan due to changes in musculoskeletal or nervous systems, fatigue, posture, injury, disease, or the environment. Changes related to age, include but are not limited to, changes in muscle fiber type, reduced vision, balance, range of motion, base of support, strength, reaction time and vestibular function in addition to increased postural sway, flexed posture, and pain. These changes influence functional mobility, balance and posture in older adulthood. However, it is important to emphasize that these changes are controllable through movement training and exercise.

#### **2. Movement and musculoskeletal health**

Musculoskeletal deficits are among the most detrimental effects of aging due to loss of muscular strength, flexibility, balance and functional ability [7]. Loss of muscle strength accelerates with age. By the age of 75–85 years, a typical person has lost about 45–50% of their muscle strength and by the age of 85, more than 55% [1]. Muscle strength plays a role in walking speed as weak muscles provide less power to support walking speed. Regular strength and neuromuscular training assists in reversing or slowing down a decline in walking speed due to the aging process. Joints are subject to the state of muscles, connective tissue and cartilage and concentrating on stretching and ROM exercises will aid in improving flexibility in older adults.

Sarcopenia, the loss of muscle mass, strength and function affects 10–50% of people over 60 years of age [8]. It is considered a precursor syndrome for the physical manifestation of frailty leading to impaired mobility and reduced independence. It has been shown that older adults with sarcopenia have poorer bone health [9]. Over time osteoblast activity is reduced affecting bone loss and skeletal strength. Older adults engaging in high physical activity/low sedentary behaviors have greater skeletal muscle strength and muscle power [10]. Resistance training exercise helps to maintain muscle strength and size in older years. Inactive adults after the age of 60 have less strength due to sarcopenia or loss of muscle mass and exercise clearly helps to maintain muscle mass needed for daily living activities and injury prevention [11]. Exercise, proper diet and endocrinological balance are recommended as interventions that are interconnected to improve musculoskeletal health and quality of life.

Obesity, which is involved in the development of many chronic diseases, also affects musculoskeletal health. Older adults with a BMI of 30 kg/m2 or greater significantly demonstrate functional limitations [12]. Being overweight and/or obese has been suggested to lead to alterations in the musculoskeletal system that place overweight individuals at higher risk of musculoskeletal pain and restricted range of movement [13]. There is a dose-response relationship between obesity and knee osteoarthritis (OA), meaning the greater an individual's BMI, the greater the likelihood of developing OA [14]. Furthermore, obese adults with BMI over 35 perform poorly on tasks of executive function involving planning and mental flexibility when compared to normal individuals [15]. Older obese adult males showed deficits in cognitive functioning when completing cognitive tasks evaluating learning and visual memory [16]. The multidimensional nature of mobility issues among older adults with obesity requires a multidisciplinary approach to assessment and intervention with movement training (e.g., postural control and motor planning) as requirements.

Activities of daily living (ADL's) are used as a gauge of functional independence. Physical activity improves physical function among individuals of all ages, enabling them to conduct their daily lives with energy and without undue fatigue. This is true for older adults, for whom improved physical function reduces risk of falls and fallrelated injuries and contributes to their ability to maintain independence. Among the elderly, fall-related injuries are a primary public health challenge [2]. Furthermore, projections of fall-related injuries continue to increase [17, 18]. Aging consequently worsens the efficacy of musculoskeletal systems and functional abilities [7]. Due to the increasing frequency of falls among the vastly growing population of older adults, targeted interventions to minimize fall risks are of utmost priority. Physical activity in general for the elderly has proven reductions in the rate of fall related injuries [19, 20]. However, correlating specific activity programs is challenging given the vast array of types of exercises, individual differences and limitations of high-quality clinical trials. Programs that focus on balance [21] and have high doses of physical activity have been proven successful in fall reduction [20]. Increased reaction time as one ages is a proven risk factor in falls [22]. Similarly changes in gait and mobility from aging are associated with functional decline [23] and gait kinematics have been linked to predicting fall risk [24–26]. Older adults exhibit several changes in gait and paired with increased reaction time and decreased strength, endurance and visual acuity, falls are a major public health issue. Identifying training programs that focus on decreasing the risk of falls are of tremendous value. Although neurophysiological changes as one ages will occur, reaction and response time reduction is curtailed by regular physical activity.

Functional mobility, which requires both strength and flexibility, is another musculoskeletal challenge among older adults. Regular physical activity, specifically stretching, has been shown to create instantaneous and long-lasting changes to maximal joint range of motion and improves flexibility and functional mobility. Several studies reported that stretching efficacy was not limited to the targeted joint being moved [27–29]. For example, unilateral stretching performed on one lower limb also increased the range of motion of the contralateral limb; stretching of the lower limb increased the maximal range of motion of the distant upper limbs and vice versa. The role of fascia and connective tissues provides an explanation of the efficacy of stretching beyond the targeted joint. Recent histologic findings showed that fascia contains contractile cells, free nerve endings, and mechanoreceptors and therefore plays a proprioceptive and mechanically active role that functions as a body-wide mechanosensitive signaling network [30]. Full body exercises that include full body stretching therefore offer more benefits for musculoskeletal health.

#### **3. Movement and pain**

As we age, pain is viewed as an inevitable part of life. Low back pain, for example, is one of the most common and complex musculoskeletal ailments. Reducing low back pain in many cases may be accomplished through improving strength, balance and flexibility. We begin with little aches and pains due to sports injuries, to more extreme injuries due to falls. In order to address pain, we begin by taking over the counter medication to numb the pain, but persistent pain sometimes occurs. In most cases, over-the-counter medication helps, and we continue with our daily living activities. According to the Consumer Healthcare Product Association (2023) approximately 23% of U.S. adults use Acetaminophen weekly. The Mayo Clinic (2023) states that Acetaminophen is "usually recommended as the first line treatment for mild to moderate pain." The struggle to manage pain is rather complex and has been discussed with much detail in the last decade, but pain management has been an integral part of medicine throughout history, where medication was almost always the preferred choice. In the 17th Century European doctors gave opium to their patients to relieve pain and by the 20th Century morphine and heroin were used to control pain [31]. While opioid use can be very effective in pain management relief, The American Society of Anesthesiologists states that it is also highly addictive. In fact, they report that "The risk of addiction is especially high when opioids are used to manage chronic

pain over a long period of time" [32]. Older adults should be given the lowest analgesic dose for the shortest possible time to adequately manage their pain.

But what is pain? Pain, as described by the International Association for the Study of Pain (IASP) is, "an unpleasant sensory and emotional experience associated with, actual or potential tissue damage, or described in terms of such damage" [33]. There are two major types of pain: acute pain and chronic pain. Acute pain comes on quickly, can be severe, but in most cases a temporary condition that does not last for a long period of time. Chronic pain lasts beyond normal tissue healing time, generally taken to be 12 weeks/3 months and limits quality of life because it contributes to disability, anxiety, depression, sleep disturbances, poor quality of life and healthcare costs [34].

Pain among older adults leads to functional impairment, sleep disturbance, reduced socialization, depression, reduced mobility and impaired or slowed rehabilitation. There is an estimated 70–80% reduction in the ability to perform activities of daily living among older adults with pain. They also exhibit decreased gait speed, weaker grip strength and decreased self-reported physical activity [35]. Frailty, a common clinical syndrome among older adults often display reduced functional reserve and pain related impairments profoundly impact cognition and independence [36]. Pain is the most common reason people seek health care and the leading cause of disability in the world. In 2011, one in every five adults worldwide suffers from pain and one in every 10 adults is diagnosed with chronic pain each year [37]. The 2020 Global Pain Index reports that one third of the world's population is in pain everyday [38]. Acute pain is experienced regularly by up to 49–83%of elderly individuals above the age of 60 living in care homes and 40% of elderly individuals living in the community [38]. The prevalence of chronic pain among US adults ranged at 20.5–21.8% [39]. According to the Center for Practical Bioethics (2021) more than 116 million Americans are impacted by chronic pain, resulting in high healthcare costs. A report published by John Elflein [40] who conducted a survey in 2021 with 29,482 participants over the age of 18, showed that 26.8% of adults between the ages of 45 and 64; 30% of adults between the ages of 65 and 84; and 34.3% of adults 85 and over live with chronic pain in the United States. Chronic pain, especially in the elderly population, is more prevalent as pain is a frequent side effect of chronic illness. Although the aforementioned study did not discuss the causes of pain, it did demonstrate that chronic pain increases with age. While each individual's level and frequency of pain differs, as one ages, the duration of pain increases [41]. Stressful situations, depression and anxiety can exacerbate chronic pain because pain and these mental health states share overlapping nerve biological pain pathways in the brain. Prevalence of pain is common among the older age group highlighting the need for pain management that goes beyond analgesics and considering alternative options [42].

For many years, the non-pharmacological treatment choice for pain included recommendations for rest and inactivity [34]. However, movement or physical activity programs and exercise regimens are increasingly promoted to reduce chronic pain and improve mental health and physical functioning. Although pain is a normal protective response to injury and potentially harmful stimuli, prolonged or dysfunctional neuromuscular adaptations in response to pain may contribute to disability and chronicity in a variety of pain conditions [43]. Clinically, pain produces a large range of motor adaptations. This ranges from subtle motor compensations during task completion to complete avoidance of painful movements and/or activities [44]. Movement, individualized exercise programs and specific motor learning/functional tasks are often prescribed to help decrease pain and restore/improve function.

Studies provide evidence of the effectiveness of exercise for the treatment of pain. For example, exercise is effective for the management of chronic low back pain and for fibromyalgia strength, endurance training and stretching of the neck and upper extremities improve neck pain [45].

Physical therapy or physiotherapy is another non-pharmacological treatment for pain. Physical therapists or physiotherapists are considered movement experts who treat pain and improve quality of life through hands-on approaches: stretching, soft tissue release, joint mobilizations, fascial release, etc. Treatment also includes exercise-based approaches to strengthen muscles, improve balance and sharpen coordination. Physical therapy takes on a more holistic approach to pain relief because the interventions are based in the knowledge that all forces in the body affect each other. It works to restore the balance of coordination, flexibility and strength so that movement, blood flow and nerve functioning are facilitated. For example, pain due to a nerve pinch may happen because of compression from a muscle or fascia. Reducing the strain and restoring fluid movement through physiotherapy helps alleviate the pain. Many of the exercises used in a physical therapy session are encouraged to continue at home. Physical therapy works to restore movement and improve functional mobility, eliminate pain and reduce the need for surgery and pain medicines like opioids.

Studies also support that those engaging in regular physical activity are associated with less frequent back pain and reduced incidence of musculoskeletal pain [46, 47]. Some studies show that regular physical activity may reduce pain sensitivity, and some demonstrate no change, but greater pain sensitivity has never been observed. It should be noted that some acute exacerbation of chronic pain when beginning an exercise program may happen and therefore the need to gradually increase physical activity is critical with the goal of eventually reaching recommended guidelines. Regular exercise leads to chronic adaptations that provide the greatest benefit to addressing pain. It is recommended that engaging in physical activity at a young age builds muscle, helps with range of motion, and improves overall movement.

#### **4. Movement and the immune system**

As we grow older, our immune system slows down, weakens, and loses the ability to fight against illness, such as infections, cancer, and appropriate wound healing [48]. Our immune system plays an important role in protecting us from harmful substances, germs, and cell changes. It is made up of two parts: the innate immune system and the adaptive immune system. Innate immunity responds immediately to an invading pathogen, is antigen-independent, and has no immunologic memory [49]. Innate immunity is known as the first line of defense against germs or foreign substances. Adaptive immunity is antigen-dependent and antigen-specific and has immunologic memory which enables for an immune response when it recognizes the same antigen [49]. Inflammation is the body's immune response to any form of irritant.

A review conducted by Ghauri [50] showed that chronic pain negatively impacted the immune system. An immune response to chronic pain is the release of inflammatory substances such as antibodies, cytokines, and chemokines. When the immune system attacks the body, it results in inflammation of joints, which may cause pain, stiffness, and difficulties with mobility [51]. Inflammation contributes too many age-related degenerative joint diseases such as frailty, osteoporosis, atherosclerosis,

#### *Movement and Aging DOI: http://dx.doi.org/10.5772/intechopen.113974*

type 2 diabetes, sarcopenia, and Alzheimer's disease [52]. Inflammation can be acute or chronic: acute inflammation will respond immediately to trauma due to injury, whereas chronic inflammation is slow, and long-term lasting [53].

With age, the risk of inflammation increases due to an unhealthy lifestyle, such as an unhealthy diet or physical inactivity. A review of studies conducted shows that, "…lifestyle interventions such as exercise training and dietary modifications may provide a low cost and long-term alternative to limit inflammation and slow declines in the elderly." [54].

According to Pahwa, et al., [53] 350 million people worldwide and almost 42 million Americans, suffer from arthritis and joint diseases of which osteoarthritis and osteoporosis occur more in menopausal women than older men [55]. As osteoarthritis is the most common age-related disorder in the world [56], the deterioration of the connective tissues that holds the joints together is found to be a major contributor to the development of osteoarthritis, which results in the increase of stiffness of ligaments and tendons [57]. To slow down the progression of osteoarthritis or osteoporosis, an exercise program that consists of spinal extensor strengthening with progressive measured resistance is recommended to prevent falls and fractures [58]. In addition to resistance training, movement to improve range of motion and overall functional performance should become a part of every aging adult. The Arthritis Foundation states the "movement is the best medicine for osteoarthritis."

Oxidative stress or reactive oxygen species (ROS) can cause chronic inflammation and affect a variety of physiological and pathological processes playing a role in agerelated diseases like sarcopenia, cancer, cerebrovascular and neurodegenerative diseases. ROS induces cellular senescence eventually leading to cell death. Studies show that low to moderate levels of exercise-induced ROS production plays an essential role in exercise-induced adaptation of skeletal muscle [59]. Lack of exercise, suboptimal amount and quality of sleep, and poor diet all contribute to the accumulation of ROS. Homocysteine, an amino acid, influences ROS accumulation. There is evidence that elevated levels of homocysteine is associated with lower muscle strength in women and considered a risk factor for vascular and coronary heart disease. Recent studies report on the positive effects of Nordic walking (walking with poles mimicking the motion of cross- country skiing), reducing homocysteine levels and ensuring adequate supply of vitamin D. Vitamin D is essential for bone health and skeletal muscle function and continuously decreases over a lifetime. Vitamin D supplementation combined with outdoor activity in fresh air lowers homocysteine levels compared to supplementation alone.

There is growing evidence that depression is accompanied by increased levels of proinflammatory cytokines. This is based on a theory of a link between innate immunity and the central nervous system leading to decreased synthesis of serotonin and increased cortisol levels, characteristics of depressive conditions. Several studies have shown the benefits of movement and showed that regular physical activity improves immunity and may limit the effects or delay immunological aging. Regular aerobic exercise increases immune system function to prevent and defend against infection through reducing age-related increase in proinflammatory cytokines.

Recent genomic and functional studies suggest that immune and inflammation pathways are involved in the pathogenesis of Alzheimer's disease (AD) and Parkinson's disease (PD), the most common age-related neurodegenerative disorders. Both of these diseases are characterized by chronic inflammation in the brain. The chronic neuroinflammation compromises the blood–brain barrier (BBB) integrity, increasing its permeability and leading to loss of immunological protection of the

central nervous system. There is body evidence that regular physical exercise has anti-inflammatory effects and reduces blood-brain barrier permeability reinforcing antioxidative capacity and reducing oxidative stress [60]. Furthermore, regular physical activity improves endothelial function and increases the density of brain capillaries. Therefore, physical training should be a component of prevention programs to reduce the risk of neuroinflammatory diseases.

Gentle stretching helps resolve inflammation and reduce pain. Stretching exercises and guided exercise programs with a prominent stretching component like Yoga, Tai-Chi and Essentrics have been found to decrease levels of circulating pro-inflammatory cytokines. Researchers from Harvard found that rats who were comfortably stretched for 10 minutes twice per day had better mobility (longer gait), less pain and reduced inflammatory infiltration in the connective tissues 2 weeks after pain injection. Furthermore, stretching also increased the rate of healing [30].

#### **5. Movement and brain health**

As we age, it is inevitable that not only our physical ability declines, but our cognitive ability declines, as well. As with physical impairment, cognitive impairment can be prevented and delayed. But what is cognition? Cognition is defined as "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses." [61]. Cognitive impairment in older adults can have many causes, including, but not limited to, the side effects of medication, infections, depression, dementia, and stress to name a few. A cohort study conducted by Kulsheshtha et al. [62] with 24,448 participants over the age of 45 found that there is an association between stress and cognitive impairment. Another study conducted in Sweden showed a significantly higher level of perceived stress in adults of advanced age [63]. Acute and chronic stress can result in oxidative stress, neuroinflammation and dysfunction of the blood–brain barrier leading to poor health outcomes. Anxiety and depression often accompany aging, increasing by up to 6% among those over the age of 65. Significant changes due to aging can cause feelings of insecurity, loss of selfesteem, anxiety and depression. Regular exercise therapy reduces stress and depression. In fact, studies show that running therapy was shown to have more beneficial effects on biological aging than antidepressant medications. Many studies have also shown the benefits of exercise in cognition. A literature review conducted by van Uffelen et al. [64] showed that exercising programs that included strength, flexibility, and balance training, improved cognition in both healthy older adults as well as older adults with cognitive decline. A study by Lautenschlager [65] reported that physical activity reduces the risk of cognitive decline later in life. Aspects of cognitive function that may be improved include memory, attention, executive function (the ability to plan and organize; monitor, inhibit, or facilitate behaviors; initiate tasks; and control emotions).

The protection of the aging brain and the central nervous system from neurodegeneration poses significant challenges. In addition to apparent physical changes due to aging, there are often equally significant changes in the brain and in mental health. The brain shrinks in volume, particularly in the frontal cortex and its weight declines with age at a rate of around 5% per decade after age 40. The white matter found in the deeper tissues of the brain that contain nerve fibers wrapped by a fatty sheath called myelin deteriorates after around the age of 40. Memory loss is the most widely seen cognitive change associated with aging. There are four sections that comprise memory

#### *Movement and Aging DOI: http://dx.doi.org/10.5772/intechopen.113974*

functioning: episodic, semantic, procedural and working memory. Loss of episodic memory characterizes memory loss in Alzheimer's disease. Several studies demonstrated that physical activity, especially aerobic exercise performed by elderly people is protective against Alzheimer's disease, slowing the decline in cognition and slows disease progression through reducing amyloid-B level deposition. On the other hand, sedentary life patterns and lack of physical activity increase the risk of dementia and Alzheimer's disease [66].

There is a growing interest in the gut-brain axis and there is accumulating evidence that the gut microbiota is critical to health and disease. Dysbiosis, a term for poor gut health, is characterized by microbiota dysregulation and results in an unbalanced microbiome in the gut. A healthy microbiome (symbiosis) promotes overall health. The gut-brain axis is the bidirectional link between the central nervous system (CNS) and the enteric nervous system (ENS). It seems like an "unhealthy gut" can lead to an "unhealthy brain". Dysbiosis is associated with neurodegenerative diseases including Alzheimer's, Parkinson's, Huntington's, and multiple sclerosis. For example, a review conducted by Ref. [67, 68] highlighted the role of Vitamin D deficiency or hypovitaminosis D among patients with Parkinson's disease due to a deterioration in the gastrointestinal function. Furthermore, the paper also states that neurodegenerative diseases and hypovitaminosis D led to frailty, a concept that has grown in importance in understanding the functional status of older adults' health. Frailty is a condition of risk and vulnerability diminished resistance to stressors and is associated with poor gut health [68]. Meanwhile, there is compelling evidence that shows many different types of exercise not only enhance cognitive functioning but provide a promising role for neurodegenerative diseases [1]. Exercise has been shown to increase the diversity of the microbiota, balancing beneficial and pathogenic bacterial communities and enhance colon health. Regular physical activity also increases butyrate-producing bacteria critical for maintaining the mucosal barrier, modulating immune response, preventing infections and regulating energy expenditure. Furthermore, exercise increases both endogenous and exogenous production of vitamin D which further increases the capacity to exercise.

Brain-derived neurotrophic factor (BDNF), a key protein molecule involved in learning and memory, decreases with aging. BDNF is also considered as the main player in brain plasticity. Movement, particularly aerobic and resistance exercise and endurance activity plays a neuroprotective role by increasing BDNF production [68]. Some studies indicate that exercise improves neuropsychiatric and cognitive symptoms in people with mental disorders. Interestingly, these studies show that the delivery of exogenous BDNF into the patient's brain had no therapeutic effect on the disease but releasing BDNF through physical activity was neuroprotective. Irisin, commonly referred to as the "sport hormone" is released from muscle cells after physical activity that induces oxygen consumption and heat production. Irisin protects against neuroinflammation by acting directly on glial cells in the brain, reducing oxidative and physiological stress, and protects against cerebral ischemia [1].

Regular physical activity provides a variety of other benefits, including helping people sleep better, feel better, and perform daily tasks more easily. There is a bidirectional relationship between sleep and exercise. Studies demonstrate that moderate to vigorous physical activity improves quality of sleep among adults. On the other hand, insufficient or poor quality of sleep leads to lower levels of physical activity. Regular physical activity reduces the length of time it takes to go to sleep, reduces the time one is awake after going to sleep and before rising in the morning and lengthens deep sleep. Exercise is also used to treat sleeping disorders. For example, 4 months

of aerobic exercise training in a sample of older adults with insomnia significantly improved sleep quality while also reducing daytime sleepiness and depressive symptoms. Another research study found that 12 weeks of moderate-intensity aerobic and resistance exercise resulted in a 25% reduction in obstructive sleep apnea (OSA) severity despite less than 1 kg of weight loss [69]. Indeed, regular exercise leads to better subjective and objective sleep and improvements in daytime functioning.

#### **6. Recommendations**

Past studies have aimed to determine an ideal movement program for older adults to combat changes in aging. Combining scientific support and motivational attributes, educating adults about the type and dose of movement in quality of life both before and at the onset of such reductions is critical [6]. Various forms of movement have all shown to be beneficial in some way in countering various weaknesses from aging, whether it be resistance training [70], endurance training and concurrent strength [71], Tai Chi [72, 73], multidimensional exercise training [7], functional training [74], dance [75], vibration therapy [76, 77], dynamic stretching [78–80] and static stretching [78, 81].

Both medical professionals and community/public health programs are essential in promoting movement as prevention and treatment. This ideology is the foundation for the American College of Sport Medicine (ACSM) Exercise is Medicine global initiative. ACSM and Health Level Seven International (HL7), a global health care database network approved a Physical Activity Implementation Guide that includes physical activity as a vital sign to facilitate health care professionals providing referrals to exercise professionals [82]. The Physical Activity Guidelines for Americans (2018) recommends that adults should move more and sit less throughout the day acknowledging that some physical activity is better than none. Furthermore, it recommends that at least 150 minutes (2.5 hours) to 300 minutes (5 hours) a week of moderate intensity or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity will lead to substantial benefits and even more additional health benefits beyond 300 minutes (5 hours). Recommendations for older adults (aged 65 and older) are the same but with additional elements of including multicomponent physical activity that emphasizes balance training, aerobics, and muscle-strengthening activities at moderate or greater intensity on 3 or more days a week to enhance functional capacity and to prevent falls. These recommendations align with the WHO recommendations (**Table 1**, **Figures 1**–**3**).

The intensity of exercise is based on absolute rates of energy expenditure commonly described as light, moderate, or vigorous intensity. Light intensity activity is non-sedentary waking behavior including walking at a slow or leisurely pace (2 mph or less), cooking activities, or light household chores. Moderate intensity activity includes activities like walking briskly (2.5 to 4 mph), playing doubles tennis, or raking the yard. Vigorous intensity activity samples include jogging, running, carrying heavy groceries or other loads upstairs, shoveling snow, or participating in a strenuous fitness class.

Aerobic physical activity is also classified into levels: inactive, insufficiently active, active, and highly active. The classifications are useful to help one determine his/her level and how to work on becoming more active. Inactive is basic movement derived


#### **Table 1.**

*WHO guidelines for physical activity and sedentary behavior for older adults.*

#### **Figure 1.**

*WHO guidelines on physical activity and sedentary behavior for adults.*


**Figure 2.** *WHO guidelines on physical activity and sedentary behavior for older adults.*

from daily life activities. Insufficiently active is doing some moderate- or vigorousintensity physical activity but less than 150 minutes of moderate-intensity physical activity a week or 75 minutes of vigorous-intensity physical activity or the equivalent combination. This level is less than the target range for meeting the key guidelines for adults. Active is doing the equivalent of 150 minutes to 300 minutes of moderate-intensity physical activity a week. This level meets the key guideline target range for adults. Highly active is doing the equivalent of more than 300 minutes of moderate-intensity physical activity a week. This level exceeds the key guideline target range for adults.

Guided exercise programs provide opportunities for older adults to meet the additional elements of including multicomponent physical activity that emphasizes

**Figure 3.**

*WHO guidelines on physical activity and sedentary behavior for adults with chronic conditions.*

balance training, aerobics, and muscle-strengthening activities to enhance functional capacity and to prevent falls. The most popular are Yoga, Tai-Chi and Pilates. A 10-year comparison study conducted in Australia showed that participation in Yoga, Pilates, and Tai Chi exercises increased over the course of time, with Yoga and Pilates being the preferred method of movement in adults age 55 and over [83]. Recently, Essentrics, a full body guided exercise program that seeks to rebalance the body was introduced in Canada as a "reverse aging" program and is becoming popular. Essentrics may have the most potential benefits and the least number of side effects because of its gentle approach and focus on aging. Although there are differences between these guided exercise programs all forms of movement are designed to improve physical and mental health using a full body approach.

#### **6.1 Essentrics**

A holistic approach was introduced as a full body work-out that uses a dynamic combination of strengthening and stretching aimed to rebalance the body. Essentrics was created by Miranda Esmonde-White a former ballerina with the National Ballet of Canada and draws on the slow and flowing movements of Tai-Chi, the strengthening techniques of ballet and the healing principles of physiotherapy. Essentrics relies on bodyweight as the source of resistance, which contrasts with traditional strength training or resistance training programs that use external weights. The movement sequences of Essentrics consist of low impact full body stretches emphasizing alignment to loosen and decompress the joints and relax the muscles. A study conducted by Zarco et al. [79] included older adults who participated in a guided exercise program, which showed an improved flexibility, balance, and strength (**Figures 4** and **5**).

#### **6.2 Yoga**

The practice of yoga was developed in Northern India around 2700 BC and offers physical benefits as well as mental wellness [84]. It is a type of exercise in which the body moves into various positions to become more fit or flexible, to improve breathing, and relax the mind. There are many different types of yoga in the world, but "Hatha Yoga" is the most popular in the West [85]. Blending western gymnastic styles with classic yoga became very popular. Since, the United Nations Assembly

#### *Movement and Aging DOI: http://dx.doi.org/10.5772/intechopen.113974*

**Figure 4.** *Essentrics sample exercise - windmill sequence.*

announced an "International Day of Yoga," in 2015, and UNESCO claimed yoga as an "intangible cultural heritage" [84]. The benefits of yoga include increased joint flexibility and joint function, and with regular practice it can reduce joint pain [86]. In a randomized control study conducted by [87] yoga improved flexibility, strength, and balance in older adults. Yoga is especially recommended for aging-related chronic ailments [88].

**Figure 5.** *Sample Essentrics exercise - washes and lullabies sequence.*

#### **6.3 Tai Chi**

Another form of complementary therapy is Tai Chi. Tai Chi is a form of Chinese martial arts. It was developed around 1670 by Chen Wangting as a method for self-defense but has shown to have great health benefits [89]. Tai Chi is a type of exercise where different postures and flowing movements result in attaining optimal physiological and psychological benefits [90]. Tai Chi is used to manage chronic pain conditions since slow motion and weight shifting may improve musculoskeletal

strength and joint stability. A review of studies showed that a 24-week Tai Chi exercise program for patients diagnosed with osteoporosis resulted in reduced pain, particularly in reduced lower back pain [91].

#### **6.4 Pilates**

Joseph H. Pilates developed these exercises in the 1920s as a method of conditioning ballet and modern dancers. Pilates is defined as an exercise regimen that is typically performed on a floor mat or with the use of a specialized apparatus and aims to improve flexibility and stability by strengthening the muscles, especially torso-stabilizing muscles of the abdomen and lower back. It focuses on controlled movement, posture, and breathing [92] A review conducted by [93] showed that the Pilates method reduces the risk of falls in older adults and improves balance and mobility.

These guided exercise programs share the same fundamental goal of mastering control over lifting and moving the body in space, are low impact and use the body weight as the resistance force for strengthening. Furthermore, they all utilize synchronized breathing with movements and varying degrees of body and mindful awareness. Studies on Pilates, Yoga, and Tai Chi have all had significant effects on the improvement of strength, body composition and flexibility. Furthermore, studies on Yoga and Pilates show it's beneficial in reducing inflammation. Pilates strengthens the bones and joints while yoga helps to build and increase the flexibility of the muscles around the joints [94]. Studies on Tai Chi show that it improves balance because of increased joint stability and postural control. There are few studies on Essentrics but initial studies show improvements in balance, strength, flexibility and address pain (**Table 2**).

It has been generally accepted that a reduction in functional capabilities is just a natural part of aging. However, more recent ideologies suggest that changes in functionality are not simply due to mere aging but increasing sedentariness or an inactive lifestyle. Distinguishing inevitable age-related changes versus those resulting


#### **Table 2.**

*Suggested physical activities or guided exercise programs for aging adults.*

from inactivity are critical for preserving quality of life. It is inevitable that aging and slowing down go hand and hand. However, this linkage is largely a result of a sedentary lifestyle. There is overwhelming evidence that the body is capable of responding to exercise throughout one's life and gives hope to all that effective movement may be sustained as we age. Although it's never too late, learning movement skills early in life will assist in maintenance with greater ease over the life span. Undeniably, movement, physical activity and exercise benefit aging and streamlining technology-based analyses, conducting research at the cellular and molecular levels and pinpointing interventions is the wave of future directions.

### **Author details**

Emilia Patricia Zarco\*, Anne Gibbone and Hanna Matatyaho Adelphi University, Garden City, NY, USA

\*Address all correspondence to: zarco@adelphi.edu

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 7**

## Impact of Physical Activity on Physical and Cognition Function among Community-Living Older Adults

*Milan Chang Gudjonsson*

#### **Abstract**

The aging population presents unique challenges to healthcare systems worldwide, particularly in terms of maintaining physical function and cognitive abilities in old age. Physical activity (PA) is emerging as a potent intervention to enhance the well-being and functional independence of older individuals. The current review chapter will focus on the effect of PA on physical and cognitive function to provide comprehensive understanding of the interplay among community-dwelling older adults. The review (1) overviews the positive impact of PA on physical functions, including muscle strength, endurance, balance, and cardiovascular health, elucidating how these benefits contribute to improved mobility and reduced risk of falls among older adults, and (2) explores also how regular PA is associated with the cognitive benefits, including its preventive or delaying effect of cognitive decline, enhancements in memory, attention, executive function, and overall cognitive vitality. It emphasizes the critical role of PA in enhancing the overall capacity on managing daily living of older adults and offers insights into effective strategies for promoting active and healthy aging. These knowledge and insights can also guide healthcare practitioners, policymakers, and researchers in developing and implementing effective strategies to promote PA and support healthy aging in older populations.

**Keywords:** physical activity, cognitive function, lifestyle, aging, physical function

#### **1. Introduction**

Aging is an inevitable process that every individual undergoes as they progress through life. The global demographic changes show a significant shift that the proportion of older adults (aged 60 and above) steadily increasing [1]. This demographic transition has caused a growing interest in healthy aging and age-related health challenges [2, 3]. This phenomenon is attributed to a combination of factors, including declining birth rates and advancements in healthcare, resulting in extended life expectancies [4]. This review chapter underscores the significant role of PA in enhancing the quality of life and functional independence of community-living older

adults, illuminating the pathways through which it positively impacts both physical and cognitive functions. It calls for continued research and targeted interventions to harness the potential of PA as a cornerstone of healthy aging. This perspective sheds light on the following impact of an aging population on our society. The potential impact of an aging population on our society are followings:


#### **2. Understanding factors contributing to the increase of older population**

Chronological aging refers to the passage of time as measured by one's date of birth [5], commonly used to determine an individual's age, wherein each passing year contributes to one's chronological age. Life expectancy (LE) is an important indicator for measuring the growth of the aging population [6], which is increasing globally as a result of reduced mortality among the older individuals [7]. Another significant factor contributing to the growth of the older population is the decline in birth rates observed in many countries [7, 8], resulting in a phenomenon known as "population aging." With fewer young people being born, the proportion of older individuals in the population naturally increases. Enhanced healthcare and medical advancements have also played a pivotal role in extending LE [9]. Medical conditions that were once fatal are now manageable or treatable, allowing individuals to lead longer and healthier lives. Improved accessibility to healthcare services and preventive measures has further contributed to this trend [10]. Moreover, economic stability and social welfare programs have provided support for older individuals [11], enabling them to lead more comfortable lives during their later years.

#### **3. Impacts of PA on physical and cognitive function among older population**

Physical and cognitive function are two fundamental aspects of an individual's wellbeing, influencing their ability to live independently and maintain a high quality of life (M. [12–14]). Aging-related functional decline can result in numerous health issues, reduced autonomy, decreased independence, and heightened pressure on healthcare systems [15, 16]. Given the importance of physical function and cognition in the lives of older adults, understanding how PA impacts these domains is crucial. The present

#### *Impact of Physical Activity on Physical and Cognition Function among Community-Living… DOI: http://dx.doi.org/10.5772/intechopen.114091*

chapter explores the current body of evidence on the topic, highlighting the potential benefits of regular PA on the physical and cognitive function of older adults.

Muscular strength declines 3% every year, and muscle mass reduces about 2% after 40 [17–20]. These phenomena of decline in both muscular strength and muscle mass with aging are well-known, and it is important to consider that the cause of this decline may not solely be attributed to the aging process itself but could also be linked to the reduction in PA that typically accompanies the aging process. Reduction in PA accelerated myoatrophy, which causes the loss of muscle mass and eventually lower basal metabolism [21, 22]. These changes lead to surplus energy increases and the accumulation of lipids [23, 24], which may further cause health problems, including higher blood pressure or blood glucose levels [25–27]. The significance of PA in maintaining our health has been long acknowledged. Regular PA offers numerous benefits, including (1) improving cardiovascular health, (2) enhancing or preserving cognitive and physical function [28, 29], and (3) reducing the risk of cognitive decline and major neurocognitive disorder among older adults [30, 31].

Clear evidences suggest that PA is beneficial for maintaining cognitive function, reducing risk of major neurocognitive disorder, and brain atrophy among older adults [30, 32]. While obesity and overweight were found to increase risk of major neurocognitive disorder [33], brain volumes (total brain tissue volume and gray matter and white matter volumes) are also strongly related to atherosclerosis [34], as well as to vascular risk factors such as systolic and diastolic blood pressure [35] or diabetes [36, 37]. The effect of regular PA and obesity on brain health may reflect lifestyle factors [32] or underlying modulation of neurotrophic and vascular risk factors as demonstrated in clinical and experimental research [38, 39].

#### **4. Impact of PA on mobility and associated cognitive function**

Those with low physical performance have a significantly higher risk of future institutionalization and disability onset [40–42]. While regular PA participation is linked with positive health outcomes, lack of PA has been also associated with increased disability and poor physical function among older adults [43]. Particularly, the mobility disability has been shown its predictive value for future institutionalization, mortality, and disability onset [40, 44]. Therefore, mobility function of older adults is often used as a clinical screening tool for the older population [43]. On the other hand, it is also suggested that those with low cognitive function have a lower mobility function compared with those with normal cognitive function (M. [12, 45, 46]). As the ability to move from one location to another is closely linked to factors such as attention, body coordination, and adaptability to one's surroundings [12, 47], older adults may need to maintain a higher level of cognitive function in order to sustain their independence in daily life.

#### **5. Cognitive impairment among older adults**

It is crucial to prioritize efforts to prevent or postpone cognitive decline in older adults [48]. Nevertheless, a substantial number of major neurocognitive disorder patients also experience damage from other vascular brain diseases, including ministrokes, which are ranked as the fifth leading cause of death in the United States [49]. Earlier research has suggested that this major neurocognitive disorder could potentially rank as the third leading cause of death for older individuals, trailing

only behind heart disease and cancer [50]. Memory problems are typically one of the first signs of cognitive impairment [51]. Some people with more memory problems than normal for their age may also have mild cognitive impairment (MCI), but their symptoms do not interfere with their everyday lives [52]. Movement difficulties and problems with the sense of smell have also been linked to MCI [53, 54].

While the impact of PA on cognitive functions is evident, several limitations need to be considered when interpreting the results. First, most studies had PA data collected close to the time at which cognitive function was assessed or major neurocognitive disorder diagnosed. With the short time intervals between PA and major neurocognitive disorder, it is difficult to determine whether the reported PA acts as a risk factor for cognitive decline or serves as an indicator of incipient disease. Second, most previous studies have examined either the relationship between PA and global cognitive performance or major neurocognitive disorder, but not both simultaneously. Third, studies that investigated the relationship between midlife PA and the risk of major neurocognitive disorder were mixed, and there is limited information on the association between levels of PA earlier in life and brain atrophy among older adults. At last, most studies investigating age-related changes in cerebral volume were cross-sectional and utilized small sample sizes of healthy older individuals or larger samples with all age groups. Further, longitudinal research on the impact of long-term PA on brain health is vital for a comprehensive understanding of these relationships.

While older people with MCI are at greater risk for developing major neurocognitive disorder, some may go back to normal cognition [53]. Researchers are studying biomarkers (biological signs of disease found in brain images, cerebrospinal fluid, and blood) to detect early sign in the brains of people with MCI and people with normal cognition who may be at greater risk for the major neurocognitive disorder [55]. Previous studies indicated that early detection is possible, but more research is needed before these medical techniques are available for the everyday medical practice to diagnose AD [48].

#### **6. Effective PA intervention to prevent functional decline**

Numerous exercise intervention studies have demonstrated that exercise improves physical performance in old age [12, 56, 57]. Further, regular PA or exercise also has a positive association with cognitive performance in the short- or long-term period [12, 58, 59]. Among various types of exercise for older adults, resistance exercise is one of the most feasible types of exercise to increase muscle mass and strength [59–61]. Particularly for the prevention of mobility disability and sarcopenia, the strength training is suggested as the most effective training method for older adults [59, 62, 63], even for those with limited mobility or cardiovascular fitness [64].

Cross-sectional studies have also shown that PA and physical performance are strongly associated with cognitive function [65–67], while it is possible that the improvement of physical performance by the exercise intervention may vary by baseline cognitive status [12]. Exercise intervention studies have primarily focused on investigating the improvement of physical performance and cognitive function among older adults following the intervention period [12, 13, 56, 62]. The specific findings related to the influence of various types of physical activity on cognitive function are as follows.

*Impact of Physical Activity on Physical and Cognition Function among Community-Living… DOI: http://dx.doi.org/10.5772/intechopen.114091*


#### **7. Other potentially modifiable risk factors for cognitive decline**

Although age is the strongest risk factor for cognitive decline, major neurocognitive disorder may not be an inevitable consequence of aging [81, 82]. Several recent studies have shown that lifestyle-related risk factors, including physical inactivity, tobacco use, unhealthy diets, and harmful use of alcohol, are strongly associated with cognitive impairment and major neurocognitive disorder [83]. Hypertension, diabetes, hypercholesterolemia, obesity, and depression are all associated with an elevated risk of experiencing cognitive decline or developing major neurocognitive disorder [84, 85]. Other potentially modifiable risk factors, such as social isolation and cognitive inactivity, were also linked to the development of major neurocognitive disorder [48]. The risk reduction guidelines for cognitive decline and major neurocognitive disorder from WHO provide evidence-based guidance for a public health response to major neurocognitive disorder. These modifiable risk factors suggest that prevention of cognitive decline or major neurocognitive disorder is possible through a public health approach. Several evidence-based research have investigated whether reducing modifiable risk factors decrease the risk for major neurocognitive disorder [14, 86].

#### **8. Types of intervention to prevent cognitive decline**

Cognitive impairment and major neurocognitive disorder are complex, multifactorial disorders, and multi-domain interventions targeting several risk factors and disease mechanisms simultaneously could be needed for optimum preventive effects [85]. Previous prevention trials for cognitive impairment and major neurocognitive disorder have reported positive associations with cognition for PA, cognitive training, Multimodal intervention programs: Implementing a long-term multicomponent program that combines various types of intervention including PA, cognitive training, social activity, and nutritional and cardiovascular counseling, has been shown to be effective in improving overall fitness, reducing sedentary behavior, and preventing a major neurocognitive disorder [85, 93].

Aerobic exercise programs: Implementing structured aerobic exercise programs, such as walking, jogging, or cycling, has shown significant effectiveness in reducing sedentary behavior and improving overall physical health. These programs are often tailored to individual fitness levels and can be conducted in group settings or individually [94–96].

Strength training interventions: Incorporating strength training interventions, including resistance exercises and weightlifting, has been found to be effective in promoting muscle strength, improving overall fitness, and combating the negative effects of a sedentary lifestyle, particularly in older adults [97].

Mind–body with flexibility and balance exercise programs: Interventions that integrate mind–body exercises, flexibility, and balance include tai-chi, yoga, and Pilates have demonstrated effectiveness in reducing sedentary behavior and promoting PA, while also providing benefits for mental well-being and stress reduction [74, 75, 77].

#### **Table 1.**

*Effective types of intervention on cognition for older adults.*

or both in smaller and shorter intervention studies [87–89]. Few prevention trials for cardiovascular disease and type 2 diabetes have emphasized the importance of a multi-domain approach [37, 87]. Multicomponent randomized controlled trials in individuals at risk of major neurocognitive disorder have been also recommended as an effective and feasible approach [85, 90]. Previous findings suggest that a risk factors other than genetics play a role in the development of AD [84]. One of a great deal of interest could be the relationship between cognitive decline and vascular conditions such as heart disease, stroke, and high blood pressure, as well as metabolic conditions, such as diabetes and obesity [91]. In general, a nutritious diet, PA, social engagement, and mentally stimulating pursuits have all been associated with helping people stay healthy as they age [90, 92]. These factors help in reducing the risk of cognitive decline [85]. However, evidence that short-term and single-component PA interventions promote cognitive function and prevent cognitive decline or major neurocognitive disorder in older adults is largely insufficient. Various forms of PA and exercise interventions have provided compelling evidence in countering sedentary habits and encouraging PA. These interventions include the followings (**Table 1**).

#### **9. Impact of preventive intervention in adults with MCI**

For cognitive outcomes in adults with MCI, evidence is still insufficient to indicate that PA interventions have a positive effect on cognition [31, 91]. However, these benefits are not consistent across all cognitive domains. This clinical trial proposal tests the efficacy and additive/synergistic effects of an exercise and cognitive training intervention on cognition with other risk factor management (social activity, nutrition, alcohol, and metabolic syndrome) in older adults who are diagnosed with MCI. Exercise and cognitive training are two promising interventions for preventing major neurocognitive disorders. Exercise increases fitness, which, in turn, improves brain structure and function, while cognitive training improves selective neural function intensively [48]. Various studies that tested cognitive training effects have reported discrepant findings due to varying programs [79, 98]. Hence, combined exercise and cognitive training may very well have an additive or synergistic effect on cognition

*Impact of Physical Activity on Physical and Cognition Function among Community-Living… DOI: http://dx.doi.org/10.5772/intechopen.114091*

by complementary strengthening of different neural functions. A meta-analysis of randomized controlled trials revealed a moderate effect of PA, with the most significant effect size observed for executive control processes [69, 99]. Optimal cognitive benefits were observed when aerobic training was combined with strength and flexibility training. Those review studies emphasized that a minimum of 30 minutes of PA training for over 6 months appeared necessary to establish stable cognitive effects in older adults. Moreover, the study suggested that engaging in moderate-intensity exercise, with an average duration of 1 hour per session, at least three times per week, could yield more pronounced cognitive and brain effects.

#### **10. Conclusion**

The impact of PA and exercise on physical function and cognition among community-living older adults is substantial. Regular PA and exercise have been proven to boost muscular strength, balance, mobility, cognitive function, and overall well-being in older population. The mechanisms underlying the positive impact of PA on physical function and cognition in older adults are multifaceted. Factors, such as increased blood flow to the brain, the release of neurotrophic factors, and reduced inflammation, contribute to these benefits. It is crucial for healthcare professionals, policymakers, and community organizations to facilitate initiatives that promote regular PA among older adults. This includes providing accessible exercise programs, educating about the benefits of PA and exercise, and establishing age-friendly environments. While existing literature highlights the positive relationship between PA, physical function, and cognition, further research is needed to fully understand this complex association. Long-term randomized controlled trials and investigations into the most effective types and intensities of exercise for different older adult populations can offer valuable insights.

Highlighting PA as an essential component of healthy aging is crucial, and continuous research in this area will further inform strategies aimed at improving the lives of older adults globally. As societies age, investing in older adults' health through PA initiatives will help to promote a healthier and more dynamic future for all.

#### **Author details**

Milan Chang Gudjonsson Icelandic Gerontological Research Institute, University Hospital of Iceland, Iceland

\*Address all correspondence to: changmilan@gmail.com

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Edited by Sara Palermo*

Discover the cutting edge of geriatrics and gerontology research in *Advances in Geriatrics and Gerontology - Challenges of the New Millennium*. As the world's population ages at an unprecedented rate, understanding the complexities of aging is of paramount importance. This volume provides a comprehensive exploration of the diverse landscape of aging, addressing key topics such as neuropsychology, comprehensive geriatric assessment, and the impact of physical activity on cognitive function in older people. Through interdisciplinary collaboration and evidence-based insights, this book offers valuable perspectives for addressing the challenges facing older adults in the 21st century. From deciphering the pathways of aging to optimizing quality of life, each chapter offers innovative approaches to improving the well-being of older people. With contributions from distinguished researchers and clinicians, *Advances in Geriatrics and Gerontology - Challenges of the New Millennium* is an indispensable resource for anyone involved in geriatric care and research. Whether you work in health care, policy, or research, this book offers invaluable insights into promoting healthy aging and improving the lives of older people worldwide. Join us on a journey through the latest advances in geriatrics and gerontology and discover how interdisciplinary collaboration is shaping the future of ageing research and care.

Published in London, UK © 2024 IntechOpen © vsijan / nightcafe. studio

Advances in Geriatrics and Gerontology - Challenges of the New Millennium

Advances in Geriatrics and

Gerontology

Challenges of the New Millennium

*Edited by Sara Palermo*