Effects of a Community-Based Tai Chi and Dietary Weight Loss Intervention on Body Composition in Obese Older Women

Background: Obesity is a risk factor for many chronic diseases in older women. Tai Chi is an alternative exercise that has not been thoroughly investigated in this population in a community setting for its effects on body fat mass when combined with dietary weight loss. Methods: A 16-week community-based intervention using Tai Chi and behaviorally-based dietary weight loss (TCWL, n=29) in older (68.2 ± 1.5 yr) obese (BMI=35.4 ± 0.8kg/m 2 ) women was conducted compared to a control group (CON, n=9; BMI=38.0 ± 1.5 kg/m 2 ; age=65.5 ± 2.7 yr). Primary and exploratory outcomes included were body fat mass, BMI, percent fat (via bioelectrical impedance), fat-free mass, hip circumference, waist circumference, and waist to hip ratio. Participants in the TCWL group engaged in twice weekly Tai Chi sessions (~50 min) and once weekly nutritional weight loss meetings. The CON group was asked to continue with their daily routines. Results: The TCWL group did not see changes (p < 0.05) when compared to the CON group in weight (-1.6 ± 0.5 kg vs. -1.1 ± 0.9 kg, p=0.66), body fat mass (-3.0 ± 1.5 kg vs. 1.5 ± 2.8 kg, p=0.16), BMI (-0.7 ± 0.2 kg/m 2 vs. -0.4 ± 0.3 kg/m 2 p=0.53), or waist circumference (-4.8 ± 1.2 cm vs. -3.0 ± 2.2 cm, p=0.48). There was also a lack of significant change (p < 0.05) between groups in percent body fat (-0.3 ± 0.2 % vs. -0.4 ± 0.4% p=0.10), fat-free mass (-0.7 ± 0.4 kg vs. -0.9 ± 0.7 kg, p=0.81), hip circumference (-0.2 ± 0.8 cm vs. -0.9 ± 1.4 cm, p=0.67) and waist to hip ratio (-0.03 ± 0.01 vs. -0.03 ± 0.02, p=0.69). Conclusion: The results from this study show that the combination of Tai Chi and dietary weight loss is not effective in altering key measures of body composition in obese older women. There is need for further research with more substantial weight loss and when combined with other exercise modalities.


INTRODUCTION
The rise in obesity prevalence in the United States has become a public health problem seen more often in older women when compared to younger women (1) as 42.5% of women aged 60-69 yr are currently considered obese (2). Obesity is measured as having a body mass index (BMI) ≥ 30 kg/m 2 (1) and is related to an increased risk of excessive body fat mass (3) and chronic diseases (4).
Postmenopausal women have a higher rate of disability (5) and show a greater decline in physical function when carrying excess body fat (6). Field et al. (7) found a higher likelihood of chronic disease, including hypertension, heart disease and diabetes, in obese women when comparing overweight and normal weight women (7). The increase in weight in older adults can be attributed to an imbalance of energy expenditure, and while it is considered to be a normal part of the aging process, decreases in their energy expenditure in addition to an increase in food intake often results in a high percentage of body fat (8).
There are numerous treatments for obesity, however not all methods are considered as a safe or effective option as side effects can at times be more dangerous than the benefits of the weight loss (9). Current treatments have included weight loss surgery, however in this population, the potential risk from medications and the procedure is higher when compared with younger populations (10). Research has shown the success of using a diet only intervention for weight loss. However, there are also significant findings in the amount of fat free mass that is lost in this process which can often lead to an age related decrease in muscle mass in older adults; also known as sarcopenia (11). This can be particularly detrimental to older women as they tend to have less muscle mass then men, so a further loss will only create more health concerns (11). Studies have shown there to be considerable success in the use of regular exercise (most days per week for a total of 150 min/wk) when combined with a well-balanced, hypocaloric diet for losing fat mass and attenuating fat-free mass loss (12). In the past 10 years, the combination of exercise and dietary changes have been widely studied; some have included the use of aerobic exercise, while others used resistance training (13,14,15,16) and have seen successful reductions in body fat.
However, there is a need to determine the full complement of exercise modalities to improve body composition in obese older women that are both appealing and feasible (17).
Tai Chi, a form of low-impact exercise based on traditional Chinese martial arts, has become increasingly popular worldwide, especially with older adults (18). Its benefits include improvements in psychological and physiological function, aerobic capacity, muscle strength, and cardiovascular disease risk factors (19), as well as reductions in tension, anxiety and mood disturbance (18). Several other studies (19,20) have reported that Tai Chi reduces body fat. However these studies did not include a dietary component.
In a recent randomized study by Katkowski et al. (21), the added effects of Tai Chi during dietary weight loss on body composition in obese older women were examined, where the results showed that the combined effect of Tai Chi and weight loss led to a reduction in body weight, BMI, waist circumference, body fat mass, and percent body fat (21). Despite that study showing some improvements in body composition, it is unclear how these laboratory based results would translate into a community-based intervention. Thus, the purpose of this study was to determine the combined effect of Tai Chi plus behaviorally based dietary weight loss on body fat mass in obese older women in a community-based setting. It was hypothesized that the Tai Chi during dietary weight loss (TCWL) group would have a significant decrease in fat mass compared to a control (CON) group. Exploratory aims were to determine the effect of Tai Chi plus dietary weight loss on other anthropometric measures related to body composition, including waist circumference, retention of lean mass, BMI, and waist-to-hip ratio compared to the CON group.

METHODS
This non-randomized, extension intervention study with pre-and postmeasures was conducted over a 16-week period at two suburban Rhode Island senior centers. Upon completion of the preliminary interviews and baseline testing, participants were placed in the TCWL or CON group on a first come first served basis.
This study was approved by the Institutional Review Board of the University of Rhode Island.

Participants
Each potential participant was required to complete a phone screening, attended an orientation session, complete a medical history, and sign an informed consent. This study's inclusion criteria were 1) females, 2) aged 55-80 years, 3) a BMI of 30.0-50.0 kg/m 2 , 4) postmenopausal by self-report, 5) not engaged in a regular physical activity program within the last six months, and 6) weight stable within 5% over the previous three months. The exclusion criteria included 1) significant or suspected cognitive impairment, defined as known diagnosed dementia, 2) severe hearing loss, speech disorder, language barrier or visual impairment, 3) Progressive, degenerative neurologic disease, 4) terminal illness with life expectancy of < 12 months, as determined by a physician, 5) severe pulmonary disease, uncontrolled diabetes, blood pressure, or anemia, 6) medications not taken for > 3 weeks, lipid lowering medications for > 6 months, 7) major joint, vascular, abdominal, or thoracic surgery within three months, 8) significant cardiovascular disease, 9) inability to safely engage in mild to moderate exercise with muscular exertion. Participants were recruited in the South County and URI area using ads in local newspapers, by word of mouth, through online community sites, flyers sent to the URI faculty, staff, homes in the surrounding area, and posted in the affiliated community centers. If they appeared to qualify, the participants met with a study coordinator to have their height, weight, and BMI measured to ensure that they were qualified. Participants who matched the inclusion criteria were asked to sign an informed consent, and complete baseline testing, and participate in the intervention.

Primary Outcome
Body Fat Mass: Body fat mass, fat-free mass, and percent body fat were measured using a Tanita BF-556 model bioelectrical impedance analysis (BIA) device.
This BIA device required each participant's age, gender, height, and activity level to be entered before they stepped on foot-to-foot with bare feet. This BIA device closely resembles a bathroom scale often found at home; it is battery operated and uses a very low (50 kHz) electrical current to pass through the body to determine the resistance and reactance values to calculate the amount of body fat (22). For safety precautions each participant was asked if they have a pacemaker, there were however no participants to whom this applied. Fat-free mass was calculated by subtracting total fat mass from their weight.

Exploratory Outcomes
The following measures were used for descriptive data and also served as potential covariates in the analyses of the primary and exploratory outcome measures. Arbor, MI) in inches around the umbilical line, and the broadest part of the hips above the gluteal fold. Each measurement was taken twice to the nearest . 25 inch, and the average of the two was recorded and converted to cm for analyses (14). Body mass index, which is a strong predicator of obesity-related health risks, was determined using the standard equation of calculating weight (kg) divided by height (m) squared.

Other Measures
Physical Activity: The Yale Physical Activity Survey (YPAS) was used to evaluate physical activity energy expenditure and has been validated in older adults (23). The YPAS determines total hours of activity as well as total kcal expenditure per week for each individual along with a physical activity index, which assesses the sum of the of 5 groups (vigorous activity, leisurely walking, moving, standing and sitting) to better evaluate activity dimensions (23). The activities included in the questionnaire include regular physical activity, such as walking and activities of daily living, such as housework (23).
Dietary Intake: Dietary intake was measured using the Dietary Screening Tool (DST). The DST was created to assess diet quality and dietary patterns among older adults and to relate the patterns to markers of general health and nutrition status (24).
While a simple tool, it has been shown to be very practical and categorizes older adults into one of the following: at nutritional risk, possible nutritional risk, and not at nutritional risk (24).
Education: The level of education was assessed by a one-question survey.
Each participant was given nine options to best describe their highest level of education completed: high school or GED, some college, two-year college degree, four-year college degree, masters degree, doctoral degree, professional degree, or other and asked to specify. For analysis purposes, these groups were consolidated into three groups: 1) High School, GED or Less; 2) Associates or Some College; and 3) Bachelors Degree or Higher.

Group Assignment
After recruitment and baseline testing there were 54 participants, 39 in the TCWL group and 15 in the control group ( Figure 1). Participants were placed in their group on a first-come, first-placed basis. Additionally, some participants were eligible but had scheduling conflicts, or there was a lack of room in the intervention site, so they were placed in the control group.

Intervention
Tai Chi: The Tai Chi intervention took place twice per week on nonconsecutive days for 16-weeks for the TCWL group. A principal investigator (FX) with over six years of experience in Tai  of caloric intake) and moderate intake of total fat (≤ 35% of caloric intake); 2) high intake of fresh fruits, vegetables, and whole grains; 3) consumption of low-fat dairy and meat products, and 4) moderate intake of sodium (3,000 mg or less/day). In these dietary sessions, there were also topics on how to estimate portion sizes, healthy choices when dining out or eating in, how to read food labels, decreasing saturated and trans fat via recipe modification, decreasing sodium intake and promoting an increase in vegetables and fruits, lean meats and dairy. The nutrition study staff monitored all participants' food intake through the use of food logs that participants were encouraged to complete each week and turned in during the following week's session.
Control Group: The CON group of 15 participants was included in the study to help strengthen and improve the design. They did not receive the 16-week intervention or weekly dietary sessions and dietary assessments and were asked to maintain their current daily lifestyles, and upon their participation in post-testing, they received the same incentives as the intervention group. These incentives included a study t-shirt, DVD, supermarket gift card, and a binder of nutritional information on the DASH diet. They were also given an option to participate in two weeks (four sessions) of Tai Chi practice led by study staff at the senior centers upon the conclusion of the post testing.

Statistical Analyses
Sample Size. All of our sample size calculations were completed using the SAS Analyst version 9.2. In order to detect a significant between-group difference in fat mass loss using a statistical power of 0.80 and an alpha to 0.05, we estimated a baseline fat mass value of 45kg. We predicted a change of ~10% total body fat which equaled a 4.6 kg loss of fat mass in the TCWL group. We had no reason to believe there would be any change in the CON group. In order to detect this change with a standard deviation of 3.4, we would have needed a sample size of at least 9 participants per intervention group (25). We also estimated an attrition rate of 15%, but this study was a community extension project, so our goal was to recruit as many participants as possible to maximize the impact on the community.
Data Analysis. The significance was set for p < 0.05, and all data was analyzed using SAS version 9.2. Between-group differences in baseline values s were determined using independent samples t-test and were represented using a mean scores and standard deviations. Tests for normality on changes in primary outcome variables were done using a Shapiro Wilk test. Paired samples t-tests were conducted to examine within-group changes for normally distributed data and Wilcoxin Rank Sum tests were run for non-normally distributed data. Outliers were determined in the changes in the primary outcome variables of greater than 3 standard deviations above or below the mean for any data point. All outliers that were found were kept in our final results as this was a community extension study, where the goal was to get as true of a representation of the studied population as possible. Categorical data in the 3 education groups, and the DST measures were analyzed using Fisher's exact test.
Between group differences in changes in outcome measures (including weight, BMI, fat change, body fat mass, fat-free mass, waist circumference, hip circumference, waist to hip ratio, and percent body fat) were determined using analysis of covariance (ANCOVA) adjusted for baseline values. Additionally, because of the variability in weight loss the TCWL group, we stratified participants for further analysis by weight loss of more than 3% (weight losers, TCWL-WL) or not (non weight losers, TCWL-NWL) to better determine the effect of weight loss in those who better complied with the dietary weight loss intervention.

RESULTS
Our final analytical sample size for those who completed this 16-week study was 39 participants; 29 participants in the intervention group and 9 participants in the control group. Explanations for participant dropouts are shown in the flow chart in Figure 1. There were a total of 39 participants who began in the TCWL group, and fifteen in the control group. Over the course of the intervention, there was an attendance rate of 76.5% in the TCWL group for the Tai Chi sessions, and 86.5% in the TCWL dietary sessions.
The baseline characteristics of all participants are presented in Table 1. There were no statistically significant differences in these baseline variables between groups.
Other outcomes measured and presented in this higher. These results show the education levels to be not significantly different between groups, with the majority of participants in both groups having completed their bachelors or higher. The amount of kcals expended via physical activity at baseline were compared between groups, where the TCWL had 8020.9 ± 784.6 kcals, and the CON group had 7610.7 ± 1408.3 kcals, p = 0.80. Since the amount of kcals expended in the TCWL group was higher than those in the CON group, it may have been attributed to these participants being more active than those in the CON.
The changes in body composition and anthropometric variables between the TCWL group and CON group are shown in Table 2. There were no significant changes found between the TCWL and CON group body composition and anthropometric variables. However, there was a significant within group change (p < 0.05) in the TCWL in body fat mass (-3.0 ± 1.5 kg, p = 0.05), when compared to CON group. There was also significant changes (p <0.01) in within group measures for TCWL changes in weight (-1.6 ± 0.5 kg, p = 0.003), BMI (-0.67 ± 0.2 kg/m 2 , p < 0.001), waist circumference (-4.8 ± 1.2 cm, p < 0.001) and waist-to-hip ratio (-0.03 ± 0.01, p = 0.001).
Due to the variability of weight losers to non-weight losers within the TCWL, the groups were divided into three categories; TCWL-WL (n=9, weight losers in the TCWL group with a >3% change of baseline weight), TCWL-NWL (n=20, non weight losers in TCWL group having a < 3% change of baseline weight) and the CON group (n=9). The changes in anthropometric variables in body composition between these groups are shown in Table 3. There were significant between-group findings in the weight (p <0.0001), BMI (p <0.0001) and body fat mass (p < 0.003). There were no other significant changes in any other anthropometric variables.

DISCUSSION
The main finding of this investigation was that the combination of Tai Chi and a dietary weight loss intervention did not significantly change body fat mass or other measures in body composition compared to the control group. This study is the first to report on a community-based Tai Chi and weight loss intervention in this population and extends the knowledge base on the effect of these combined intervention strategies on body fat mass changes.
Despite no significant between-group changes, there were within-group decreases in changes in the TCWL-WL group for weight, BMI, body fat mass, waist circumference that were similar to the results in the laboratory-based study by Katkowski et al. (21). In that study, the effects of Tai Chi during dietary weight loss on body composition in obese, postmenopausal women were examined where results showed participants in the TCWL group also experienced a significant within-group reduction in body weight, BMI, body fat mass, and waist circumference. Comparing the similarities of significant results from the TCWL-WL group in the current study to the intervention by Katkowski et al. (21), gives further evidence that despite the present study's lack of significant changes between groups, the use of Tai Chi combined with a dietary intervention has the potential to improve body composition.
A plausible explanation for the lack of change in body composition in the TCWL group is that each participant participated in approximately 50 minutes twice per week (100 minutes total) of exercise while in the senior centers along with additional practice at home for an unspecified recommended amount of time. Despite a previous study by Straight,et al (14) who also used twice weekly exercise in overweight, older adults had produced where a change in body mass (-1.0±1.8 kg, P<.001) was seen, the use of Tai Chi in the current study may not have been enough physical activity to aid in the loss of fat mass. All TCWL participants were encouraged to practice the Tai Chi on their own time outside of the intervention days, however, most participants were not actively engaging in the extra activity when asked each week. Dietary restriction has shown to be the main cause of weight loss (28), and significant changes occur more often when combined with physical activity (14).
However, in order for physical activity to be considered enough for a change in weight and body composition, current physical activity guidelines recommend at least 30 minutes of moderate intensity activity per day to prevent and limit health risks and chronic disease (coronary heart disease, diabetes, etc), which totals 150 minutes, over 5 days per week (25).
For example, in a study by Dechamps  This study has several strengths, which include a relatively homogenous population of obese older women who were participants with no significant between group differences at baseline. Next, we used an intervention method of combining dietary weight loss and exercise that has been shown to be successful changing body weight, body fat mass, BMI, waist circumference, and an increase of fat-free (21).
Additionally, this study included a control group, which allowed for controlling for other potential confounders that might have resulted in spurious within-group findings.
Lastly, the duration of the study is comparable to other studies that implemented a physical activity and dietary weight loss intervention for older obese women (27,28,29).
Despite the strengths listed above, the weaknesses of this study included the use of the non-randomized design, a higher drop-out rate, and a relatively small sample size. Although the current study was non-randomized, there were no significant baseline differences between groups, which created a strong foundation and improved the interventions strength. The use of a non-randomized design was chosen out of convenience, as this was a community outreach study, where we wanted to include as many participants as space in the community centers would allow.
Participants were later assigned to their group based on a first come first serve basis.
Our dropout rate was noticeably higher than expected beginning with 54 participants, and ending with 38 (30% attrition rate) when compared with previous studies (21).
In conclusion, this study is the first to show the effects of a community-based,  Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared). 1 Data analyzed using independent samples t-test 2 Data are expressed as mean ± SD 3 Data analyzed using Fisher's exact test.  TCWL-NWL (n = 20) Between-Group p Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared). 1 Data were analyzed using analysis of covariance adjusted for baseline values. 2 Data are expressed as mean ± SD 3 Data missing from one participant in these variables. Non-weight loser defined as weight loss < 3% of baseline weight. Weight loser defined as weight loss ≥ 3% of baseline weight. *p < 0.05 within group **p < 0.01 within group Withdrew n = 10 4 due to illness 4 due to change in time commitment 2 due to family matters

Introduction
The purpose of this review of literature is to discuss the research literature rising rate and prevalence of obesity particularly in postmenopausal women as well as existing and potential treatment methods for obesity. Additional topics to be examined will include the causes of obesity in the postmenopausal population, as well as the negative consequences associated with obesity and excessive body fat mass.
The current treatment options as well as other potential future methods in treating obesity in postmenopausal women will be discussed. This review will also include previous research on various treatments for obesity including dietary weight loss, physical activity, the additive and combined effects of physical activity and diet, the effects of Tai Chi exercise, and the potential for Tai Chi during dietary weight loss to improve obesity and body fat mass.

Obesity in Older Adults
Obesity is a growing public health problem in older women (1) as 42.5% of women aged 60-69 are considered obese (2). In obese individuals, there has been shown to be an increased risk of excessive body fat mass (3) and numerous chronic diseases (4). However, research shows that obesity can be prevented and treated through regular exercise and healthy diet and weight loss (5). While most exercise interventions have utilized traditional exercise modalities such as aerobic or resistance training, there is a need to examine alternative forms of physical activity that have not yet been thoroughly studied to determine if they are effective in modifying body composition in older women (6).
The rise of obesity has become prevalent over the last past 20 years where there has been a dramatic increase in obesity in the United States and rates are remaining high. More than one-third of U.S. adults (35.7%) are obese (7) and 42.5% of women aged 60-69 have a body mass index (BMI) of 30 kg/m 2 or more (2).
Currently, 7% of the total population is over the age of 65 (8) and that number is expected to increase to 20% by 2030 (8) with older women outnumbering older men, 23.0 million to 17.5 million (9). Body mass index and body weight gradually begin to increase throughout a lifetime, particularly through adulthood and then reaches a peak for most adults around ages 50-59 (10). This is especially important to monitor in older adults as fat mass levels have a tendency to increase with age, even without a change in body weight (11). Older adults can see an increase of independent risk factors for chronic health diseases (1) such as cardiovascular disease, diabetes, early mortality, and physical disability including frailty and poor physical function (2) with the decrease of fat-free mass and increase of fat mass (12).  (13). The waist-to-hip ratio increased (mean 0.015) over the 8- year study regardless of age or physical activity levels. The amount of weight gain was influenced on the level of activity expended. There was less weight gain (p = 0.08) in women who expended >500-1200 MET/min/wk as well as those in the >1200 MET/min/wk group when compared with women in the ≤ 100 MET/min/wk group. In conclusion it was reported that the use of regular exercise in postmenopausal women could show differential body weight changes, most seen through ages 50-59 (13). kcal/day versus 64 ± 60 kcal/day, p ≤ 0.01) (14). There were greater increases in fat mass (2.5 ± 2 kg versus 1.0 ± 1.5 kg, p ≤ 0.01), and waist-to-hip ratios (0.04 ± 0.01 versus 0.01 ± 0.01, p ≤ 0.01) (14). This study was able to show the reduction of energy expenditure levels associated with the onset of menopause. Although this study was not tested on overweight or obese women, it is evident that the addition of menopause to a woman who is overweight or obese my have increased health risks if their health is not improved prior. However, whether overweight, obese or normal weight, the onset of menopause typically results in decreased energy expenditure levels and has the potential for weight gain.

Causes of Obesity in Older Adults
Obesity is clinically defined by a BMI of ≥ 30 kg/m 2 , where one of the main contributing factors lies in the excess amount of body fat mass. This excess fat stems from an imbalance of the amount of energy taken in and what is then expended. The obesity problem for a person typically begins when they consume more calories than they can expend, which, after a long duration of time can begin to add up and result in weight gain (15). As adults continue to age, their dietary intake does not always decrease along with their energy expenditure. Therefore, those whose dietary habits remain the same as when they could expend more calories, are at a higher risk of overweight and obesity (15). Along with the continued dietary patterns, there are other factors that can influence the weight gain in an older person, including hormonal changes. During the aging process, it is natural for hormones (most often growth and thyroid) to begin to shift and change, often resulting in an increase of fat (15). Also associated with the increase in age, is a decrease in physical activity levels. Research evidence suggests that the combination of these two variables can exacerbate weight gain in older inactive adults.
In a cross-sectional study by Williamson et al. (16)  showed that over the 10 year span, recreational physical activity had a strong correlation to a >13 kg weight gain. The relative risk for those who did not participate in regular exercise at baseline or follow-up was 2.3 (95% CI = 0.9-5.8) in men, and 7.1 (2.2-23.3) in women (16). The relative risk of major weight gain between those who had low levels of physical activity at baseline, compared with those who had high levels at follow up, was 3.1 (95% CI = 1.6-6.0) in men, and 3.8 (2.3-6.5) in women (16). The results of this study suggest that the lower the levels of physical activity tend to create a higher chance of weight gain (16).  (4). This study's results showed that there is an association between aging and increases in fat mass in women. There was minimal change in fat-free mass amongst both men and women, however it was concluded that with continued weight stability, minimal weight gains, or increased levels of activity there is less risk for a loss in fat-free mass during the aging process.
Maintaining a healthy body and lifestyle throughout one's lifetime is particularly important. Without doing so, research shows the potential for excess amounts of body fat, especially in an older person can lead to an increased risk of chronic heath problems.

Consequences of Obesity
Consequences associated with a large amount of body fat mass include multiple types of health concerns: disease (cardiovascular disease, diabetes, cancer, etc), disability, and even mortality. A method commonly used for classifying body composition, particularly in the obese population, is BMI (17). Data suggests that having a high BMI in older women is a strong predictor of long-term risk for mobility disability and that this risk will continue and increase with age (18).
In a study by Visser et al., (17)  considered to be at a much higher risk for limitations in physical function when compared with those in the normal body weight range (BMI = 18.5-24.9 kg/m 2 ) (19).
Results also showed that those individuals who were not physically active (sedentary) were more likely to have abnormal physical functioning scores when compared with participants who engaged in physical activities on a more consistent basis. Comparing the men to women, women showed lower scores of physical functioning ability, which can ultimately place them in a higher risk category for future disability (19). Lastly, the correlation of age to physical functioning was strong as it showed that with age there is a higher risk of decline in physical functioning and can be exacerbated with the onset of additional weight (20).
Studies have shown that over time, women are more likely to become obese when compared with men (21), as well as having an increased risk of disability (22).
With older women currently outnumbering older men 23.0 million to 17.5 million, there is a need to find a way of reducing these numbers. cm or higher in women is considered a marker for abdominal obesity and is an independent risk factor for cardiovascular disease (1).
Unfortunately, due to lifelong dietary, exercise and lifestyle habits it is difficult to induce behavior changes of adding physical and dietary improvements into the older populations (24). The risk of obesity in older adults is becoming more apparent as it may create an early onset of frailty, impairing the general quality of life, and can result in an increased number of admissions to nursing homes (24). Obesity is also used as a predictor of decline later in life, including the risk of being limited to living at home (25) or the likelihood of being admitted to a nursing home (26).
With the medical cost to treat obesity in 2008 around $147 billion (27), and is becoming increasingly more expensive, there is a need for prevention and further treatment. With the baby-boomer generation entering old age, there is currently 7% of the total population over the age of 65 (15). However, in a few short years that number is expected to increase to 20% by 2030 (15). The number of older adults will be increasing rapidly, as will the number of nursing home admissions.
A study performed by Jensen et al., (24)  With these potential consequences, there is a need for weight loss options to assist in the prevention of a decline in fat-free mass while aiding in a loss of fat mass.
By accomplishing this, there will be a decrease in the risk of future disability, as well as declines in function and disease.

Obesity Treatments
With the high risk for disease and disability associated with obesity and being overweight, there is a critical need for more treatment options that reduce body weight, particularly in the older adult population. Obesity rates have increased substantially has due to its association with an increase in the prevalence of obesity comorbidities (such as type 2 diabetes, hyperlipidemia, hypertension, heart disease, stroke, asthma, etc) (27). Because of these comorbidities, there are more than 2.5 million deaths per year worldwide (15). This plays a major impact on life expectancy rates where when compared to a normal-weight person, a 25-year-old morbidly obese person has a 22% reduction in their expected remaining lifespan, which equals a loss of approximately 12 years of life (15).
Studies have shown that not all weight loss changes need to be dramatic, but even smaller more achievable amounts between 5-10% of the person's body weight can be significant in improving metabolic abnormalities and reducing the risk for coronary heart disease (28). Other studies have come to show that even lower amounts of weight loss, around 3-5% of total body weight, can show a significant decrease in the risk for other chronic disease (type 2 diabetes, hyperlipidemia, hypertension and more) while also increasing the patients longevity (29). from discussing this practice with their physician (35). The major issue with using these weight-loss supplements is that they often contain stimulants, which for someone who is already at risk for numerous health concerns can create a potentially dangerous outcome such as a further increase in blood pressure or heart rate (34). The Participants in the CR and CR+RT groups attended weekly group sessions that provided information on nutrition, while those in the RT and CR+RT participated in a resistance-training program. After 3 months of the intervention, the subjects had shown a significant decrease in their body fat mass, body weight, percent fat mass, and BMI (p < 0.01) however they also experienced a decrease in fat-free mass (p < 0.05) (36).
As previously noted, this loss is detrimental to adults, women in particular as it can lead to a functional decline and accelerate sarcopenia (38). in other studies where diet is the main change in the intervention, the loss of lean body mass could later become a health concern especially in older women (40).
A minimal weight loss of 5-10% of total body weight has shown to be effective in improving an individual's metabolic profile. The way in which weight loss is achieved is important, as there has been successful studies performed using a diet only approach, but without physical activity the fat free mass tends to decrease.
For example, in the study by Brouchu et al. (40), they found that those participants who continued with a diet only induced weight loss had a loss of approximately 75% of fat mass, but the remaining 25% was due to a loss in fat-free mass (40).
In order for obese postmenopausal women to appropriately lose weight, they must do so by eliminating as much fat mass as possible, while preserving and improving their fat free mass. Implementing a strong, well balanced diet during The study found that even those who were without hypertension prior to the study, but had followed the combination diet, had seen a positive correlation in the prevention of high blood pressure (41). The participants who began the study with high blood pressure also saw a decrease in blood pressure levels with the use of the combination diet. These results were particularly useful as it shows the DASH diet could be used as an alternative form from drug therapy in treating hypertension. The implementation of this diet throughout the US could result in an increase of prevention rates, and a decrease in blood pressures on a large-scale (41). While this study was effective in showing results in the changes of blood pressure, it did not discuss the potential effects it had on changes in body composition or weight loss.
In a study by Blumenthal et al. (42), the effects of the DASH diet alone

Physical Activity
While the benefits of a modified dietary pattern have shown to be helpful in many ways, the benefit of using physical activity (particularly in older, obese women) is important for its role in strengthening muscles, improving cardiorespiratory status, increasing fat free mass levels and decreasing fat mass levels (43). group. Results showed the exercise group had a reduction in body weight of -8.4% ± 5.6% (-8.2 ± 5.7 kg) when compared to the control who lost .05% ± 2.8% (0.7 ± 2.7 kg, between group p <.001) (10). Differences were also see in fat mass (Exercise: -6.6 ± 3.4 kg, -17.1 ± 11.3%; Control: 1.7 ±4.1 kg, 2.6 ± 6.9%, between group p <.001) (10). These results are important as they show that the inclusion of physical activity in an older adults' lifestyle can create decreases in body weight and fat mass when compared with older sedentary adults.
In a randomized controlled study looking specifically at women, Slentz et al. When compared to the controls, the participants in the exercise group had a significant decrease in body weight (mean -2.0 kg, p < 0.034), waist circumference (-2.0 cm, p < 0.0001), % body fat (-1.6%, p < 0.0001) (45). The participants in the exercise group were also the only ones to see an increase in lean body mass (+0.3 kg). Despite seeing positive results and changes in that study, there is much more to be accomplished for a successful and safe weight loss or change in body composition through the addition of a diet with an exercise program.

Physical Activity and Dietary Weight Loss
As shown previously, there has been success seen through the use of diet only and exercise only interventions on changes in body composition and weight loss.
However, there is also a great amount of research that shows how beneficial the combination of these two interventions can be. As seen in the previous study by  (48). This study showed that the combination of the DASH diet with a resistance-training program could create small, yet statistically significant improvements in body composition. However the addition of resistance or aerobic training can become too strenuous or not preferable for some older adults when implemented their exercise routine (49). Thus, there is a need to determine the full complement of exercise modalities to improve body composition in obese older women that are both appealing and feasible (6).

Tai Chi
Tai Chi is a form of low-impact exercise based on traditional Chinese martial arts. It has become increasingly popular worldwide, especially within older adult populations (50). Benefits from this exercise include improvements in psychological and physiological function, as well as decreases in tension, anxiety and mood changes (50) and the ability to improve muscle strength, balance, and cardiovascular disease risk factors (51). Other studies have also shown that Tai Chi can be a more feasible Participants were randomly assigned into the Tai Chi group or sedentary control.
Those in the Tai Chi group reported fewer difficulties in physical functioning (p < 0.008) and also saw improvements in their balance (p < 0.009) when compared to the control group who had no change in either group (54). This study confirms the safety of this form of exercise in an older population, and its benefits towards improving balance and physical functioning skills. The study did not examine overweight or obese women, body composition, weight loss or the use of a dietary component for potential outcomes. women. Using a randomized design, the overweight participants were placed into a Tai Chi group, consisting of practice for 1 hour per day, 4.6 ± 1.3 days per week over 12 months, or they were placed in a sedentary control group (51). The women in the Tai Chi group had decreased levels in percent body fat (28.8 ± 4.5% vs. 27.5 ± 4.8%; p < 0.068) when compared to the control group (29.0 ± 4.6% vs. 29.5 ± 5.1%; p < 0.089) (51). As mentioned previously in their earlier study, it is common for older adults to gain weight as they age. However, despite these results lacking a significant change in body fat, the increasing trend towards a change in body fat gives evidence that excess fat mass in women may be preventable through the use of Tai Chi.

APPENDIX B: CONSENT FORM FOR RESEARCH
Title of Project: A community-based Tai Chi and weight loss study obese in women at Rhode Island senior centers You are invited to take part in a research project described below. The researchers will explain the project to you in detail. You should feel free to ask questions. If you have more questions later, Drs. Matthew Delmonico (Phone: 401-874-5440), Ingrid Lofgren (401-874-5706), and Furong Xu (401-874-2412) from the Departments of Kinesiology and Nutrition and Food Sciences at the University of Rhode Island, the persons mainly responsible for this study, will discuss them with you. The general eligibility criteria for inclusion to this study include having/being 1) female, 2) age 55-80 years, 3) a body mass index (BMI) of 30-50 kg/m 2 , 4) body weight stable, 5) no recent medication changes, 6) post-menopausal, and 7) free of diseases or conditions that would prevent safe weight loss and/or participation in a Tai Chi exercise program.

Description of the project:
You understand that the primary purpose of this study is to assess the role that a 16-week Tai Chi exercise program plays in improving physical functioning, retaining muscle mass, losing fat mass, and improving heart disease risk factors when combined with intentional weight loss (~ 5-10%). Tai Chi is a form of martial arts that is a slow and low-impact exercise and has been shown to be effective for improving health outcomes in older women, including physical functioning. Another purpose of the study will be to assess the influence of intentional weight loss with Tai Chi training on changes in bone density, blood pressure, blood sugar metabolism, blood fats, muscle function, and other important health-related measures. Your participation will vary depending on which group you are assigned. However, the study may require your participation of 2-3 hours per week. All of the testing and intervention sessions will take place at your local senior center (North Kingstown, South Kingstown, or Warwick). You are responsible for your own transportation to all of the testing and intervention sessions.

What will be done:
You understand that if you choose to participate, the study requires your involvement in three phases. PHASE 1: During the first phase, you will undergo preliminary testing (a 1-2 hour visit). Your blood pressure, height, weight, waist and hip girths, body composition, muscle strength, and ability to complete selected tasks similar to common activities of daily living will be assessed during this first phase. These activities of daily living tasks include rising from a chair, standing balance tests, and short (4-meter) brisk walks. Any risk of injury during the completion of these tasks will be minimized by having all sessions supervised by an exercise physiologist qualified to direct this type of testing. In addition, you will be asked to complete several questionnaires. These include the National Cancer Institute fat screener questionnaire, a dietary screening tool, a food frequency questionnaire, a physical activity survey, a sleep quality questionnaire, a cognitive function test, life and body satisfaction surveys, and a general health survey.
You will also complete two finger sticks that will be used to analyze blood sugar, fats, and C-reactive protein (CRP, a blood protein associated with heart disease risk). Analysis of blood will be conducted using a portable Cholestech machine. For the 12 hours prior to the finger sticks, you will be asked to refrain from eating and/or drinking anything, unless it is plain water. For example, if your finger sticks are scheduled for 9:00am on a Wednesday, you are asked to not eat and/or drink anything besides plain water after 9:00pm on Tuesday evening. We do encourage you to drink as much plain water as you would like. The total amount of blood drawn for these tests over the course of the study will be equivalent to less than one teaspoon.
You understand that trained personnel, using universal precautions and established methods, will conduct the two finger sticks. You understand that the two finger sticks require a very small amount of blood. You understand that there is a risk of bruising, pain, and in rare cases, infection or fainting as a result of blood sampling. However, these risks to you will be minimized by allowing only qualified people to draw your blood.
You understand that strength assessments will be performed using portable devices that measure how much force you can exert force through a typical knee extension motion and your grip strength. You understand that you may experience some temporary muscle soreness as a result of the muscle testing. There is also a risk of muscle soreness or skeletal injury from strength testing as well as from exercise training. The investigators of this study will use procedures designed to minimize this risk. The flexibility of your leg muscles will also be tested by using a simple test that requires you to attempt to touch your toes while seated.
Your percent body fat will be performed using bioelectrical impedance analysis, which is a battery powered, portable device that uses a very low electrical current (~ 50 kHz) in order to estimate fat mass and percentage body fat. This test only takes about 20 seconds to complete but is a valid and reliable measure of body composition with very few risks. Even though the risk is low, as a precaution, individuals with a pacemaker will not be tested on the bioelectrical impedance analysis device.
At the end of the first phase (testing), you may be assigned (based on group availability) to either a weight loss plus Tai Chi group or to a control group.

PHASE 2: INTERVENTION Dietary Sessions (Weight Loss plus Tai Chi Group)
For those assigned to the weight loss plus Tai Chi intervention, you will be asked to participate in a diet designed to produce a moderate weight loss of 5-30 pounds (about 5-10% of your current weight). You will be instructed to consume a wellestablished, lower calorie, low fat diet, in which the goal will be to reduce your food intake by about 500 to 1000 Calories per day. In your senior center, you will meet in a group (~ 10-20 other participants) with an expert in nutrition once per week (~ 45 minutes per session) for 16 weeks who will give you instructions and expert advice on food selection, preparation, and other dietary changes. Weight gain or loss will be monitored weekly, and you will be instructed to keep careful records of your food intake.

Tai Chi Sessions (Weight Loss plus Tai Chi Group)
If you are assigned to the weight loss combined with Tai Chi exercise group, you will also be asked to participate in two (2) supervised exercise sessions per week (40-45 minutes per visit) for the 16-week intervention in your local senior center. Tai Chi is considered a soft form of Chinese martial arts (not for self-defense) that incorporates slow and low-impact exercise movements while you are standing on your feet. You will be asked to come to assigned room at your local senior center. During these sessions, you will receive instructions from trained exercise staff and will undergo Tai Chi exercise training using a modified Tai Chi protocol specifically designed for older adults. Your progress will be monitored and you will always be instructed by an exercise specialist regarding proper form for Tai Chi techniques. No special clothing is required. You will also be instructed to stop exercising immediately if you experience chest pain, muscle injuries, or any other unexpected symptoms. Although you will always have supervision when doing Tai Chi exercise training during this study, if you ever experience chest pain while exercising at other times, you should immediately call 911 to seek emergency care and notify your primary care physician. If you have any problems or injuries, you should also notify a member of the study team. Study team members and their phone numbers are noted on the first page of this consent form.
During each Tai Chi exercise training session you will be asked to exercise for approximately 40-45 minutes per session. All sessions will start with a brief warm-up. The first several Tai Chi training sessions will begin with lighter intensities focusing on learning different Tai Chi movements. The difficulty will be gradually increased based on individual progress. The difficulty of the Tai Chi exercise will be adjusted so that you are exercising an effort level that is judged to be appropriate to improve your fitness level. Your blood pressure will also be monitored at each training session. You will be able to provide feedback using standardized pain and discomfort rating scales. Your overall progress will be monitored by an exercise specialist so that you are able to tolerate the exercise. Each session will end with a final blood pressure measurement and five minutes of stretching. You will be given printed diagrams and a DVD of the Tai Chi exercises so that you may practice the movements on your own between exercise sessions if you choose. Once you have mastered several of the movements, we will encourage you to practice Tai Chi on your own, and we will have you keep a journal of any extra Tai Chi practice that you perform.

Control Group
If there is no space available in the intervention group, you understand that you may be asked be in the "waitlist control" group. If you assigned to this group, we will ask you to participate in the baseline (phase 1) and follow-up (phase 3) testing phases, but you will not be participating in the 16-week intervention phase. However, by serving as a control participant you will receive the results of your health-related testing and the other participation incentives that the intervention group will receive. Additionally, as another incentive once the follow-up testing is complete, we will offer you four supervised Tai Chi exercise sessions at your local senior center along with the Tai Chi DVD so that you may continue to practice Tai Chi. These Tai Chi sessions will be very similar to the sessions conducted as part of the Tai Chi plus weight loss group and are intended to give all participants the opportunity to learn Tai Chi. You understand that participation in these sessions is not part of the research investigation and is optional. PHASE 3: The third and final phase will be a repeat of all previously taken measures after the 16 week intervention. All data will be sent and stored with a study number only at the University of Rhode Island and without any personal identifiers (including initials or birth dates). You will receive a copy of your results 2-3 months after the study is complete, although some of the results will be available immediately.

Risks or discomfort:
You understand that it is possible that heart, blood vessel, or other health problems could arise during your participation in the testing or training involved in this study. Although highly unusual, it is possible that these problems could lead to a heart attack or even death. Therefore, prior evaluation and written clearance with a signature from your personal physician is strongly recommended, but not required, to participate in this study. Your local senior center may also require that you sign their liability waiver prior to participation. You also understand that it is possible that these risks will not be eliminated completely, even with a medical evaluation prior to participation in the study. However, the investigators believe the risk of harm from study participation is small and that the benefits of the study will likely outweigh any potential risks. Additionally, you understand that with the testing described above, Tai Chi, and exercise in general there is a risk of muscle soreness or other muscle injury as well as skeletal injury. Because Tai Chi does require some degree of balance, there is also a risk of falling associated with this type of exercise. However, the investigators will take precautions in order to reduce the likelihood that these adverse events will occur.

In case there is any injury to the subject:
In the event of physical injury resulting from participation in this study, upon your consent, emergency treatment will be available at the nearest local hospital with the understanding that any injury that required medical attention becomes your financial responsibility. You understand that the University of Rhode Island at Kingston will not provide any medical or hospitalization insurance coverage for participants in this research study, nor will they provide compensation for any injury sustained as a result of this research study, except as required by law.
You understand that if you are injured while participating in this research project as a result of negligence of all state employees who are involved in this research project, you may be able to be compensated for your injuries in accordance with the requirements of the Federal Tort Claims Act. If you are a federal employee acting within the scope of your employment, you may be entitled to benefits in accordance with the Federal Employees Compensation Act.

Confidentiality:
All information collected in this study is confidential, and your name will not be identified and linked to any study data at any time to anyone other than the principal investigators of the study. Your data will be coded with an ID number only, which will be linked back to you only by the principal investigators of the study. All study data, including this consent form, will be locked in a file cabinet and also stored in a study computer with a password secured in our study office (Independence Square building, Suite P, room 225). Study records are retained securely for ten years after study end.

Benefits of this study:
You understand that although this study may help you personally, it may also help the investigators better understand which interventions are the most effective in helping obese older women improve their physical function, body composition, and heart disease risk factors. However, because of what is already known regarding the individual effects of weight loss and Tai Chi exercise training, it is likely that you will notice some benefits. These potential benefits include increased understanding of nutrition, a reduction in overall weight and body fat, and improved mobility.
For your participation in the study and after the study is completed, you will receive, free of charge, information about your blood pressure, blood test results, body composition, muscle strength, and physical function.

Compensation:
You will receive a $20 supermarket gift card and a study t-shirt for your participation in the study.

Decision to quit at any time:
You understand that is your decision and your decision alone whether or not you consent to participate in this study. You are free to ask questions about this study before you decide whether or not to consent to participate. Also, if you consent to participate in the study you are free to withdraw from participation at any time without penalty or coercion, or without any requirement that you provide an explanation to anyone of your decision to withdraw.

Rights and Complaints:
If you are not satisfied with the way this study is performed, you may discuss your complaints with the principal investigators, Drs. Matthew Delmonico at (401) 874-5440, Ingrid Lofgren at (401)  Alternatives to study participation: You understand that you might achieve similar results by another method i.e., a healthy diet plan and other exercise programs, which may be discussed with your physician. If you choose not to participate in this study, you are encouraged to discuss with your physician about weight loss and exercise strategies.
You have read and understand the above information in the Consent Form and have been given adequate opportunity to ask the investigators any questions you have about the study. Your questions, if any, have been answered by the investigators to your satisfaction. Your signature on this form means that you understand the information and you agree to voluntarily participate in this study.

Signature of Participant
Signature of Researcher Emergency contact name and address & phone: DIRECTIONS: Read the following questions out loud to each prospective volunteer and check "yes" or "no". Any answers that require qualification should be written in the space below the question or on the back of the sheet.

SECTION A
Musculoskeletal system:

YES NO
Have you ever been told by your doctor that you have any of the following? If the subject answers "no" to any of the above questions 2. Any problems with vision other than corrective lens changes?
If yes, which of the following conditions-Blindness, temporary loss of vision, double vision, glaucoma, cataract, macular degeneration or others.

Do you have:
3. Ringing in your ears?

Medical Clearance to Participate in Dietary Education and Exercise Research Project
It is my understanding that (name of the volunteer), a patient under my care, has volunteered to participate in a dietary weight loss and exercise study entitled "The University of Rhode Island Dietary Education and Active Lifestyle (UR-IDEAL) Study." It is strongly recommended that volunteers have the clearance of his or her physician to participate in this study.
The aim of this study is to evaluate the impact of a 16-week Tai

Exclusionary criteria for eligibility
Severe cardiovascular disease, Severe stenotic or regurgitant valvular disease, Unstable angina Uncontrollable hypertension uncontrolled dysrhythmias, hypertrophic cardiomyopathy, Severe COPD or other signs of significant pulmonary dysfunction, rest or upon exertion, Musculoskeletal diseases that cause severe joint pain at _Having any condition that is likely to be aggravated by muscular exertion, Major joint, vascular, abdominal or thoracic surgery in the past three months, Being unable to engage safely in mild to moderate exercise, such as independently walking up at least one flight of stairs or walking 1/4 mile on level ground, Not within age range for study (55-80 years) Although we are unaware of any cardiac complications that have resulted from Tai Chi, strength or physical functioning testing, there is only a limited amount of data available in older adults. Please check one of the following: Clearance granted Clearance not granted Please send me the following information about the study: Volunteers in this study will either participate in 1) a 16-week dietary weight loss program plus Tai Chi (a low-impact martial art) exercise training or 2) a waitlist control group. Both groups will be under the supervision of exercise specialists trained specifically for this study under the direction of the Principal Investigators Matthew J. Delmonico Which of the following best describes your nutritional supplement use.
I don't use supplements I use supplements other than vitamins and mineral I use a multivitamin/mineral preparation (e.g. Centrum)