IMPACT ON NUTRITION RISK IN COMMUNITY DWELLING OBESE WOMEN WITH NUTRITION AND PHYSICAL ACTIVITY INTERVENTION

Statement of the problem: There have been no studies examining a combination of behaviorally-based dietary education, resistance training, and Tai Chi on dietary quality and resilience. Objectives: To examine the effect of a behaviorally-based diet education, resistance training, and Tai Chi intervention on dietary quality as well as physical resilience in obese older women. Design: Community health outreach with a non-randomized quasi-experimental design. Setting: Urban senior center in Providence, Rhode Island. Participants: There were 33 women with mean age of 65 ± 8.2 years and BMI of 37.3 ± 4.6 kg/m 2 who were enrolled in the study at baseline however only 17 women in the intervention group and 9 women in the control group completed the study. Intervention: Participants engaged in 12 weeks of 45 minutes of Tai Chi 3 times per week, resistance training 2 times per week, and behaviorally-based dietary education once per week. The dietary education was based off of the modified Dietary Approaches to Stop Hypertension (DASH) diet and led by a registered dietitian. Measurements: Testing occurred at baseline and post-intervention. Dietary quality and nutrition risk were measured using the Dietary Screening Tool (DST), resilience was measured by the Resilience Scale, and physical resilience was examined using the Physical Resilience Scale. Results: Although there was no significant effect for dietary quality in terms of group and time (p=0.078), the proportion of variance that dietary quality is explained by the intervention was considered a large effect (partial eta 2 = 0.147). There was no change seen in resilience, however the intervention improved physical resilience (p=0.048, partial eta 2 = 0.17). Conclusion: A community health outreach that involved behaviorally-based dietary education, resistance training, and Tai Chi may promote higher dietary quality as well as improve physical residence in obese older women.


INTRODUCTION
Approximately, 80% of older Americans have at least one and 50% have at least two chronic health conditions [1]. Women are more likely to be obese, have chronic conditions [2] and have a greater rate of functional decline due to aging compared to men [3][4][5]. Additionally, about 1 in every 5 Americans are over the age of 65 years [1]. Successful, healthy aging is important as the aging U.S. population will significantly increase the burden on the health care system making preventative health care imperative [6][7][8]. Older women have more health care visits and emergency room visits compared with their younger and male counterparts [1]. It is important that health interventions target older obese women in order to reduce their risk of chronic disease and thus the burden to the U.S. health care system as nutrition is a critical component of therapeutic plans for chronic diseases as is physical activity [9][10][11][12].
The United States Department of Agriculture (USDA) and American Academy of Nutrition and Dietetics (AND) recommends that adults focus on overall healthy food patterns as the key to a healthy way of life [13]. However, up to 48% of older adults are not at optimal nutrition status [14,15]. The Dietary Approach to Stop Hypertension (DASH) diet, which was developed originally to manage hypertension, supports the overall diet approach USDA and AND advocates [16] and has been shown to help individuals prevent or control high blood pressure, lower cholesterol and help facilitate weight loss [17,16]. The DASH diet is a well accepted and effective diet for older adults [18,19].
Furthermore, less than half of older adults met the federal physical activity recommendations for aerobic and muscle strengthening exercise [20,21]. It is recommended that older adults participate in physical activity that includes flexibility, balance, strength training, and aerobic training which is accomplished by participating in multiple modalities of physical activity [22,23]. Physical resilience, the ability to recover or optimize function in the face of age related loses or diseases, facilitates recovery and coping with the daily physical challenges associated with aging and chronic illness [24]. It is speculated that physical resilience could be modified However, to date, there is limited research examining nutrition education combined with multiple modalities of physical activity intervention on health related outcomes in obese women, especially in minority populations. The primary aim of this study is to examine dietary quality and nutrition risk in older obese women in response to Tai Chi, resistance training, and dietary education intervention in obese older women compared to a non-treatment control group. The exploratory aim was to study the effect of a Tai Chi, resistance training, and dietary education intervention in older obese women on physical resilience.

Study Design
This study was a quasi-experimental 1week community health outreach intervention at an urban Providence, Rhode Island Senior center. The intervention consisted of behaviorally-based diet education, Tai Chi, and resistance training and was approved by the University of Rhode Island (URI) Institutional Review Board (#HU1213-08). The intervention and all measures performed in this study were taken at baseline and post-intervention.

Subjects
Ninety-two women responded to recruitment efforts; however 59 women were ineligible due to variables that include inability to obtain medical clearance, BMI too small and too large, time constraints, and inability to communicate in English, see figure 1 for study flow chart and table 1 for eligibility criteria. Prior to starting the study, all participants completed the informed consent process. This resulted in 33 eligible participants of which 23 were first assigned to the intervention group and then 10 women werenon-randomly assigned to the control group. There were 6 participants in the intervention group who did not complete the study as well as 1 participant in the control group was lost to follow-up. Thus 17 individuals completed the intervention group and 9 completed the wait-list control group.

Questionnaires
Participants completed the Dietary Screening Tool (DST) in order to identify dietary patterns and nutritional risk [15,44]. The total score of the DST ranges from 0-100 with 5 'bonus' points for dietary supplement use; the higher the score indicating healthier dietary patterns. Furthermore, the composite score of the DST is associated with three different nutritional risk levels; (<60) at risk, (60-75) possible risk, and (>75) not at risk [15]. Physical resilience was measured via the Physical Resilience Scale, which was developed and validated by Resnick et al. [24,45]. This questionnaire is 15 validated questions and has the participant use a physical challenge they have experienced to base their answers ; higher scores indicates greater physical resilience. Resilience was measured using the Resilience Scale developed by Wagnild and Young, which is a series of 25 questions that are answered on a Likert scale from 1 to 7; higher scores indicate greater resilience [46]. The Yale Physical Activity Scale (YPAS) was also administered which measured activity index as well as weekly calorie expenditure [47].

Anthropometrics
Following an overnight fast and voiding of the bladder, weight was measured to the nearest 0.25 pound via a medical beam scale (Webb City, MO, USA) and height was measured with a stadiometer (Webb City, MO, USA) to the nearest 0.25cm; both were measured in duplicate and averaged. Body mass index (BMI; kg/m 2 ) was calculated from the average height and weight after appropriate conversions. Body composition was measured in all participants via foot-to-foot bioelectrical impedance analysis device (Tanita BF-556, Arlington Heights, IL, United States). The waist to hip ratio (W:H) was calculated from the waist circumference measurement using a standard tape measure with a tensometer (Creative Health Products, Ann Arbor, MI) at the point of the iliac crest and hip circumference measurement at the broadest circumference of the hips above the gluteal fold.

Biochemical
A lipid and glucose panel was obtained via a finger stick (Cholestech ® LDX system) after participants fasted for 12 hours and abstained from caffeine or nicotine.
Researchers measured serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triacylglycerols, and glucose. Forty microliters of blood was collected using a lancet and analyzed using a portable Cholestech machine.

Clinical
Manual blood pressure (BP) was taken twice one minute apart after the participant had been seated for 5 minutes with arm at heart level using a standard sphygmomanometer (752 Mobile Aneriod, American Diagnostic Corp) [48].

Repeatable Battery for the Assessment of Neurological Status
The Repeatable Battery for the Assessment of Neurological Status (RBANS) test measures attention, language, visuospatial/constructional abilities, and immediate and delayed memory in individuals aged 20-89 years; the higher the score signifies better cognitive function [49].

Intervention
The intervention group participated in three 90-minute sessions a week over a consumption of low-fat dairy and meat products, and a moderate intake of sodium (3,000 mg or less/day) [16,53]. The wait-list control group did not receive any intervention during the 12 week intervention period and were asked to maintain their normal lifestyle.

Statistical Analysis
It was determined that a sample size of 24 total participants would be adequate in detecting a difference in DST score resulting in an effect size of 0.77 with an alpha of 0.05 and this number was consistent with past interventions [37][38][39][40][41]. Data waere analyzed using SPSS for Windows (version 22.0, IBM Corp. Summers, NY).
Significance was set at a p value > 0.05. Variables were assessed for normality: skewness between -1 to 1 and kurtosis between -1.5 to 2. The following variables were log transformed: YPAS weekly calorie expenditure change score, resilience change score, total cholesterol, LDL-C, and triglycerides. Resilience at baseline and postintervention were square root transformed. Lastly, physical resilience at baseline and post-intervention were reflect square root transformed. However the following variables were not able to be transformed and thus non-parametric tests were used: systolic blood pressure, diastolic blood pressure, body fat percent, YPAS weekly calorie expenditure at baseline and post-intervention as well as in waist to hip ratio change. Data was assessed for differences between groups and completer status. All further tests were performed on completers only. Categorical variables were expressed as number and percentages. Continuous variables were expressed as mean ± standard deviation.
The independent variable was group (intervention and control) while dependent variables included nutrition risk, diet quality, and physical resilience. At baseline and post-intervention, between subject tests conducted included Independent to determine changes between baseline and post-intervention within each group. Table 2 presents participant characteristics. Participants in this study were primarily non-white women with a mean age of 65 ± 8.2 years, BMI of 37.3 ± 4.6 kg/m 2 and the majority with a high school degree or less. More than half of the women had heart disease and42% had diabetes. Attendance was 67.5% for the overall intervention and 69.4% specifically for the dietary sessions. There was no difference in baseline variables between groups as well as was no difference in baseline variables in those who completed the study compared to those who did not. Therefore further statistical tests were run on completers only.

RESULTS
There was no significant effect for dietary quality in terms of group and time There were 87.5% of women at baseline and 86.4% of women at postintervention who were at or possibly at nutrition risk at baseline. There was no significant difference in nutrition risk between groups at either baseline or postintervention or with-in groups from baseline to post-intervention; see Figure 3 and 4.
However, 5 participants (33.3%) in the intervention group improved their nutrition risk category, while no one in the control group improved their nutrition risk category.
There was a significant group by time effect for physical resilience; with participants in the intervention group increasing their physical resilience from baseline to post intervention while those in the control group decreased their physical resilience (p=0.048). A large part of the variance of that physical resilience is explained by the intervention given a large effect size (partial eta 2 = 0.166), see Figure 5. At post intervention. participants in the intervention group had significantly higher physical resilience (13.8 ± 1.0) compared to those in the control group (12.1 ± 2.5, p=0.032). A greater change in physical resilience was measured for participants in the intervention group who increased their physical resilience score (0.2 ± 1.1) while participants in the control group's physical resilience score decreased (-1.0 ± 1.5, p=0.025). There was no change in overall resilience either between or within groups and overall resilience was not impacted by the intervention (p=0.835, partial eta 2 = 0.002).
There was a significant decrease in systolic and diastolic BP from baseline to post intervention in both groups as shown in Table 3. The control group significantly increased their triglycerides from 128.8 ± 61.9 mg/dl at baseline to 168.6 ± 85.9 mg/dl post-intervention (p=0.033). There was a significant effect for time in regards to an increase in waist to hip ratio (p=0.002, partial eta 2 =0.345). In the control group, waist to hip ratio from 0.89±0.08 at baseline to 0.94±0.09 at post intervention (p=0.018).

DISCUSSION
The novel aspect of this research is that this intervention combines Tai  Although there was no difference in proportion of participants in nutrition risk categories between groups nor was there a change in nutrition risk over time in either group,, 87.5%of completers were at nutrition risk as classified by DST score and only 5 participants increased their nutrition risk category at post intervention; all in the intervention group. This is of particular concern as individuals with good nutrition status have better overall health, decreased chronic disease, improved quality of life, increased life expectancy, better functional ability, and decreased disability [10,9,54,55].
Resilience is crucial for successful aging as it involves an individual's ability to adjust and adapt, which is particularly important as older adults often experience a loss of a spouse, other family members or close friend, an event that negatively impacts independence, or a general decline in physical health [7,56] [10,9,71,72,11,73]. However, up to 48% of older adults do not have optimal nutrition status [14,15] and less than half met the federal physical activity recommendations for aerobic and muscle strengthening exercise [20,21]. A healthy diet and regular physical activity contribute to successful aging as does an individual's resiliency [74], the ability to positively adapt to significant stress, trauma or other challenge [24, 75,57]. Successful, healthy aging is important due to of the rising number of older adults and the high cost of medical care. This is particularly challenging because 80% of older Americans have at least one and 50% have at least two chronic health conditions [1].
The aging U.S. population will significantly increase the burden on the health care system making managing current conditions and preventative healthcare imperative. Women are more likely to be obese, have chronic disease conditions [2] and have a greater rate of functional decline due to aging compared to men [3][4][5]. Older women have more health care visits and emergency room visits compared with their younger and male counterparts [1].
Nutrition and physical activity are critical components of therapeutic plans for chronic diseases [9][10][11][12]37,36,42,35,38]. It is essential that health interventions target older obese women in order to reduce their risk of chronic disease and decrease the burden to the U.S.
health care system.
Research has shown that behaviorally-based diet education and physical activity interventions in older adults promote improvements in body composition, blood pressure, lipid-related measures, diet quality, and physical functioning [35][36][37][38]. It is recommended that older adults participate in physical activity that includes flexibility, balance, and strength training, as well as aerobic training which is accomplished by participating in multiple modalities of physical activity [22,23]. However, to date, there is limited research examining nutrition education combined with multiple modalities of physical activity on health related outcomes in obese women, especially in minority populations.

OLDER ADULTS
The life expectancy of Americans has increased over 60% in the past century [76,77]; from 47 in 1900 to almost 77 in 2000 [78]. In 2005, more than half of the population over the age of 65 years were women; see figure 1 [79,80]. Between 2000 and 2030, the number of Americans over the age of 65 is projected to grow from 35 million to 72 million [78]. In 2030, nearly 1 out of 5 Americans will be over the age of 65 years ( Figure 2) [81] and older adults are project to become more racially and ethnically diverse [78]. This shift to an aging population shift will impact the health care system as more people live longer. The average age of chronic disease onset has not changed as like life expectancy has, resulting in a greater increase in years of disability due to disease versus active health years [76]. Healthy life expectancy (HLE), defined by the World Health Organization, estimates the number of years a person can expect to live in full health [82]. and cancer) will increase by $48-66 billon/year [84]. The average cost of health care is 5 times greater in adults with one or more chronic health conditions compared to those without any conditions [85]. Approximately 80% of older adults in the U.S. have at least one chronic health condition, and 50% have at least two chronic health conditions [78]; the most common health conditions include hypertension, arthritis, diabetes, and heart disease [78]. Older adults with five or more chronic health conditions have an average of 37 doctor visits and 50 different prescriptions annually [86]. Women are more likely than men to have multiple chronic health conditions (See Figure 3) and older adults are more likely to have multiple chronic conditions compared to their younger counterparts ( Figure 4) [87,77,78,3].
Subsequently, older women have more health care visits and emergency room visits compared with their younger and male counterparts [78]. It is these additional visits that consumes much of the public health dollars and many of these issues are preventable [88]. Since several of these issues are preventable, it is imperative that health interventions target older women in order to reduce their risk of chronic disease and thus reduce health care costs in America. Successful aging is more important than ever as it is a combination of engagement with life, lack of disease and disability, as well as high physical and cognitive function [89]. The American population is aging and women outnumber men at every age category over the age of 55 years [79,80].

RESILIENCEY
Individuals who age more successfully tend to be resilient [7,8]. Resiliency is when a person positively adapts and adjusts to a significant source of stress, trauma or challenge that can be emotional, financial, social and/or physical [24, 75,57]. Positive adaption, a component of resilience, is reinforced through a person's individual attributes (such as personality traits), relationships, and external support system [57]. Furthermore, resiliency has been positively associated with morale, self-esteem, and life satisfaction and negatively associated with depression and perceived stress [6]. Resilience is crucial for successful aging as it involves an individual's ability to adjust and adapt, which is particularly important as older adults often experience a loss of a spouse, other family members or close friend, an event that negatively impacts independence, or a general decline in physical health. However, not all individuals are able to successfully adapt to life changes and stressors [56]. Research indicates that resilient individuals are motivated to age successfully [7]. Therefore, it may be beneficial to screen adults for resiliency levels in order to determine who might need more support and services in order to promote successful aging in at risk older adults. It would also be beneficial to examine if and which types of resilience are dynamic and thus can be influenced.

Resilience: Trait or State
There is controversy as to whether resilience is static (a trait) or dynamic ( Conversely, some researchers believe that resiliency is a dynamic process that is bidirectional between a person and their environment thus making an argument that resilience is a state [91,92]. Dynamic resilience can be influenced which suggests that dynamic or state resilience could be effected by a diet and physical activity interventions to promote successful aging. Researchers that argue resilience is a state because it is unrealistic for an individual to be resilient to all things, at all times [93]. Currently, there is no consensus in the scientific literature on whether resilience is a trait or state.

Physical resiliency
Successful aging can be facilitated through the personality traits of physical resilience including humor, adaptability, capitalizing on one's strengths, and social support [7].
Physical resiliency is a novel subcategory of resiliency that has yet to be fully explored.
Physical resiliency is defined as the capacity to recover or optimize function in the face of agerelated losses or disease and can result in the determination and perseverance to overcome physical challenges [24]. Resilience was a protective characteristic for physical well-being in older adults (mean age 69.6 years) [94]. Individuals with better self-reported physical health had greater resilience [95,6].
Physical resilience is a combination of psychological, physiological, social and other types of resilience and facilitates recovery and coping with the daily physical challenges associated with aging and chronic illness [24]. There is no other research examining physical resilience to the author's knowledge. Although, given the definition of physical resilience, it is likely a dynamic resilience and thus can change. Research studies are needed to determine if physical resilience is dynamic and thus can be affected by a nutrition and physical activity intervention.
There is currently no research examining change in physical resilience following an intervention.

Resilience and Diet
An individual with dietary resilience has developed strategies to adapt and enable him/herself to maintain dietary quality even when facing dietary challenges [96]. Vesnaver et al. [96] studied dietary resilience by examining nutritional vulnerabilities such as not prioritizing eating well, not having the ability to prepare grocery shop and not being able to prepare food. In this study, dietary resiliency was defined as maintaining or improving diet quality over the 3-year study. Thirty older participants (80% female) from the five year "NuAge" study reported that key themes of dietary resilience are "prioritizing eating well, doing whatever it takes to keep eating well, being able to do it yourself and getting help when you need it" [96]. An individual's daily diet is a dynamic and thus dietary resilience is a type of dynamic resilience, thus it is plausible that dietary resilience can be changed.
A study of 1,091 people with mean age of 69.9±0.8 years found associations between dietary patterns and personality traits [97]. Dietary patterns were assessed using a food frequency questionnaire and were classified as Mediterranean-style, health-aware, convenience, and sweet foods diet. People who follow the Mediterranean-style diet had higher extraversion, openness, and lower neuroticism than those with other patterns. The healthaware diet was significantly associated with higher agreeableness and conscientiousness than those following other patterns. Conversely, following theconvenience diet was significantly associated with high neuroticism and low openness. Preference for sweet foods was correlated with less openness. BMI was negatively associated with conscientiousness [97]. Although this study had a large sample size, a major limitation is that this was a cross-sectional study and thus dietary habits and personality were only measured once even though they likely change over the course of a life. However, this study suggests that personality, a component of resilience, may be associated with diet.
Cross-sectional studies have shown that resilience was positively associated with appetite [98], a more healthful diet, education, and personality traits [26]. Resiliency may impact diet in a similar fashion as emotional and psychological health affects appetite [98].
Furthermore, healthful dietary patterns, particularly in women from socioeconomically disadvantaged neighborhoods, may contribute to an individual's resilience to obesity [99,100].
Dietary resiliency may have an advantageous effect on chronic diseases such as obesity.

OBESITY IN OLDER WOMEN
By 2035, more than one in five Americans are predicted to be obese [5]; obesity is defined as having a body mass index (BMI) ≥ 30 kg/m 2 [101]. The prevalence of obesity is greater in women compared to men [2]. Body weight typically increases throughout adulthood and reaches its peak during the 5 th decade of life [101];due to the lower resting energy expenditure, thermic effect of food, and physical activity [102]/ However most adults do not decrease their energy consumption as total energy expenditure decreases [103].  [2]. The rate of obesity is higher in women aged 65-74 compared to those 75 years and over except in non-Hispanic black women, where about one in two were obese in both age groups [105].
Obesity and excess fat mass is associated with adverse health outcomes. Clinically, BMI is associated with mortality until the age of 75 years [106]. The Framingham Heart Study reported that life expectancy decreased by 6-7 years if one is obese at 40 years of age [107].
Obesity in older women is associated with many serious co-morbidities including diabetes, hypertension, dyslipidemia, CVD and osteoarthritis [108]. Furthermore, in older adults, obesity has been associated with a decrease in quality of life [109] and disability [110]. While obesity is a major problemwith older women, it is also to consider sarcopenia as iss a related condition that benefits from physical activity and diet interventions [111,112].

Sarcopenic Obesity
Sarcopenia is the age-related loss of lean body mass and muscle function and often leads to a decreased quality of life [113,114,38,115]. Sarcopenia currently costs the U.S. $20 billion in annual health care dollars [116]. It can affect up to 50% of 70-80 year olds [86,117,113,118,119]. Although, the mechanism for sarcopenia is not completely understood, it is believed to be a combination of poor nutrition [113], physical inactivity [119], inflammation and oxidative stress [120,121], insulin resistance [122], abnormal protein and hormone kinetics [123,124], and adverse change in muscle morphology [125]. Sarcopenic obesity is an additional risk for disability and adverse health related outcomes compared to obesity or sarcopenia alone [111,112]. Although weight loss is warranted in sarcopenic obesity, weight loss is also associated with loss of lean body mass, thus it is important to treat sarcopenic obesity with a weight loss program that retains lean body mass.
One hundred seven obese adults ≥ 65 years of age were randomized to 1 of 4 groups to determine the most efficient treatment to treat sarcopenic obesity: control, behavioral weight behavioral therapy group. Although, this study did not have a control group that did not participate in exercise or weight loss only nor did they examine sex differences, it did show that an exercise regime that includes resistance training, balance training, flexibility exercises, as well as low impact aerobics would be beneficial for older adults with sarcopenic obesity [127].
Research demonstrate the importance of sarcopenic obese adults losing weight via diet and exercise while maintaining lean body mass through diet and physical activity [113,128,127]. More specifically, the research suggests that interventions which include multiple modalities of exercise along with a dietary component, are more successful in treating sarcopenic obesity [127,126]. Individuals with sarcopenic obesity tend to be older [86,117,113,118,119] and thus are more likely to have other chronic health conditions including diabetes and heart disease.

DIABETES IN OBESITY
In the United States, 25.8 million people have diabetes [129]. In 2011, the age-adjusted incidence of diabetes for women was 7.5 per 1,000 compared to 3.5 per 1,000 in 1980 [130] and this rate is expected to continue to rise [131]. Furthermore, the age-adjusted incidence of diagnosed diabetes was more than 2 times higher in 2010 compared to 1980 [130]; see figure   5. It is estimated that diabetes costs $245 billion in the U.S. [129]. Individuals with diabetes have 2.3 times greater health-care expenditures compared to those without diabetes [129].
The average age of diabetes onset has remained stable from 1997 to 2011 in adults 18-79 years of age although the median age of onset for women has increased by 1.6 years; from 53.6 to 55.2 years [132]. Due to the increasing older population, the number of individuals 65 years or older diagnosed with diabetes is projected to increase by 4.5 fold between 2005 and 2050 [133]. Age-Adjuested

Incidence
Year Type 2 diabetes is caused when the body is unable to use insulin effectively [134,135].
Conversely , type 1 diabetes is an autoimmune disorder that damages the pancreas' beta cells that results in decreased insulin synthesis and concentrations and is typically diagnosed early in life [134,135]. Of all the diagnosed cases of diabetes; 90-95% have type 2 diabetes [135].
There is a link between the large proportion of the population with type II diabetes and the obesity epidemic, see Figure 6 [136], as well as other chronic diseases [137]. [136] . Individuals with type 2 diabetes have increased risk of mortality and morbidity compared to those without diabetes [138][139][140]. Most notably, individuals with uncontrolled diabetes are at greater risk of co-morbidities from microvascular disease (affecting the kidneys, eyes, and limbs) and macrovascular disease (involving the coronary, peripheral, and cerebrovascular systems) compared to those without complications [137]. Cardiovascular disease involves the heart and/or blood vessels and includes diseases such as CHD, hypertension, atherosclerosis, arrhythmia, and heart failure and is exacerbated by excess weight [152]. Excess adipose tissue results in an adverse change in body weight homeostasis, lipids, blood pressure, and insulin resistance which leads to atherosclerosis and endothelial dysfunction [153]. Longitudinal studies have shown that there is a direct relationship between obesity and CHD in both men and women [154,155]. Results from 16

Figure 6: Diabetes and Obesity Rates by County
years of follow-up in the prospective Nurses' Health Study of middle-aged women found that the CVD death rate was four times higher in women with a BMI >29 kg/m 2 compared with those women with a lower BMI [154]. A prospective cohort study with a 12-year follow-up Obesity is also positively related to dyslipidemia [156], a risk factor for the development for atherosclerosis and CHD [157]. In 2005, 74.6% of women were screened for dyslipidemia compared to 77.6% who were screened in 2009, see figure 7 [158]. More specifically, 12.3% more Rhode Island adults were screened in 2003 compared to 1991 [158].
Although screening for CVD has increased, it is still below the Healthy People 2020 recommendation of 82.1% of adults screened for dyslipidemia [159]. Due to the prevalence of dyslipidemia and the inadequate screening, it is important to promote the prevention of CVD.

FIGURE 7: Age-adjusted percentage of adults aged ≥18 years who had been screened for high blood cholesterol during the preceding 5 years and percentage who had ever been screened for cholesterol and were told by a health-care provider that they had high blood cholesterol -Behavioral Risk Factor Surveillance System, United States, 2009 [158]
CVD can be prevented or treated through lifestyle changes involving healthy eating and physical activity, which are also key treatments of obesity and sarcopenic obesity [160]. A study Stampfer et al., found that 82% of the coronary events could have been prevented if the women in the study maintained a healthy body weight, participated in moderate to vigorous exercise for half an hour a day, moderate consumption of alcohol if it all, did not smoke and followed a healthy diet [161]. A heart-healthy lifestyle which includes an emphasis on nutrition has been beneficial in preventing or treating CVD [160], including populations of older adults [162,163].

NUTRITION IN OLDER ADULTS
Individuals with good nutrition status, defined as meeting physiological needs for nutrients [164,165], have better overall health, decreased chronic disease, improved quality of life, increased life expectancy, better functional ability, and decreased disability [10,9,54,55].
However, almost half of the older adult population is at increased nutrition risk [14,166]. Ford et al. [167] found that 86% of 4,009 adults with a mean age of 81.5 years and the majority being women were at nutrition risk or possible nutrition risk as assessed using the Dietary Screening Tool (DST) to measure dietary quality and nutrition risk. Furthermore, participants with lower dietary quality tended to be underweight, skipped breakfast, decreased their food consumption over the past 3 months, concerned about having enough food as well as difficulty chewing and swallowing [167].
Diet quality is determined by the composition of an individual's diet; foods that are more nutrient dense, have greater diet quality. Diet composition, which was composed of 14 components of diet including low fruits, low vegetables, low nuts and seeds, high sodium, high processed meats, and high trans-fat intake, was predictive of 26% of deaths and 14% of disability-adjusted years in a systematic analysis of descriptive epidemiology study of diseases, injuries, and leading risk factors in the U.S. from 1990-2010 [168]. However, considering that 5 of the top 10 risk factors for health were diet related, the number of deaths associated with diet increases to 74.5% [168]. Dietary patterns and their relation to dietary recommendations comprise an individual's dietary quality [169,170,54]. Poor dietary quality is a major contributing factor to obesity, diabetes, and CVD [108,171,76,168,11].

Dietary Quality
Diet quality is the measure of how closely an individual's diet complies with the USDA's dietary recommendations [172]. Murray et al. [168] identified the most prominent dietary risks in Americans adults as diets low in fruits, vegetables, nuts and seeds, as well as high in sodium, processed meats, and trans fats. One widely used measure of dietary quality has beens the Healthy Eating Index-2005 (HEI-2005) scores; scores range from 0-100 with higher scores indicating better diet quality with a score below 80 indicating poor dietary quality [173,172]. Higher HEI-2005 scores are associated with a significant reduction in chronic disease risk in women [174]. Data from NHANES 2003-2004 found that women, 55 years and older, had a mean HEI-2005 score that was below 80 [175]. Furthermore, women (20 years and older) only received a perfect score on two categories (total grains, meats and beans) and older adults only received a perfect score on three categories (whole fruit, total grains, and meats and beans) [175].  [173]. This is a concern because higher diet quality is associated with quality of life and functional ability [54] and inversely associated with all cause-mortality [169]. High diet quality and overall good nutrition is the cornerstone of therapeutic plans for many chronic diseases; including heart disease, diabetes, and obesity [10,9]. The United States Department of Agriculture (USDA) and American Academy of Nutrition and Dietetics (AND) recommends a focus on overall healthy food patterns as the key to healthy eating and is the basis of many therapeutic dietary interventions [13].

Dietary Approaches to Stop Hypertension
The Dietary Approach to Stop Hypertension (DASH) diet supports the overall diet approach of the USDA and AND advocates [16]; see Table 1. The DASH Diet is a healthy eating plan that has been shown to help individuals prevent or control high blood pressure, lower cholesterol and help facilitate weight loss [17,16]. 30 g *1,500 mg sodium was a lower goal tested and found to be even better for lowering blood pressure. It was particularly effective for middle-aged and older individuals, African Americans, and those who already had high blood pressure.
The DASH diet recommends 6-8 servings of grain per day with at least 50% of them being whole grains; see Table 2. Also recommended are four to five servings of vegetables and fruits per day with a focus on choosing whole versus juices. The DASH diet recommends individuals consume 6 servings or less of lean meat, poultry, or fish per day and limiting consumption of red meat. Furthermore, the DASH diet recommends 4-5 servings of nuts, seeds, and legumes per week. According to the DASH diet, low-fat dairy intake should be 2-3 servings per day as well as 2-3 servings of fat per day. Furthermore, DASH recommends limiting sweets or added sugars to 5 servings per week and sodium to less than 2300 mg per day or 1500 mg per day for those who are at risk [17]. Though the DASH diet has been promoted since 1997, most Americans are not meeting all of the DASH recommendations. indicates the diet of Americans is suboptimal; total score of 51.9 and 53.5 respectively [172].
The HEI-2005 found that only 18% of older adults meet the dietary recommendations for grains [176] and merely 4% of older women consume at least 6 servings of grains with at least half whole grain per day [170]. On average, Americans consume 1.8 cups of milk or milk products which is below the DASH serving recommendations [177]. Older adults are also only meeting 27% of their dietary recommendations for fruit and 32% of their vegetable recommendation [176]. More specifically, women 65 years of age or older consumed only 1.3 cups and 1.5 cups of fruits and vegetables respectively, which is below the DASH and federal guidelines [178]. Adults increased their fruit consumption from 2001-2002 to 2007-2008 however this beneficial change was negated by an increase in sodium and empty calories, resulting in no change in the total HEI-2010 score [172].
Conversely, Americans exceed the DASH guidelines for fat, sugar, and sodium.  [182,70]. Participants with better DASH adherence at post-intervention had significantly greater improvements in blood pressure compared to those who did not adhere to DASH guidelines [182]. The DASH diet not only improves nutrition knowledge, it also improves overall diet and cardiovascular health [182,70,19,16]

PHYICAL ACTIVITY IN OLDER ADULTS
Regular physical activity results in many physiological, psychological, and social benefits for older adults [183,184] and can contribute to successful aging [183,185,186]. There is strong evidence that physical activity reduces the rate of all-cause mortality, heart disease, stroke, and type 2 diabetes as well promotes healthier body composition, increased functional health, improved cognition, and increased cardiorespiratory and muscular fitness [12,23,[187][188][189]]. According to a burden of disease analysis by Lee et al. [12], physical inactivity alone results in 6% of the burden of CHD and 7% of type 2 diabetes. Approximately 9% of the deaths in 2008 worldwide were due to physical inactivity [12]. By decreasing the amount of physical inactivity by 25%, 1.3 million deaths could be prevented annually [12]. According to a systematic review of physical activity in the elderly, older women tend to be more physically inactive when compared to older men [22]. Thus it is important to promote physical activity in older women and provide appropriate education and training to facilitate sustainable physical activity.

Physical Activity Recommendations
The

Physical Activity and Obesity
Research indicates that physical activity can prevent obesity [191,101]. Research from the Women's Health Study followed 34,000 middle-aged women for 13 years and found that women at a normal weight range at baseline needed the equivalent of an hour per day of moderate-to-vigorous activity to maintain their weight [192]. Additionally, the Nurses' Health Study II prospectively followed 46,754 premenopausal women in 1989 found women were less likely to gain weight if they sustained or in 1997 increased to ≥ 30 minutes of physical activity per day [193]. Although, 62% of the population gained greater than 5% of their baseline weight by 1997, women who sustained 30 minutes or more per day of running or jogging experienced less weight gain than those who did brisk walking or other activities [193]. These studies indicate that physical activity, particularly moderate to high intensity aerobic exercise is beneficial in preventing obesity. However other studies examining different modes of physical activity have also shown positive health outcomes including favorable changes in anthropometrics [27,26,30,194].

Resistance Training
Research has shown that resistance training (RT) reduces the symptoms of chronic diseases including type 2 diabetes, heart disease, osteoporosis, and arthritis [113,195].
Resistance training is beneficial to older adults as it allows muscles to move dynamically

RT and Dietary Interventions:
A meta-analysis of studies with adult pre-diabetics or individuals at risk for diabetes, found that interventions that contained RT, aerobic exercise, and dietary education resulted in improvement in dietary and physical activity outcomes [204]. the total fat goal was modified to ≤35% in order to encourage unsaturated fatty acids given their cardiovascular benefit [206]. The behaviorally-based dietary education classes were 30 minutes and participants were given an individualized DASH-based diet plans utilizing the Harris-Benedict equation [207]

Tai Chi
Tai Chi is a Chinese low impact mind-body exercise [208] that is a slow and gentle form of exercise that is appropriate for adults with chronic health conditions as it can improve health without aggravating an individual's current impairments [209]. Tai Chi is an effective exercise to improve the health of older adults [209]  and minorities [210].
A study examining 74 hypertensive men and women with mean age 58.5±7.5 years found a decrease in blood pressure in the individuals who were assigned to the Tai  were encouraged to attend 2 classes per week for 16 consecutive weeks. Although attendance did not affect cardiovascular measures or anthropometrics, participants who were mid to high attendees (attended 9 or more sessions) had musculoskeletal improvements. However, this study lacked a control group and did not measure dietary quality, it did demonstrate that low income minorities can experience improvements following a Tai Chi intervention [210].
Although it is important to consider interventions that include Tai Chi and diet education.

Tai Chi and Dietary Interventions:
Dechamps et al. [212] looked at anthropometrics, cardiovascular, and dietary measures in 21 women with mean age of 44 ± 12 years and BMI of 38 ± 6 kg/m 2 . All participants attended 10 weeks of a weight management program which included an individualized hypocaloric diet which was monitored by a dietitian. Participants were randomized into 2 hour weekly conventional structured exercise or Yang-style Tai Chi. At post-intervention, participants in the Tai Chi group had significantly lower percent of fat mass (-3.6 ± 4.8%), compared to the conventional structured exercise group (-1.4 ± 6.5) as well as reduced dietary restraint, or self-control relating to food (1.9 ± 4.3 vs. 3.4 ± 3.6 respectively). Limitation of the study includes small sample size and lack of a control group that participated in no exercise [212]. However this study indicates that Tai Chi may impact dietary behaviors although it would be advantageous for research to examine dietary composition or quality. . This study demonstrates that a behaviorally-based diet intervention combined with Tai Chi can improve dietary quality but not more than diet alone; however this future research should examine a similar intervention in minority populations.

Lack of Tai Chi, RT, and Dietary Interventions
The USDA recommends that older adults participate in multiple modalities of physical Americans have at least one and 50% have at least two chronic health conditions; including diabetes and CVD [1]. This is of particular concern as both CVD and diabetes, which are exacerbated by aging and obesity, are in the top 10 leading causes of death in American women [138,147]. Thus it is important to promote successful aging in women.
Resilience, defined as the ability to "bounce back" or adapt to significant sources of stress, trauma, or a challenge [24,214], and promotes healthful aging. Resilience may be associated with obtaining and maintaining a balanced diet [13], physical activity routine [23] and ultimately successful aging [7]. This is important as 24-48% of older adults may be at increased nutrition risk [14,15]. Nutrition is a key part of therapeutic plans for many chronic diseases; including heart disease, diabetes, and obesity [9,10]. Older adults with a good nutrition status have better overall health, increased life expectancy, and decreased disability [10,9]. Research indicates that the DASH diet results in beneficial outcomes including cardiovascular and weight improvements [16,53,17]. Furthermore, regular physical activity can facilitate successful aging [183,185,186].

Study Design
This study is phase VI of the University of Rhode Island Dietary Education and Active Lifestyle (UR-IDEAL) Study. It is a non-randomized quasi-experimental design with a 12- week intervention (See the University of Rhode Island's Institutional Review Board application HU01213-028). Measurements were taken at baseline and post intervention, see

Participants
Potential participants were women recruited from the Providence area. Participants were recruited via flyers which were mailed to women ≥50 years in a 1.5 mile radius of the St.
Martin de Porres Senior Center, flyers posted in local senior living communities, and from announcements at the St. Martin de Porres Senior Center. Women were screened to meet eligibility requirements initially through a phone interview at which time, study staff asked the prospective participant about her height, weight, medications, and past medical history, see Table 2. If a woman appeared to meet eligibility requirements, she was invited to an orientation session. The orientation sessions consisted of a discussion the purpose, the activities and risks and benefits of the study, signing the informed consent for those women who were eligible and interested, and a more in-depth past medical history after the consent had been signed in a one-on-one interview with study staff. Participants were placed in the intervention group until it was at capacity (n=25). Additional individuals who qualified for the study and wanted to participate had the opportunity to participate in the wait-list control group.
When a principle investigator deemed a participant's medical history may indicate that the exercise intervention could be unsafe or contraindicated, participants were given a medical clearance form for their primary care provider to complete and return to the staff. There were a total of 92 respondents to recruitment efforts. Of those 92 women, 59 were ineligible due to inability to obtain medical clearance, BMI to low or too high, time constraints, and inability to communicate in English. This resulted in 33 eligible participants of which 23 started the intervention group and 10 started in the control group. Throughout the study, 4 participants dropped-out of the study due to the sessions being too early, inability to obtain travel to the sessions, gallstones, and the program being "too easy." There was 1 person who was lost to follow-up from the wait-list control group. Thus 19 individuals completed the intervention group and 9 completed the wait-list control group, see Figure 1.

Methods for Hypothesis
The primary hypothesis of this project is that nutrition risk will decrease following dietary education, Tai Chi, and resistance training intervention in obese older women compared to a non-treatment control group. Participants completed the Dietary Screening Tool (DST) in order to identify dietary quality and nutrition risk. The total score of the DST ranges from 0-100 with 5 'bonus' points for dietary supplement use; the higher the score indicating healthier dietary patterns. Furthermore, the composite score of the DST is associated with three different nutritional risk levels; at risk (<60), possible risk (60- 75), and not at risk (>75) [15].

Anthropometrics
During anthropometric testing, all participants wore scrubs, had fasted overnight and voided their bladder. Weight was measured in pounds in duplicate to the nearest 0.25 pounds; the average was taken. Then, weight was converted to kilograms. Height was measured with a stadiometer in duplicate to the nearest 0.25cm and averaged. Body Mass Index (kg/m 2 ) was calculated from the height, converted to meters, and weight. Body composition was measured in all participants except those who have a pacemaker via foot-to-foot bioelectrical impedance analysis device (Tanita BF-556). Waist circumference was measured at the point of the iliac crest. Hip circumference was measured at the broadest circumference of the hips above the gluteal fold. Measurements were taken using a standard non-stretch tape measure with tensometer. Waist to hip ratio was calculated.

Methods for Exploratory Hypothesis
The exploratory hypothesis is that there will be a positive relationship nutrition risk and resiliency. Resiliency was measured using two questionnaires. Participants were given the Matthew Delmonico. Resistance training was comprised of 6 exercises; the leg press, knee extension, leg curl, overhead press, chess press, and back row. Participants were supervised while performing the exercise to make sure they were doing it safely and effectively. Blood pressure was taken before and after exercise sessions.
A total of 12 sessions of behaviorally-based dietary education was provided to participants for roughly 45 minutes once a week. A nutrition graduate student conducted the nutrition education sessions that had been develop by Dr. Ingrid Lofgren's lab. Participants learned about healthy eating and lifestyle changes with each session focusing on a different topic related to the modified DASH diet; which includes low intake of saturated fat (<7% of caloric intake), moderate intake of total fat (<35% of caloric intake, modified from the original DASH diet recommendation of 27%), high intake of fruits, vegetable, and whole grains; consumption of low-fat dairy and meat products, and a moderate intake of sodium (3,000 mg or less/day) [16]. Participants filled out food logs three days per week and were given constructive, motivating feedback by the nutrition undergraduates and graduate student from Dr. Lofgren's lab on their dietary choices.

Wait-list control group
The wait-list control group did not receive any intervention during the 12-week intervention period. Participants in the wait-list control group were asked to maintain their normal lifestyle. Following post-intervention testing, participants in the wait-list control group were given two weeks of Tai Chi, resistance training, and nutrition education along with the other incentives provided to the intervention group.

Repeatable Battery for the Assessment of Neurological Status
The

Chronic Diseases
The presence or absence of diabetes and cardiovascular disease was determined from the participant's answers to questions on the phone screener and medical history questionnaire.

Blood Pressure
Manual blood pressure (BP) was taken twice within one minute of each other while the participant is seated with arm at heart level using a standard sphygmomanometer after the participant was seated for 5 minutes [48]. Blood pressure was also measured prior to each exercise session; however these were not included in the analysis.

Biochemical
A lipid and glucose panel was obtained via a finger stick (Cholestech ® LDX system) after participants fasted for 12 hours and abstained from caffeine or nicotine. Researchers measured serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triacylglycerols, and glucose. Forty microliters of blood was collected using a lancet and analyzed using a portable Cholestech machine.

Questionnaires
The following 9 questionnaires were completed by participants involved in the study at baseline and post intervention. The additional questionnaires given to participants include Yale Physical Activity Scale (YPAS) measured activity index and weekly calorie expenditure [47] as well as Sleep Quality Questionnaire [215], Social Support and Exercise Survey [216], REACT II Life satisfaction questionnaire [217,218], Body Satisfaction Measure [219], and the Activities-specific Balance Confidence (ABC) Scale [220].

Physical Function
Beyond the scope of this proposal, the Kinesiology research assistants conducted several physical functioning tests, including: the short physical performance battery (SPPB), which is comprised of three tests: balance assessment, gait speed assessment, and timed chair stands, 8-foot up and go (UG) test, grip strength, as well as the chair-sit and reach [221].

Statistical Analysis
It was determined that a sample size of 24 total participants would be adequate in and Communicative Disorders at the University of Rhode Island, the persons mainly responsible for this study, will discuss them with you. Individuals may be able to participate if they have/are 1) female, 2) age 50-80 years, 3) a body mass index (BMI) of 30-50 kg/m 2 , 4) no recent medication changes, 5) post-menopausal, and 6) free of diseases or conditions that would prevent safe changes in diet and/or participation in an exercise program.

Description of the project:
This is a research project designed to assess the role that a 12-week Tai Chi and resistance exercise training program plays in improving physical functioning, muscle mass, fat mass, and improving heart disease risk factors when combined with a dietary intervention to improve dietary intakes. Tai Chi, a form of martial arts that is a slow and low-impact exercise, and resistance training (RT) have 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 dietary changes with Tai Chi and resistance exercise training on changes in cognitive function, sleep quality, blood pressure, blood fats and sugar metabolism, muscle function, and other important health-related measures. Your participation will vary depending on which group you are assigned to. However, the study may require your participation of about 4 hours per week. All of the testing and intervention sessions will take place at the St. Martin de Porres Center. 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 (two visits, 1-2 hours per visit). At the first testing 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 that will take only 30-40 minutes. These include a dietary screening tool, a physical activity survey, a social support survey, a sleep quality questionnaire, balance questionnaires, life and body satisfaction surveys, and resiliency surveys. You will also complete one finger stick that will be used to analyze blood sugar, fats, and cholesterol. 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 8:00 am on a Wednesday, you are asked to not eat and/or drink anything besides plain water after 8:00 pm 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.
At testing visit 2, a brief cognitive screening test will be administered that will take 30 minutes. The screening tasks include list learning, naming, short-term recall, figure drawing, and coding.
You understand that trained personnel, using universal precautions and established methods, will conduct these finger sticks. You understand that the finger stick requires 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 trained 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 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 device.
At the end of the first phase (testing), you will be assigned to either the exercise (Tai Chi and resistance training) plus dietary group or to a waitlist control group based on group availability.

Dietary Sessions (Exercise plus Healthy Diet Group)
For those assigned to this intervention, you will be asked to participate in a dietary intervention designed to improve your diet. You will be instructed on how to change your diet to increase fruit, vegetable, whole grain, and monounsaturated fat intakes with reductions in saturated/trans fats, refined carbohydrates, and sodium by the end of 12-week protocol as measured by the dietary questionnaires. At the senior center, you will meet in a group (~15-25 other participants) with an expert in nutrition once per week (~ 45 minutes per session) for 12 weeks who will give you instructions and expert advice on food selection, preparation, and other dietary changes. Body weight will be monitored periodically, and you will be instructed to keep careful records of your food intake.

Exercise Sessions (Exercise plus Healthy Diet Group
Tai Chi. If you are assigned to the diet plus exercise group, you will also be asked to participate in three (3) supervised exercise sessions per week (~ 40 minutes per visit) for the 12-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 lowimpact exercise movements while you are standing on your feet. You will be asked to come to an assigned room at the 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 the 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 and other 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 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 at an effort level that is judged to be appropriate to improve your fitness level. Your blood pressure will also be measured at the start of 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 5-10 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.
Resistance Training. On two of the days that you participate in Tai Chi, you will be asked to do some additional exercises using basic resistance exercise training equipment (for example, rubber bands), which offers resistance against extending and flexing your arms, legs, and trunk region for approximately 20 minutes. All sessions will start with a brief warm-up that will be achieved by doing the Tai Chi exercise. The first several resistance training sessions will begin with lighter resistances to get you used to the resistance training program. Your overall progress will be monitored by an exercise specialist so that you are able to tolerate the exercise.

Control Group
If there is no space available in the exercise plus diet group, you understand that you may be assigned to the "waitlist control" group. If you are 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 12-week intervention (phase 2). 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 the dietary materials, six supervised Tai Chi exercise sessions, and four resistance training sessions at the St. Martin de Porres 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 healthy diet 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.
The third and final phase will be a repeat of all previously taken measures from Phase 1 after the completion of the 12 week intervention. All data will be coded with a study number and stored only at the University of Rhode Island without any personal identifiers (including initials or birth dates) to ensure confidentiality. 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. The St. Martin de Porres 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, resistance training, 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 participant:
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 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, room 120). Study records are retained securely for ten years after the study ends.

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 a healthy diet and 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 at the end of the study.

Decision to quit at any time:
You understand that it 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. If you wish to quit, simply inform one of the principal investigators listed in the next section of this consent.

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  Alternatives to study participation: You understand that you might achieve similar results by another method i.e., another 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 healthy diet 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.  straighten your arm out to the side shoulder height. About 1 second  When as straight as possible, pause at the end and then slowly return to starting position. About 2 seconds Option 2: • Raise your right hand above your head until your arm is vertical and elbow is by your ear. Bend your arm at the elbow until it is behind your neck or back.