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doi:10.1093/gerona/glu099 Advance Access publication November 11, 2014

A Physical Activity Intervention to Treat the Frailty

Syndrome in Older Persons—Results From the
LIFE-P Study
Matteo Cesari,1,2 Bruno Vellas,1,2 Fang-Chi Hsu,3 Anne B. Newman,4 Hani Doss,5 Abby C. King,6
Todd M. Manini,7 Timothy Church,8 Thomas M. Gill,9 Michael E. Miller,3 and Marco Pahor6;
for the LIFE Study Group

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1
Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
Institut national de la santé et de la recherche médicale (UMR1027), Université de Toulouse III Paul Sabatier, France.
2
3
Department of Biostatistical Sciences, Wake Forest University Health Sciences, Winston Salem, North Carolina.
4
Department of Epidemiology, University of Pittsburgh, Pennsylvania.
5
Department of Statistics, University of Florida, Gainesville.
6
Department of Health Research and Policy and Stanford Prevention Research Center, Stanford University, Palo Alto, California.
7
Department of Aging and Geriatric Research, Institute on Aging, University of Florida, Gainesville.
8
Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge.
9
Department of Medicine, Yale University, New Haven, Connecticut.

Address correspondence to Matteo Cesari, MD, PhD, Gérontopôle, Université de Toulouse, 37 Allées Jules Guesde,
Toulouse 31000, France. Email: macesari@gmail.com

Background.  The frailty syndrome is as a well-established condition of risk for disability. Aim of the study is to
explore whether a physical activity (PA) intervention can reduce prevalence and severity of frailty in a community-
dwelling elders at risk of disability.

Methods.  Exploratory analyses from the Lifestyle Interventions and Independence for Elders pilot, a randomized
controlled trial enrolling 424 community-dwelling persons (mean age=76.8 years) with sedentary lifestyle and at risk
of mobility disability. Participants were randomized to a 12-month PA intervention versus a successful aging education
group. The frailty phenotype (ie, ≥3 of the following defining criteria: involuntary weight loss, exhaustion, sedentary
behavior, slow gait speed, poor handgrip strength) was measured at baseline, 6 months, and 12 months. Repeated meas-
ures generalized linear models were conducted.

Results.  A significant (p = .01) difference in frailty prevalence was observed at 12 months in the PA intervention group
(10.0%; 95% confidence interval = 6.5%, 15.1%), relative to the successful aging group (19.1%; 95% confidence interval
= 13.9%,15.6%). Over follow-up, in comparison to successful aging participants, the mean number of frailty criteria in
the PA group was notably reduced for younger subjects, blacks, participants with frailty, and those with multimorbidity.
Among the frailty criteria, the sedentary behavior was the one most affected by the intervention.

Conclusions.  Regular PA may reduce frailty, especially in individuals at higher risk of disability. Future studies
should be aimed at testing the possible benefits produced by multidomain interventions on frailty.

Key Words:  Frailty—Physical activity—Physical function—Successful aging—Clinical trials

Received March 11, 2014; Accepted June 1, 2014

Decision Editor: James Goodwin, PhD

T he steady and rapid increase of the absolute and rela-

tive number of older persons is a global phenomenon
of Western countries. Such demographical changes require
During the last two decades, special interest has been
devoted by the scientific community to the study of the frailty,
a syndrome characterized by reduced homeostatic reserves
immediate actions to render the healthcare systems capable and resistance to endogenous and exogenous stressors (3).
of sustaining the growing number of individuals with mul- Frailty represents a major risk factor for negative health-related
tiple age-related conditions. In fact, the prevention of disa- events in the elderly, including disability, falls, hospitaliza-
bling conditions is important because disability severely tions, and mortality (4). Consequently, the clinical identifica-
impacts the quality of life of the individual (1) and is eco- tion of frailty may play an important role in the development
nomically burdening for public health (2). Therefore, pre- of preventive strategies against age-related conditions.
ventive interventions able to modify the natural history of To transfer the theoretical concept of frailty into clinical
age-related conditions are urgently needed. practice, several operational definitions have been proposed
216
 Physical Activity and Frailty Syndrome 217

(4). The best known and most commonly used is the one - Transition (weeks 9–24): two center-based exercise ses-
proposed by Fried and colleagues (5) and validated in the sions per week and home-based endurance, strengthening,
Cardiovascular Health Study. It defines the presence of a frailty and flexibility exercises (at least three times per week);
phenotype when three or more of the following features are
- Maintenance (week 25 to the end of the study): home-
simultaneously present: exhaustion, involuntary weight loss,
based intervention with optional once-to-twice per week
sedentary behavior, slow gait speed, poor muscle strength.
center-based sessions and monthly phone contacts.
Of the most promising preventive interventions for dis-
ability, physical activity (PA) is surely one of the most stud- The intervention was specifically focused on walking,
ied and promising (6). Recent findings from the Lifestyle with the aim of helping participants reach at least 150 min/
Interventions and Independence for Elders pilot (LIFE-P) wk (9). Other forms of endurance activity (eg, stationary
study showed the capacity of a PA intervention to improve cycling) were utilized when regular walking was contrain-

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physical performance in sedentary older persons (7). dicated. Each session was preceded by a brief warm-up and
To our knowledge, no study has yet explored whether followed by a brief cool-down period. Participants were
PA can modify the frailty status of elders. In this work, we instructed to complete flexibility exercises following each
hypothesize that the beneficial effects of PA may positively bout of walking. Following the bouts of walking each week,
influence the frailty syndrome, allowing a reduction of its participants were instructed to complete a 10-minute rou-
prevalence and severity toward a status of restored robust- tine primarily focused on strengthening exercises. Strength
ness. Thus, we conducted analyses aimed at exploring the training was focused on lower extremity physical activi-
effects of PA on frailty status in a sample of community- ties by using variable weight ankle weights. Balance train-
dwelling sedentary elders at initial risk of mobility disability. ing was added during the adoption phase of the program.
Participants were encouraged to increase all forms of PA
throughout the day.
Methods
The intensity of training was gradually increased over the
Data are from the LIFE-P study (7). This is a two-arm, sin-
first 2–3 weeks. Using Borg’s scale (range from 6 [ie, 20%
gle blind, multicenter, randomized controlled trial compar-
effort] to 20 [ie, exhaustion]) (10), participants were asked
ing a PA intervention versus a successful aging (SA) health
to walk at an intensity of 13 (ie, 70% effort, “somewhat
education program. The study was conducted from 2004
hard”). They were discouraged from exercising at levels
(first randomization) to 2006 at four clinical sites: Wake
≥15 (ie, 80% effort, “hard”) or ≤11 (ie, 60% effort, “fairly
Forest University-School of Medicine (Winston Salem,
light”). Lower extremity strengthening exercises were per-
NC), University of Pittsburgh (Pittsburgh, PA), Cooper
formed at an intensity of 15–16 on the Borg’s scale.
Institute (Dallas, TX), and Stanford University-School of
SA health education group. A  SA intervention served
Medicine (Palo Alto, CA). The study was approved by the
as an active control group. In this group, participants were
local institutional review boards.
invited to meet once a week in small groups for the first 26
The eligibility criteria were aimed at recruiting sedentary
weeks of the study, and subsequently on a monthly basis.
persons, aged 70–89 years, having a sedentary lifestyle (<20
The topics presented at the meetings were relevant to older
min/wk spent in structured PA during the past month) and
persons’ health, including education on nutrition, medi-
at increased risk of mobility disability (incapacity to walk
cations, foot care, recommended preventive services. At
400 m at usual pace without any assistive device). Exclusion
the end of each meeting, a bout of gentle upper extremity
criteria were based on the presence of clinical conditions
stretching was conducted.
rendering the study intervention unsafe (eg, symptomatic
As previously reported (7), the attendance rate for fol-
coronary artery disease) or infeasible (eg, severe illnesses,
low-up assessments was particularly high (ie, 94.8% and
cognitive disorders). Individuals recovering from acute
94.0% at 6 and 12 months, respectively). Attendance rates
conditions, surgery, rehabilitation, or those with conditions
were also high in the PA (ie, 70.7% and 60.9% at 6 and
amenable to medical intervention were temporarily excluded
12 months, respectively) as well as in the SA (ie, 70.0% and
and rescreened at a later time. The full list of inclusion and
73.0% at 6 and 12 months, respectively) groups.
exclusion criteria as well as details about the design/meth-
ods of the trial have been previously published (7,8).
Frailty
Frailty phenotype (5) was measured at each clinic assess-
Randomization groups
ment (ie, baseline, 6 months, and 12 months). This frailty
PA group. The PA intervention included aerobic,
definition is based on the assessment of five signs/symp-
strength, flexibility, and balance training. The intervention
toms, which are computed as follows in these analyses:
was organized into the following three phases:
- Exhaustion. As in the Cardiovascular Health Study (5),
- Adoption (weeks 1–8): three center-based exercise exhaustion was defined from two questions included
sessions (40–60 minutes) per week conducted under in the Center for Epidemiologic Studies-Depression
supervision; scale (11).
218 Cesari et al.

- Involuntary weight loss. In the LIFE-P database, no gender (stratifying variable for randomization), interven-
information is available about weight prior to the tion assignment, assessment visit, and the interaction term
beginning of the study. For this reason, at the baseline of randomization group × assessment visit were included in
visit, the criterion was considered present if a loss of the models. Models also included the baseline indicator of
appetite was reported by the participant on the Center diabetes variable due to the highly significant difference it
for Epidemiologic Studies-Depression scale (11). The showed between the two groups at baseline. Although it is
objective evaluation of changes in body weight was generally advised against wide-scale testing of the hypoth-
available at the 6- and 12-month clinic assessments. For esis of equality between baseline covariates in randomized
these two visits, commensurate with the original defini- trials, the low p value (p = .005) of diabetes may meet the
tion (5), the criterion was considered as present if the higher standard justifying its inclusion (13). Evaluation of
participant had experienced a weight loss ≥2.275 kg or the effect of the intervention within baseline subgroups was

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≥2.5% of body weight during the last 6 months of fol- performed for comparisons of the mean number of frailty
low-up, or ≥4.55 kg or ≥5% of body weight during the criteria by inclusion of the subgroup covariate and relevant
last 12 months of follow-up. interaction terms in the above models. Because we report
- Sedentary behavior. Self-reported level of PA was assessed post-hoc analyses of a clinical trial, we view all significance
using the Community Healthy Activities Model Program tests as hypothesis generating and have reported nominal p
for Seniors (CHAMPS) questionnaire (12). The gender- values. Analyses were performed using IBM SPSS version
specific cut-points (ie, men <383 kcal/wk; women <270 20.0 for Mac (Armonk, NY) and SAS 9.3 (Cary, NC).
kcal/wk) proposed by Fried and colleagues (5) were applied
to categorize the participants’ weekly caloric expenditure
in moderate-intensity exercise-related activities. Results
- Slow gait speed. The gender- and height-specific cut- The main characteristics of the LIFE-P study sample
points of gait speed used in the original definition of (n = 424, mean age 76.8 [SD = 4.2] years, women = 68.9%)
frailty phenotype (5) were applied to the results obtained according to randomization group are presented in Table 1.
from a 4-m walk test. Figure 1 reports results from the generalized linear mod-
els showing adjusted prevalence of frailty (panel A) and
- Poor muscle strength. Handgrip strength was measured adjusted mean number of frailty criteria (panel B) at the
using a Jamar handheld dynamometer (Bolingbrook, different study assessment visits according to randomiza-
IL). The original gender- and body mass index-specific tion group. After 12  months of follow-up, the estimates
cut-points (5) were used for defining this criterion.
The presence of ≥3 criteria identifies frailty, with 1–2
representing prefrailty, and the absence of criteria indicat- Table 1.  Sample Population (n = 424) According to
ing absence of frailty (5). Observations were included in Randomization Group
the analytical sample when, even in the presence of missing Successful Physical Activity
frailty criteria items, a definitive classification of presence Aging (n = 211) (n = 213) p
of frailty could be obtained. Age (years) 77.0 ± 4.3 76.5 ± 4.2 .24
Gender (women) 69.2 68.5 .89
Race
Other variables  White 73.5 75.1
 Black 19.0 17.4 .91
Main sociodemographic and behavioral characteristics
 Other 7.6 7.5
were recorded at the baseline assessment. Prevalence of Education
chronic conditions was determined using physician-diag-   8th grade or below 3.8 2.8
nosed disease information self-reported by participants.   High school 27.4 27.5 .86
  College or above 69.8 68.7
Body mass index (kg/m2) 29.7 ± 5.8 30.7 ± 6.2 .10
Statistical analysis Current smoking 3.3 3.3 .99
Chi-square and t test were used to compare the partici- Cancer 17.1 17.8 .83
Congestive heart failure 6.2 5.2 .66
pants’ characteristics from the two randomization groups.
Depression 16.6 17.4 .83
Estimates of frailty prevalence and mean number of frailty Diabetes 16.1 27.2 .005
criteria between randomization groups over time were cal- Hypertension 68.7 69.5 .87
culated using repeated measures generalized linear models Lung disease 13.7 13.6 .97
(ie, mixed effects models for continuous outcomes and gen- Myocardial infarction 7.1 11.3 .14
eralized estimating equations with a logit link for binary Osteoarthritis 20.4 23.5 .44
Stroke 5.7 3.8 .35
frailty outcomes). Unstructured covariance matrices were Number chronic conditions ≥3 22.3 27.7 .20
used within both types of models. The baseline value of each
frailty outcome (presence/absence or number of criteria), Note: Results are shown as percentages, or mean ± SD.
 Physical Activity and Frailty Syndrome 219

of prevalence were 10.0% (95% confidence interval

[CI] = 6.5%, 15.1%) for the PA group and 19.1% (95%
CI = 13.9%, 25.6%) for the SA group (p = .01); the adjusted
odds ratio at the 12-month visit was 2.12 (95% CI = 1.17,
3.84). The mean number of frailty criteria decreased in
the PA group (6  months: −0.43, 95% CI = −0.57, −0.29;
12  months: −0.48, 95% CI = −0.62, −0.33) as well as in
the SA group (6  months: −0.20, 95% CI = −0.33, −0.06;
12  months: −0.21, 95% CI = −0.35, −0.06). Statistically
significant differences in the number of frailty criteria were
observed between the PA and SA groups at the 6-month

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(∆ = −0.23, 95% CI = −0.42, −0.04; p = .02) and 12-month
(∆ = −0.27, 95% CI = −0.47, −0.06; p = 0.01) assessments.
Figure  2 shows the results of stratified analyses esti-
mating the effects of PA on the number of frailty criteria
according to different subgroups. Results are presented as
the mean number of frailty criteria in the SA group minus
the mean number of frailty criteria in the PA group, aver-
aged over the 6- and 12-month follow-up visits. Significant
differences existed for the effect of the intervention within
subgroups defined by race (p = .02) and baseline frailty
(p = .04). Noteworthy reductions in the number of frailty
criteria associated with the PA versus the SA intervention
were observed for younger subjects (0.27, 95% CI = 0.07,
0.46), blacks (0.74, 95% CI = 0.35, 1.14), participants with
Figure 1.  Results from general linear models showing the prevalence of frailty frailty (0.60, 95% CI = 0.21, 0.98), and those with multi-
at the different study visits according to randomization group. Results are reported morbidity (0.52, 95% CI = 0.17, 0.87).
as means (95% CI). Gender (stratifying variable for randomization), number of
frailty criteria at the baseline (A) or prevalence of frailty at the baseline (B), and
To understand which of the five frailty criteria was more
diabetes are included as covariates of the model. CI = confidence interval. positively affected by the study intervention, we conducted

Figure 2.  Estimated effects of the intervention on the mean number of frailty criteria according to specific subgroups. Results are reported as means (95% CI).
Estimates represent the average of the differences of mean levels between SA and PA groups over 6- and 12-mo visits obtained from a contrast estimated within a
mixed effects model for the repeated frailty outcomes. Each model contained a prerandomization term representing the number of frailty conditions, an intervention
effect, a visit effect, a term representing subgroup factor, and interactions between these last three terms. For the frailty subgroup analysis, the continuous baseline
frailty outcome was dropped from the model. The reported p values for equality of difference between subgroups are obtained as a contrast from mixed effects model.
CI = confidence interval; PA = physical activity; SA = successful aging.
220 Cesari et al.

additional exploratory analyses looking at the variation disability cascade in elders. Second, although the improve-
of each single criterion according to randomization group ment of frailty status from the PA intervention was primarily
(Figure  3). After adjustment for baseline levels of each related to the reduction of sedentary behavior, as opposed
frailty criterion, sedentary behavior was the only frailty cri- to the other components of frailty, this does not change the
terion showing a significant difference between randomized beneficial effect on the individual’s condition of risk. In
groups in prevalence over the follow-up (adjusted odds fact, if the amelioration of the risk profile comes from the
ratio for the average effect = 2.37, 95% CI = 1.64, 3.43; isolated action of the intervention on a single component
p < .001). No other significant difference between the two of frailty (sedentary behavior in this case) or from a more
groups was found. When the sedentary behavior criterion general effect on multiple criteria, the final practical result
was omitted from the definition of the frailty phenotype, (ie, reduction of frailty) still remains the same. Third, the
there was no significant difference in the modifications of lack of significant improvements reported for the frailty cri-

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frailty prevalence (adjusted odds ratio for average effect = teria other than sedentary behavior may provide important
1.02, 95% CI = 0.49, 2.12; p = .97) or the number of frailty insights about the nature of this syndrome. In our study, PA
criteria (−0.04, 95% CI = −0.18, 0.09; p = .18) between the seems to not uniformly affect the criteria designated to cap-
two groups. ture the frailty syndrome. Although the LIFE-P intervention
was not designed to prevent/reduce frailty, our results sug-
gest the existence of differences in the (sub)clinical mecha-
Discussion nisms underlying each of the frailty criteria. From a research
To our knowledge, this is the first randomized clinical viewpoint, this indicates the need for exploring the single
trial that has evaluated the effects of PA on frailty status in components of frailty in separate analyses in order to under-
older persons. Our findings support the hypothesis that a PA stand the differential responsiveness of criteria to specific
program significantly reduced the presence and severity of interventions or their underlying pathophysiological mecha-
frailty in a sample of sedentary elders, thus potentially mod- nisms. On the other hand, using a more clinical perspective,
ifying their risk profile. Secondary analyses suggest that the hypothesis that multidomain interventions are necessary
participants benefiting most from the intervention included in order to achieve the most successful results in the treat-
those with frailty and multimorbidity at baseline. ment of frailty might find support (14). The addition of pre-
The present results are of major interest for the develop- ventive programs targeting different aspects of frailty (eg,
ment of preventive interventions against disability. First, malnutrition) may enhance the benefits that the frail older
these findings support the concept that frailty is a reversible person may experience relative to a PA protocol alone.
condition and, as such, might indeed represent an impor- Another important finding was obtained in subjects with
tant target to consider for preventive programs aimed at the frailty or higher comorbidity at the baseline. Our results,

Figure 3.  Estimated effects of the intervention on the prevalence of each of the frailty criterion according to the randomization group. Results are reported as
percentages. The reported p values represent a test of the average prevalence at the month 6 and 12 visits in the PA vs the SA groups. Tests are adjusted for baseline
levels for each frailty measure. PA = physical activity; SA = successful aging.
 Physical Activity and Frailty Syndrome 221

consistent with previous evidence (7,15), suggest that have had a substantial effect on our results. Unfortunately,
elders with higher risk profiles may still benefit from pre- the detail about the presence of macrovascular complica-
ventive strategies and should not be excluded a priori from tions in diabetes is not present in the LIFE-P database. Such
interventions to prevent disability. information might have supported specific analyses aimed
It might be argued that the improvement of frailty sta- at confirming recent findings that indicate complicated dia-
tus per se may not necessarily translate into a reduction of betes as a significant predictor of frailty progression (19).
frailty-related outcomes (eg, mortality, disability). Previous Finally, the PA program consisted of a suite of endurance,
evidence from the LIFE-P study demonstrates that the strengthening, and flexibility and balance exercises. This
adopted intervention is able to significantly improve physi- makes it difficult to formally tease apart which components
cal performance measures and produce nonsignificant (but of the intervention might be particularly important in reduc-
suggestive) results on “harder” endpoints such as mobility ing frailty. Future studies that systematically dismantle

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disability (7). Unfortunately, the pilot nature of the study these different components may help to shed further light
does not allow to adequately clarifying this issue. on this issue.
It might appear surprising that the PA intervention had In conclusion, our results demonstrate a novel effect
nonsignificant effects on the slowness and weakness crite- that regular PA may exert on the health status of older per-
ria of frailty. The lack of significant results is likely due to sons, that is the improvement of frailty syndrome. Given
the categorization of the variables of interest. In our analy- that such benefits seem to be particularly evident in frailer
ses, we explored the capacity of the intervention to improve individuals, the exclusion of such persons from engaging in
gait speed and muscle strength above the thresholds of risk such types of PA is not justified when clinical contraindica-
proposed by the original definition of frailty phenotype (5). tions are not present. If our findings will be confirmed, the
Dichotomizing these features of frailty likely reduced sta- promotion of PA programs adapted to older persons might
tistical power, partly explaining the lack of significant dif- have to be strengthened by public health authorities in order
ferences. Moreover, by virtue of its inclusion criteria (7,8), to reduce the incidence of frailty and disability and limit
the LIFE-P population was frailer than that recruited in the related healthcare expenditures. Future studies should be
Cardiovascular Health Study (from which the defining cri- aimed at testing the possible enhanced benefits produced by
teria of frailty were derived). Consequently, it is possible multidomain interventions on geriatric syndromes.
that the relative improvements due to PA in the LIFE-P
sample might have been of an insufficient magnitude for Funding
overcoming the predetermined thresholds of risk. Thus, it The LIFE-P Study is funded by a National Institutes of Health/National
can be argued that the frailty phenotype may not be suit- Institute on Aging Cooperative Agreement #UO1-AG22376 and sponsored
in part by the Intramural Research Program, National Institute on Aging,
able for measuring health status modifications in the most National Institutes of Health.
vulnerable elders (16). Finally, it is possible that the frailty
improvement follows a nonlinear exponential trend accord- Acknowledgments
ing to the severity of the condition, and/or some features Authors had full access to all of the data in the study and can take
(eg, sedentary behavior) are more quickly modified by the responsibility for the integrity of the data and the accuracy of the data
analysis. Research Investigators for Pilot Phase of LIFE: Cooper Institute,
PA intervention compared with others. Dallas, TX. Steven N.  Blair, PED (Field Center Principal Investigator
Several limitations of our study need to be mentioned. [PI]); Timothy Church, MD, PhD, MPH (Field Center Co-PI); Jamile
The generalizability of our results might be limited due to Ashmore, PhD; Judy Dubreuil, MS; Georita Frierson, PhD; Alexander
N. Jordan, MS; Gina Morss, MA; RubenRodarte, MS; Jason M. Wallace,
the LIFE-P eligibility criteria, which were mainly focused MPH. National Institute on Aging. Jack Guralnik, MD, PhD (Co-PI of
at (i) defining the “at risk” group that might most benefit the Study); Evan Hadley, MD; Sergei Romashkan, MD, PhD. Stanford
from the intervention, and (ii) ensuring that the PA program University, Palo Alto, CA. Abby C. King, PhD (Field Center PI); William
L.  Haskell, PhD (Field Center Co-PI); Leslie Pruitt, PhD; Kari Abbott-
would be safe for participants. These findings can be applied Pilolla, MS; Karen Bolen, MS; Stephen Fortmann, MD; Ami Laws, MD;
to sedentary elders with some degree of functional limita- Carolyn Prosak, RD; Kristin Wallace, MPH. Tufts University, Boston,
tion. While each of the frailty criteria was evaluated, two MA. Roger Fielding, PhD; Miriam Nelson, PhD. Dr. Fielding’s contribu-
tion is partially supported by the US Department of Agriculture, under
(sedentary behavior and weight loss) were slightly modi- agreement No. 58-1950-4-401. Any opinions, findings, conclusion, or rec-
fied to accommodate the available data. For example, we ommendations expressed in this publication are those of the author(s) and
do not have information on whether any observed weight do not necessarily reflect the view of the US Department of Agriculture.
University of California, Los Angeles, CA. Robert M.  Kaplan, PhD,
loss was intentional or unintentional. Moreover, given the MA. VA San Diego Healthcare System and University of California, San
lack of information about weight loss at the baseline assess- Diego, CA. Erik J. Groessl, PhD. University of Florida, Gainesville, FL.
ment, the loss of appetite was used as surrogate for defin- Marco Pahor, MD (PI of the Study); Michael Perri, PhD; Connie Caudle;
Lauren Crump, MPH; Sarah Hayden; Latonia Holmes; Cinzia Maraldi,
ing the specific frailty criterion at this timepoint. Although MD; Crystal Quirin. University of Pittsburgh, Pittsburgh, PA. Anne
weight loss and appetite loss are associated (17), their cor- B.  Newman, MD, MPH (Field Center PI); Stephanie Studenski, MD,
relation might be modest (r ≅ .35) (18). Nevertheless, since MPH (Field Center Co-PI); Bret Goodpaster, PhD, MS; Nancy W. Glynn,
PhD; Erin Aiken, BS; Steve Anthony, MS; Sarah Beck (for recruitment
we were comparing two treatment groups in the context of papers only); Judith Kadosh, BSN, RN; Piera Kost, BA; Mark Newman,
a randomized clinical trial, these modifications should not MS; Jennifer Rush, MPH (for recruitment papers only); Roberta Spanos
222 Cesari et al.

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CMA; Diane Ives, MPH. The Pittsburgh Field Center was partially sup- intervention on measures of physical performance: results of the life-
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