Background: Current clinical guidelines for the management of type 2 diabetes mellitus (T2DM) in older adults recommend the use of antihyperglycemic medications, monitoring of blood glucose levels, regular exercise, and a healthy diet to improve glycemic control and reduce associated comorbidities. However, adherence to traditional exercise programs is poor (<35%). Common barriers to adherence include fear of hypoglycemia and the need for blood glucose level monitoring before exercise. Digital health strategies offer great promise for managing T2DM as they facilitate patient-practitioner communication, support self-management, and improve access to health care services for underserved populations. We have developed a novel web-based software program allowing practitioners to create tailored interventions and deliver them to patients via digital voice assistants (DVAs) in their own homes. Objective: We aim to evaluate the feasibility of a 12-week, home-based, personalized lifestyle intervention delivered and monitored by DVAs for older adults with obesity and T2DM. Methods: In total, 50 older adults with obesity aged 50-75 years with oral hypoglycemic agent–treated T2DM were randomized to the intervention (DVA, n=25) or a control group (n=25). Participants allocated to the DVA group were prescribed a home-based muscle strengthening exercise program (~20- to 30-min sessions) and healthy eating intervention, delivered via DVAs (Alexa Echo Show 8; Amazon) using newly developed software (“Buddy Link”; Great Australian Pty Ltd). Control group participants received generalized physical activity information via email. Outcomes were feasibility, DVA usability (System Usability Scale), and objectively assessed physical activity and sedentary time (wrist-worn accelerometers). Results: In total, 45 (90%) out of 50 participants completed this study. Mean adherence to prescribed exercise was 85% (SD 43%) with no intervention-related adverse events. System usability was rated above average (70.4, SD 16.9 out of 100). Compared with controls, the DVA group significantly decreased sedentary time (mean difference –67, SD 23; 95% CI –113 to –21 min/d), which was represented by a medium to large effect size (d=–0.6). Conclusions: A home-based lifestyle intervention delivered and monitored by health professionals using DVAs was feasible for reducing sedentary behavior and increasing moderate-intensity activity in older adults with obesity and T2DM. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000307808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381364&isReview=true

Sarcopenic obesity is the confluence of low skeletal muscle mass and function with excess adiposity. Sarcopenic obesity is becoming increasingly prevalent among older adults and may contribute to greater risk of functional decline, falls, fractures and mortality than sarcopenia or obesity alone. This narrative expert review, based on targeted literature searches and the authors' personal libraries, outlines the current understanding of sarcopenic obesity, including its multifactorial pathophysiology. We also describe the current operational definition and estimated prevalence in older populations, and its impact on musculoskeletal and cardiometabolic health. Evidence from interventional studies exploring the use of targeted multimodal lifestyle behavior interventions, with a focus on the primary role of exercise and caloric restriction, to address sarcopenic obesity and its consequences is presented. Finally, we discuss recommendations for clinical practice and future research aimed at optimizing body composition and physical function in older adults. Despite a lack of consistent evidence on its prevalence, it is clear that sarcopenic obesity conveys serious health consequences. Further research is required to determine the optimal approaches to its diagnosis and management, but this should not act as a barrier to assessment and intervention in clinical settings.

It is unclear whether comorbid low bone mineral density (BMD) and sarcopenia, known as 'osteosarcopenia', synergistically increase fall and fracture risk. This review aims to determine whether osteosarcopenia confers a greater risk for incident falls and fractures than low BMD or sarcopenia alone. Relevant databases were searched from inception to 2025 for prospective studies in populations aged ≥ 50 years comparing fall and fracture risk in osteosarcopenia to low BMD (T-Score < -1.0) or sarcopenia alone. Meta-analyses calculated risk ratios (RR) and measures of interaction on additive (relative excess risk due to interaction; RERI) and multiplicative (multiplicative interaction ratio; MR) scales. Seven records (n = 813) were included. Osteosarcopenia was associated with similar fracture risk as low BMD (RR 1.22; 95% CI 0.96, 1.56; k = 6, I² = 0%), but higher risk than sarcopenia (RR 2.12; 95% CI 1.42, 3.15; k = 5; I² = 0%). Falls risk did not differ for osteosarcopenia compared to low BMD (RR 1.15; 95% CI 0.44, 2.97; k = 3; I² = 72.9%) or sarcopenia (RR 1.06; 95% CI 0.70, 1.59; k = 3; I² = 1.1%). Synergy analyses showed pooled RERI of 0.35 (95% CI - 0.22, 0.91; k = 5) for fractures and - 0.16 (95% CI - 0.60, 0.28; k = 3) for falls, with MR estimates of 1.21 (95% CI 0.90 to 1.62) and 0.83 (95% CI, 0.64 to 1.09), respectively. Risk of incident fracture in osteosarcopenia is similar to that of low BMD, but higher than sarcopenia, and falls risk does not differ between conditions. The absence of significant additive or multiplicative interactions suggests there is insufficient evidence to support the promotion of osteosarcopenia as a distinct diagnostic entity.

Obesity is common in type 2 diabetes mellitus (T2DM) and is associated with lower fracture risk. However, older adults with T2DM have higher fracture rates, suggesting distinct effects of T2DM on musculoskeletal health. We aimed to compare associations between components of T2DM and musculoskeletal health in community-dwelling older adults with obesity, with and without T2DM. This cross-sectional study included adults aged ≥60 years with self-reported obesity (body mass index [BMI] ≥30 kg/m²). Physical function was assessed by short physical performance battery (SPPB), handgrip strength, stair-climb and jumping mechanography. Dual-energy X-ray absorptiometry (DXA) measured body composition and areal BMD (aBMD). High-resolution peripheral quantitative computed tomography (HR-pQCT) assessed tibial bone densitometry and microarchitecture. Among 116 participants, 40 (34 %) had T2DM with a higher proportion of females (80 %) compared to those without T2DM (63 %). T2DM participants had higher glucose (31 % mmol/L, p < 0.0001), HbA1c (15 %, p < 0.0001) and HOMA-IR (136 %, p < 0.0001), and exhibited lower hand grip strength (11 % ± 10 %, p = 0.036), SPPB scores (5 % ± 2 %, p = 0.044), stair-climb power (5 % ± 2 % W/kg, p = 0.010) and vertical jump power (2 % ± 8 % W/kg, p = 0.038) compared to counterparts. There were no differences between groups for bone outcomes except increased total hip aBMD (10 % ± 0.2 % g/cm², p = 0.026) and trabecular thickness (5 % ± 0.03 % mm, p = 0.017). In all participants, total fat mass was associated with impaired physical function, while appendicular lean mass was positively associated with muscle power but negatively associated with cortical BMD. Older adults with obesity and T2DM demonstrate impaired muscle function and power, but have similar bone health and body composition, compared with those with obesity alone.

Background: Supervised gym-based high-intensity resistance and impact training (HiRIT) can enhance physical function and muscle strength, but older adults may face challenges affecting adherence to HiRIT, such limited access to facilities and lack of transportation, necessitating a shift towards unsupervised home-based exercise. The aim of this study was to explore experiences and perspectives of older adults with obesity who were required to transition from supervised gym-based HiRIT to unsupervised home-based resistance training (RT) and aerobic training (AT) during COVID-19 lockdowns. Secondary aims were to compare changes in body composition and physical function after 12 weeks between participants required to transition to home-based exercise (“HOME”) and those who were able to continue gym-based exercise (“GYM”). Methods: Thirty older adults (60–89 years) with obesity were enrolled from the gym-based HiRIT intervention arm of a 12-week exercise and dietary weight loss trial. Thirteen (43%) participants were transitioned to HOME due to COVID-19 lockdowns. HOME participants were prescribed bodyweight RT and AT exercises, while maintaining the weight loss intervention. Eight HOME participants completed semi-structured interviews post-intervention. Quantitative outcomes including exercise adherence, body composition and physical function were compared to GYM participants. Results: Participants’ experiences and perspectives regarding the HOME program encompassed various elements including accessibility, accountability, maintaining physical activity levels, motivation, support from health care professionals, openness to telehealth videoconferencing for support, engagement, lack of equipment, supervision and a structured routine. Both groups had significant reductions in body mass (mean ± SD; GYM: -4.4 ± 0.4 kg, HOME: -6.2 ± 1.2 kg), but HOME demonstrated greater losses in fat mass (mean difference: -3.1 kg, 95% CI: -6.0, -0.3) compared with GYM represented by a large effect size (d = 0.8). Physical function outcomes improved only in GYM (all P < 0.05). Conclusions: Older adults with obesity transitioning from supervised gym-based to unsupervised home-based exercise face both supportive and challenging experiences. While accessibility and accountability enhanced their engagement, some participants faced difficulties related to limited equipment and digital support, emphasising areas for improvement in home-based exercise interventions. Home-based exercise may be effective for supporting dietary weight loss, but further research is needed to determine if there are any beneficial effects on physical function. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618001146280; date of registration: 12/07/2018.

Managing blood glucose levels and adhering to exercise is challenging for older adults with obesity and type 2 diabetes mellitus (T2DM). Digital voice assistants (DVAs) utilising conversation-based interactions and natural language may overcome barriers to accessing home-based lifestyle programs, but end-user perspectives are essential for implementation. This analysis investigated end-user perspectives on implementation outcomes of a DVA-delivered lifestyle program nested within a randomised controlled trial of 50 older adults (aged 50–75 years) with obesity and T2DM (DVA n = 25; control n = 25). Following trial completion, 10 DVA participants (mean ± SD age 67 ± 4 years) completed semi-structured interviews guided by the Practical Planning for Implementations and Scale-up guide and Proctor’s implementation outcome taxonomy. Over half (60%) were willing to pay for the DVA-delivered program, indicating perceived value. DVA audiovisual and conversation-based modalities enhanced engagement and acceptability. Most end-users found the DVA program feasible as a modality for delivering lifestyle programs, but suggested greater personalisation to bolster sustainability. Overall, the intervention was identified as acceptable and appropriate, suggesting digitally delivered programs may be feasible and sustainable for long-term use. Findings should be interpreted cautiously, given the small sample size and short intervention period. Nevertheless, end-users’ suggestions could inform the implementation of digital health interventions into healthcare systems.