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Abstract
BAUMGARTNER, RICHARD N., SHARON J. WAYNE,
DEBRA L. WATERS, IAN JANSSEN, DYMPNA
GALLAGHER, AND JOHN E. MORLEY. Sarcopenic
obesity predicts instrumental activities of daily living
disability in the elderly. Obes Res. 2004;12:19952004.
Objective: To determine the association of sarcopenic obesity with the onset of Instrumental Activities of Daily Living (IADL) disability in a cohort of 451 elderly men and
women followed for up to 8 years.
Research Methods and Procedures: Sarcopenic obesity
was defined at study baseline as appendicular skeletal muscle mass divided by stature squared 7.26 kg/m2 in men
and 5.45 kg/m2 in women and percentage body fat greater
than the 60th percentile of the study sample (28% body fat
in men and 40% in women). Incident disability was defined
as a loss of two or more points from baseline score on the
IADL. Subjects with disability at baseline (scores 8) were
excluded. Cox proportional hazards analysis was used to
determine the association of baseline sarcopenic obesity
with onset of IADL disability, controlling for potential
confounders.
Results: Subjects with sarcopenic obesity at baseline were
two to three times more likely to report onset of IADL
disability during follow-up than lean sarcopenic or nonsarcopenic obese subjects and those with normal body composition. The relative risk for incident disability in sarcopenic
obese subjects was 2.63 (95% confidence interval, 1.19 to
5.85), adjusting for age, sex, physical activity level, length
of follow-up, and prevalent morbidity.
Discussion: This is the first study, to our knowledge, to
indicate that sarcopenic obesity is independently associated
with and precedes the onset of IADL disability in the
community-dwelling elderly. The etiology of sarcopenic
obesity is unknown but may include a combination of
decreases in anabolic signals and obesity-associated increases in catabolic signals in old age.
Key words: sarcopenic obesity, sarcopenia, obesity, Instrumental Activities of Daily Living disability, aging
Introduction
The prevalence of sarcopenia, or a relative deficiency of
skeletal muscle mass and strength, increases rapidly after 65
years of age and is significantly associated with functional
limitation and physical disability, independent of body fatness, in community-dwelling elderly (1 6). Estimates of
prevalences have varied widely across studies because of
differences in criteria for defining sarcopenia and sample
characteristics, such as age, sex, ethnicity, socioeconomic
status, health status, and body size. The strengths of associations reported have also varied because of differences in
methods of measuring functional limitation and disability
outcomes and the measurement and statistical control of
confounders. With the exception of Janssen et al. (4), who
analyzed data from NHANES III, most study samples have
been small or not strictly population-based, making results
difficult to generalize. Finally, all studies to date have been
cross-sectional, leaving open the question of whether sarcopenia and/or obesity precedes or follows the onset of
disability.
OBESITY RESEARCH Vol. 12 No. 12 December 2004
1995
1
Nonstandard abbreviations: FFM, fat-free mass; IADL, Instrumental Activities of Daily
Living; NMEHS, New Mexico Elder Health Survey; NMAPS, New Mexico Aging Process
Study; NCEP ATPIII, ___; IL-6, interleukin 6; IGF-1, insulin-like growth factor 1.
1996
fat, using criteria similar to, but not identical to, ours and
found no significant associations between sarcopenic obesity and functional limitation.
In this study, we used longitudinal data from the NMAPS
cohort to test the hypothesis that sarcopenic obesity precedes, and therefore predicts, the onset of IADL disability in
community-dwelling elderly who have no disability at baseline. This is the first study that we are aware of to use
longitudinal data to determine the direction of the association between body composition and IADL disability in a
sample of community-dwelling elderly.
Potential Confounders
Physical activity was assessed using a modification of the
self-administered Health Insurance Plan instrument as described by Pereira et al. (24). The scores on this scale range
from 0 to 65, with higher scores indicating greater activity.
We have previously shown that physical activity scores on
this instrument are correlated with body composition (25).
Prevalent diseases were ascertained using a health history
questionnaire administered at study entry. Incident diseases
were obtained by self-report at each annual visit and verified against medical records.
Centralized obesity and the metabolic syndrome are also
potent risk factors for IADL disability and could confound
associations with sarcopenic obesity (26,27). Consequently,
we also created a variable classifying the presence of metabolic syndrome based on National Cholesterol Education
Panel, Adult Treatment Panel III criteria (28). Briefly, a
participant was considered to have the syndrome if they met
three or more of the following criteria: waist circumference
102 cm in men and 88 cm in women; serum triglycerides 150 mg/dL (1.69 mM); high-density lipoproteincholesterol 40 mg/dL (1.04 mM) in men and 50 mg/dL
(1.29 mM) in women; blood pressure 130/85 mm Hg; and
fasting glucose 110 mg/dL ( 6.1 mM).
Statistical Methods
All statistical analyses were conducted using the Statistical Analysis System (SAS Institute, Cary, NC). 2 tests for
proportions and t tests or Wilcoxon rank-sum tests for
means were used to compare body composition and drop in
IADL groups for baseline and follow-up characteristics.
Cox proportional hazards analysis was used to determine
the association of sarcopenic obesity with decline in functional status while controlling for potential confounding
variables, including age, sex, self-reported physical activity,
and morbidity. Because incident IADL disability was recorded at annual intervals, tied event times could occur. As
a result, we used a variation of the Cox model that takes into
consideration tied events caused by the use of a discrete,
rather than continuous, time-scale (SAS Ties Discrete
option). The underlying mathematics can be found in
Therneau and Grambsch (29). We did not stratify the sample for race or ethnicity because the numbers of nonwhite
and Hispanic minorities were too few for meaningful analysis.
Results
Five hundred thirty-six subjects had at least two IADL
scores between 1993 and 2001. Of these, 68 were excluded
because their baseline score was less than eight. Another 17
subjects were excluded because they had no body composition data in the year they had their first IADL score
measured. This left a final sample size of 451.
Twenty-six subjects (5.8%) were classified as sarcopenic
obese at baseline. During the 8-year follow-up period, 77
OBESITY RESEARCH Vol. 12 No. 12 December 2004
1997
By outcome
Percent with IADL drop
Mean (SD) time to IADL drop in years
Demographics
Percent male
Mean (SD) age in years at baseline
Mean (SD) activity score at baseline
Mean (SD) follow-up time in years
Prevalent conditions
Cardiovascular disease
Hypertension
Arthritis/rheumatism
Type 2 diabetes
Metabolic syndrome
Incident conditions
Stroke
Type 2 diabetes
Heart attack
Congestive heart failure
Cancer (excludes basal cell)
Hip fracture
Any fracture
Deaths
Sarcopenic
obese
(N 26)
Sarcopenic
nonobese
(N 82)
Nonsarcopenic
obese
(N 146)
Nonsarcopenic
nonobese
(N 197)
p*
38.5%
1.5 (1.1)
14.6%
2.3 (2.0)
15.1%
2.1 (1.7)
16.8%
2.4 (1.8)
0.027
0.588
61.5%
73.9 (6.6)
18.1 (4.9)
4.5 (2.5)
46.3%
74.0 (6.8)
19.8 (5.7)
4.3 (2.4)
34.2%
71.8 (5.9)
17.9 (5.9)
5.5 (2.4)
34.0%
72.7 (6.3)
20.3 (6.5)
4.7 (2.6)
0.013
0.083
0.006
0.001
11.5%
26.9%
65.4%
7.7%
19.2%
18.3%
17.1%
47.6%
1.2%
3.7%
8.2%
36.3%
50.7%
1.4%
37.5%
13.7%
20.8%
54.3%
1.0%
10.7%
0.159
0.003
0.394
0.076
0.0001
3.8%
0.0%
7.7%
7.7%
7.7%
3.8%
11.5%
7.6%
1.2%
1.2%
3.7%
1.2%
8.5%
0.0%
7.3%
13.4%
2.7%
2.1%
2.7%
0.7%
5.5%
0.0%
10.3%
6.2%
2.5%
1.5%
3.6%
1.0%
4.6%
0.5%
13.7%
10.7%
0.717
0.927
0.567
0.093
0.507
0.145
0.460
0.290
*p Value for difference between sarcopenic obesity groups in percents (2) or means (ANOVA).
Metabolic syndrome defined by NCEP ATPIII criteria.
Demographics
Percent male
Mean age in years at baseline
Mean activity score at baseline
Mean follow-up time in years
Prevalent conditions
Cardiovascular disease
Hypertension
Arthritis/rheumatism
Type 2 diabetes
Metabolic syndrome
Incident conditions
Stroke
Type 2 diabetes
Heart attack
Congestive heart failure
Cancer (excludes basal cell)
Hip fracture
Any fracture
Deaths
IADL drop
(N 77)
No drop in IADL
(N 374)
p*
45.5%
78.0 (6.3)
15.8 (4.8)
5.0 (2.3)
36.6%
71.6 (5.7)
20.1 (6.2)
4.9 (2.6)
0.134
0.0001
0.0001
0.850
16.9%
36.4%
63.6%
3.9%
19.7%
11.8%
23.3%
50.3%
1.1%
18.3%
0.218
0.016
0.032
0.068
0.766
2.6%
0.0%
1.3%
1.3%
5.2%
0.0%
13.0%
28.6%
2.4%
1.9%
4.0%
1.3%
6.7%
0.5%
10.9%
5.6%
0.921
0.226
0.241
0.979
0.628
0.610
0.520
0.001
*p Value for difference between sarcopenic obesity groups in percents (2) or means (ANOVA).
Metabolic syndrome defined by NCEP ATPIII criteria.
for drop in IADL score was 2.91 (95% confidence interval, 1.36 to 6.21) for the sarcopenic obese group. Hazard
ratios for sarcopenic nonobese and nonsarcopenic obese
groups were not significantly different from 1.0. Figure 1
shows age-adjusted Kaplan-Meier survival curves contrasting the four body composition groups, in which the markedly shorter time to drop in IADL in the sarcopenic obese
group is clearly evident. As a result, the other three groups
were combined in the final analyses.
Table 3 shows the results of proportional hazards analyses evaluating the effect of sarcopenic obesity on time to
drop in IADL score. The unadjusted hazard ratio of 3.17
(95% confidence interval, 1.55 to 6.49) indicates a rate of
decline that was three times higher in sarcopenic obese
subjects compared with those who were not sarcopenic
obese at baseline. Adjustment for age, sex, physical activity
score, follow-up time, prevalent hypertension, and arthritis/
rheumatism reduced the hazard ratio to 2.63 (95% confidence interval, 1.19 to 5.85). Cardiovascular disease was
not included in the model because it was not associated with
either body composition type or incident IADL disability.
Sarcopenic obesity remained significantly associated with
OBESITY RESEARCH Vol. 12 No. 12 December 2004
1999
Discussion
Table 3. Hazard ratios and 95% confidence intervals for proportional hazards models evaluating the effect of
sarcopenic obesity and relevant covariates on time to drop in functional status
Unadjusted model
hazard ratio (95% CI)
Sarcopenic obesity
Age in years
Gender (men 1)
Activity score
Follow-up time in years
Prevalent hypertension
Prevalent arthritis/rheumatism
2000
Intermediate model
hazard ratio (95% CI)
2.52
1.13
1.38
0.90
0.83
(1.15,
(1.08,
(0.83,
(0.86,
(0.73,
5.51)
1.18)
2.28)
0.95)
0.95)
Full model
hazard ratio (95% CI)
2.63
1.14
1.43
0.91
0.84
1.80
1.13
(1.19,
(1.09,
(0.85,
(0.87,
(0.74,
(1.06,
(0.66,
5.85)
1.19)
2.40)
0.96)
0.96)
3.06)
1.92)
quent to entry). The corresponding prevalences among nonHispanic whites in the NMEHS were as follows: coronary
heart or cardiovascular disease, 18.2%; hypertension,
32.1%, arthritis, 66.3%; history of cancer, 19.0%. The prevalence of sarcopenic obesity is also similar in the NMAPS
(5.8%) compared with the NMEHS (5%). On the other
hand, the prevalence of three or more self-reported IADL
disabilities is lower in the NAMPS (9.8%) than in the
population-based NMEHS (22%).
Whereas these results support our previously reported
finding in two separate cross-sectional studies that sarcopenic obesity is more strongly associated with IADL
disability than either obesity or sarcopenia (18), it is important to note apparently contradictory evidence. Davison et
al. (20) reported no significant association using data from
NHANES III for 2917 men and women 70 years of age.
Sarcopenia and obesity were defined using criteria similar,
but not identical, to this study; however, the outcome was
functional limitation rather than IADL disability. Functional
limitation was defined as having difficulty with at least
three of the following self-reported items: walking onequarter mile; walking up 10 steps without resting; carrying
10 lbs; stooping, crouching, or kneeling; and standing up
from an armless chair. The authors noted that an important
limitation of their study may have been that percentage
body fat and muscle mass were predicted using published
anthropometric prediction equations (1,34), rather than
measured using DXA, which could have attenuated the
associations. However, Janssen et al. (32) applied the same
prediction equation to estimate muscle mass in NHANES
III and reported significant associations between low relative muscle mass, defined as muscle mass divided by stature
squared, and IADL disability, when adjusting for body fat,
age, race, smoking, alcohol, and comorbidity. This raises
another important issue: disparities among studies for associations may also depend on the definition of the outcomes,
i.e., IADL disability as distinct from functional limitation
and the methods used to measure these. In our previous
cross-sectional studies, we found that sarcopenic obesity
was also significantly associated with abnormalities in performance-based tests of balance and gait and reported falls
in the past year (18).
Type 2 diabetes has been shown to be an important risk
factor for disability in some large cross-sectional studies
(26,27); thus, there was concern that it could be a significant
confounder of the association between sarcopenic obesity
and disability in this study. Few participants in the NMAPS
cohort had prevalent, diagnosed type 2 diabetes at baseline,
and the incidence of this disease was low. Although a
nonsignificant, increased risk for incident disability was
found for type 2 diabetes, this association was not confounded with the risk for sarcopenic obesity. Taken together, these observations strongly suggest that the association of sarcopenic obesity with incident disability is
OBESITY RESEARCH Vol. 12 No. 12 December 2004
2001
Acknowledgments
This work was supported by NIH Grants R01 AG10149
and AG02049.
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