The associations of "fatness," "fitness," and physical activity with all-cause mortality in older adults: A systematic review

Physical activity is associated with lower mortality in adults with obesity: a systematic review with meta-analysis

BACKGROUND

Obesity is a complex chronic disease associated with several adverse health outcomes that increase mortality risk. Physical activity (PA) is recommended for the prevention and treatment of obesity and is related to a decreased risk of cardiovascular disease, cancer and all-cause mortality. This systematic review and meta-analysis estimates the effect of PA levels on mortality (cardiovascular, cancer and all-cause mortality) in adults with obesity.

METHODS

A systematic search was conducted in MEDLINE, Embase, Web of Science and SPORTDiscus from inception to June 2024. Prospective cohort studies that explored the association between PA and mortality in adults with obesity (according to their body mass index, ≥ 30 kg/m2) aged ≥ 18 years were included. Our main outcomes were all-cause mortality, and cardiovascular, and cancer mortality reported in primary studies by hazard ratios or relative risk, which were pooled for the meta-analysis when at least two studies reported the effect estimate for the same outcome. The PRISMA recommendations and the MOOSE guidelines were followed. The reported mortality risk estimates comparing insufficiently active versus active (moderate to very active) adults with obesity were pooled using the DerSimonian and Laird random-effects model.

RESULTS

A total of 9 prospective cohort studies involving 199,425 adults with obesity (age range: 35-85 years) were included, of which 59,873 were insufficiently active and 84,328 were active. Active individuals had a 21% lower risk of all-cause mortality (HR: 0.79, 95%CI: 0.74 to 0.84; I2 = 38.2%), and a 24% lower risk of cardiovascular mortality (HR: 0.76, 95%CI: 0.66 to 0.87; I2 = 0.0%) than insufficiently active individuals. The HR for cancer mortality was 0.91 (95%CI: 0.80 to 1.02; I2 = 0.0%), and although this was mostly consistent with a benefit, it was based on only two studies.

CONCLUSION

Our data support that moderate to high levels of PA are associated with a 21% lower risk of all-cause and 24% cardiovascular disease mortality in adults with obesity. Although data from the only two published studies seem to indicate a protective effect of PA on cancer risk, the estimates are not statistically significant.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022309346.

Enhancing predictive validity of motoric cognitive risk syndrome for incident dementia and all-cause mortality with handgrip strength: insights from a prospective cohort study

Background

This study aimed to assess whether integrating handgrip strength (HGS) into the concept of motoric cognitive risk (MCR) would enhance its predictive validity for incident dementia and all-cause mortality.

Methods

A cohort of 5, 899 adults from the Health and Retirement Study underwent assessments of gait speed, subjective cognitive complaints, and HGS were involved. Over a 10-year follow-up, biennial cognitive tests and mortality data were collected. Cox proportional hazard analyses assessed the predictive power of MCR alone and MCR plus HGS for incident dementia and all-cause mortality.

Results

Patients with MCR and impaired HGS (MCR-HGS) showed the highest adjusted hazard ratios (AHR) for dementia (2.33; 95% CI, 1.49-3.65) and mortality (1.52; 95% CI, 1.07-2.17). Even patients with MCR and normal HGS (MCR-non-HGS) experienced a 1.77-fold increased risk of incident dementia; however, this association was not significant when adjusted for socioeconomic status, lifestyle factors, and medical conditions. Nevertheless, all MCR groups demonstrated increased risks of all-cause mortality. The inclusion of HGS in the MCR models significantly improved predictive discrimination for both incident dementia and all-cause mortality, as indicated by improvements in the C-statistic, integrated discrimination improvement (IDI) and net reclassification indices (NRI).

Conclusion

Our study underscores the incremental predictive value of adding HGS to the MCR concept for estimating risks of adverse health outcomes among older adults. A modified MCR, incorporating HGS, could serve as an effective screening tool during national health examinations for identifying individuals at risk of dementia and mortality.

Advantages and Limitations of the Body Mass Index (BMI) to Assess Adult Obesity

Obesity reflects excessive fat deposits. At-risk individuals are guided by healthcare professionals to eat fewer calories and exercise more, often using body mass index (BMI; weight/height2) thresholds for screening and to guide progress and prognosis. By conducting a mini-narrative review of original articles, websites, editorials, commentaries, and guidelines, we sought to place BMI in the context of its appropriate use in population health, clinical screening, and monitoring in clinical care. The review covers studies and publications through 2023, encompassing consensus reviews and relevant literature. Recent consensus reviews suggest that BMI is a valuable tool for population surveys and primary healthcare screening but has limitations in predicting the risk of chronic diseases and assessing excess fat. BMI can guide nutritional and exercise counseling, even if it is inadequate for reliable individual risk prediction. BMI cut-offs must be reconsidered in populations of varying body build, age, and/or ethnicity. Since BMI-diagnosed overweight persons are sometimes physically and physiologically fit by other indicators, persons who are overweight on BMI should be more fully evaluated, diagnosed, and monitored with combined anthropometric and performance metrics to better clarify risks. The use of combined anthropometric and performance metrics involves integrating measurements of body composition with assessments of physical function and fitness to provide a more comprehensive evaluation of an individual's health and fitness status. Eligibility for bariatric surgery or semaglutide satiety/appetite-reduction medications should not be determined by BMI alone. Awareness of the advantages and limitations of using BMI as a tool to assess adult obesity can maximize its appropriate use in the context of population health and in rapid clinical screening and evaluation.

Association of Body Mass Index with Long-Term All-Cause Mortality in Patients Who Had Undergone a Vertebroplasty for a Vertebral Compression Fracture

We aimed to investigate the association between preoperative body mass index (BMI) and postoperative long-term mortality in patients who underwent a vertebroplasty. We retrospectively enrolled patients with a vertebral compression fracture who underwent a vertebroplasty between May 2013 and June 2020 in a medical center in Taiwan. The survival status of the study sample was confirmed by the end of March 2021. Cox-proportional hazard models were conducted to examine the effects of being overweight/obese (≥25 kg/m2 vs. <25 kg/m2) and BMI (as a continuous variable) on all-cause mortality after adjusting for age, sex, history of smoking, diabetes, hypertension, chronic kidney disease, and osteoporosis. A total of 164 patients were analyzed (mean age 75.8 ± 9.3 years, male 25.6%, mean BMI 24.0 ± 4.1 kg/m2) after a median follow-up of 785 days. Compared with a BMI < 25 kg/m2, a BMI ≥ 25 kg/m2 was associated with a significantly lower risk of all-cause mortality (HR 0.297, 95% CI 0.101 to 0.878, p = 0.028). These findings were consistent when BMI was examined as a continuous variable (HR 0.874, 95% CI 0.773 to 0.988, p = 0.031). A low BMI (<22 kg/m2) should be considered as a risk factor for postoperative long-term mortality in this ageing population.

Body Mass Index Combined With Possible Sarcopenia Status Is Better Than BMI or Possible Sarcopenia Status Alone for Predicting All-Cause Mortality Among Asian Community-Dwelling Older Adults

Background

Body mass index (BMI) and sarcopenia are common indicators of nutritional status. Possible sarcopenia, defined as low muscle strength or performance, was recently introduced by the Asian Working Group for Sarcopenia (AWGS) in 2019. We investigated for association between all-cause mortality and BMI combined with possible sarcopenia severity in Asian older adults.

Methods

This study included a subpopulation (8,195 participants aged ≥60 years; male gender: 49.4%; mean age: 69.2 ± 6.8 years) from the Fourth Thai National Health Examination Survey (NHES-IV). BMI was classified using Asia-Pacific cut-offs. Possible sarcopenia was defined using quadriceps strength based on AWGS 2019 criteria, and possible sarcopenia severity was determined using study population quartile cut-offs. All-cause mortality data was derived from the national vital registry in 2020.

Results

The prevalence of underweight status and possible sarcopenia was 11.8 and 38.9%, respectively. Multivariate analysis showed underweight individuals with severe possible sarcopenia to be at highest risk for increased mortality [adjusted hazard ratio (aHR): 3.98, 95% confidence interval (CI): 2.89-5.48], and higher risk was found in men compared to women (aHR: 5.35, 95% CI: 1.19-8.97). Obese status without possible sarcopenia was an independent protective factor (aHR: 0.61, 95% CI: 0.38-0.97).

Conclusion

BMI combined with possible sarcopenia severity is a better predictor of mortality risk than either parameter alone.

Self-Reported Sleeping Time Effects on Physical Performance and Body Composition Among Spanish Older Adults: EXERNET-Elder 3.0 study

Objective: To determine the link between physical fitness and body composition with nocturnal and nap time in Spanish older adults. Methods: Eight hundred thirty older adults underwent several tests. Sleep was measured using Jenkins Sleep Scale. Nocturnal sleep was categorized (<7, 7-9, and >9 hours), and nap time (no nap, 1-30 minutes, and >30 minutes).Physical fitness was evaluated using validated tests, and body composition by electric bioimpedance. Results: 75.1% of participants were female, mean age 77.7 ± 5.1 years. Mean nocturnal sleep and nap time was 6.7 hours and 23.3 minutes, respectively. Models showed nocturnal sleep >9 hours was significant and positively associated with body shape index (Odds ratio[OR] = 4.07 (p = .011)) and waist circumference OR = 1.04 (p = .024) in females. Males' waist and hip circumference were positively significantly related to nap time between 1 and 30 minutes, OR = 1.08, p = .009 and OR = 1.08, p = .048, respectively. In females, nap time >30 minutes was associated with greater fat mass and body shape index OR = 1.22, p = .032 and OR = 3.95, p = .027, respectively. Physical fitness showed no associations with sleep outcomes. Conclusions: Sleep patterns do not influence physical fitness but body composition, being more related to female body composition as nocturnal and nap sleep were associated with higher fat mass, waist circumference and body shape index, while only short nap times were related to higher waist and hip circumference in males.

Handgrip Strength to Predict the Risk of All-Cause and Premature Mortality in Korean Adults: A 10-Year Cohort Study

The prospective association of muscular weakness with the risk of all-cause and premature mortality in a general population remains unknown. The aim of this study was to investigate the prospective effects of handgrip strength and muscular weakness on risk for all-cause and premature mortality over 10 years using a large nationwide sample of Korean adults. The study participants included 9229 middle and older adults (4131 males and 5098 females), using data from the Korean Longitudinal Study of Ageing 2006-2016. Muscular strength was measured using handgrip strength. Muscle weakness was defined using the sex-specific handgrip strength index based on the Asian Working Group on Sarcopenia in Older People (AWGSOP). The primary outcome was all-cause and premature mortality assessed based on the death certificate. The hazard ratio (HR) for all-cause mortality was negatively associated with level of handgrip strength independent of potential confounding factors (HR: 2.06, 95% confidence interval [CI]: 1.62-2.63 for lowest quartile vs. highest quartile). When examined using muscle weakness defined using the AWGSOP diagnosis, the mortality was 1.56 times higher in the weak group (HR: 1.56, 95% CI: 1.36-1.78). We also found that risk of premature mortality was observed in the lowest quartile (HR: 2.34, 95% CI: 1.80-3.05) and the muscle weakness group (HR: 1.80, 95% CI: 1.52-2.13) in the fully adjusted model. Our 10-year prospective cohort study showed that handgrip strength and muscle weakness are strongly associated with an increased risk of all-cause and premature mortality in healthy middle-aged and older adults.

Effects of a Randomized Home-Based Quality of Movement Protocol on Function, Posture and Strength in Outpatients with Obesity

The aim of this study was to determine the effects of two different home-based training interventions on functional parameters and body composition in obese patients. Sixty-four obese patients were recruited at the IRCCS Istituto Auxologico Italiano and randomly assigned into a movement quality group (MQ) and a conventional training group (CT). In the MQ, the training protocol combined various stimuli based on whole-body movement patterns, mobility, motor control and diaphragmatic breathing. The CT included traditional bodyweight resistance-training exercises. All patients were tested for movement efficiency (Functional Movement Screen, FMS), postural control (Modified Balance Error Scoring System, M-BESS), breathing pattern (Total Faulty Breathing Scale, TFBS), muscular strength (Handgrip Strength Test, HST and Five Repetition Sit to Stand, FRSTS) and body composition (Waist Circumference, WC, Body Mass Index, BMI, Body fat mass percentage, Fat Mass) before and after a 6-week period of training. Significant interactions and main effects of time (p < 0.0001) were found in MQ compared to CT in the FMS, M-BESS and TFBS parameters, while muscular strength (HST, FRSTS) and body composition parameters improved similarly in both groups with a main effect of time (p < 0.05). These findings suggest that a 6-week movement quality training is effective in ameliorating postural control and movement efficiency with similar improvements in muscular strength and body composition compared with a mere traditional home-based training. Fitness coaches and practitioners might consider the MQ intervention as a valuable alternative to conventional training when treating obesity.

Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks

We propose a weight-neutral strategy for obesity treatment on the following grounds: (1) the mortality risk associated with obesity is largely attenuated or eliminated by moderate-to-high levels of cardiorespiratory fitness (CRF) or physical activity (PA), (2) most cardiometabolic risk markers associated with obesity can be improved with exercise training independent of weight loss and by a magnitude similar to that observed with weight-loss programs, (3) weight loss, even if intentional, is not consistently associated with lower mortality risk, (4) increases in CRF or PA are consistently associated with greater reductions in mortality risk than is intentional weight loss, and (5) weight cycling is associated with numerous adverse health outcomes including increased mortality. Adherence to PA may improve if health care professionals consider PA and CRF as essential vital signs and consistently emphasize to their patients the myriad benefits of PA and CRF in the absence of weight loss.

Fitness vs. fatness as determinants of survival in non-institutionalized older adults: The EXERNET multi-center study

BACKGROUND

Physical fitness and body composition are important health indicators, nevertheless their combined pattern inter-relationships and their association with mortality are poorly investigated.

METHODS

This longitudinal study is part of the Spanish EXERNET-Elder project. Person-months follow-up were calculated from the interview date, performed between June 2008 and November 2009, until date of death or censoring on March 2018 (whichever came first). In order to be included, participants had to fulfill the following criteria: 1) be over 65 years old, 2) live independently at home, 3) not suffer dementia and/or cancer and 4) have a BMI above 18.5. Body fat and weight were assessed by a bioelectrical impedance analyzer. Fitness was measured with the Senior Fitness and the one leg static balance tests. The Spanish Death Index was consulted for the death's identification. Cluster analysis was performed to identify Fat-Fit patterns and traditional cut points and percentiles to create the Fat-Fit groups. Cox proportional hazards regression models were used to calculate the hazard ratios of death in clustered Fat-Fit patterns and in traditional Fat-Fit groups.

RESULTS

A total of 2299 older adults (76.8% of women) were included with a baseline mean age of 71.9 ± 5.2 years. A total of 196 deaths (8.7% of the sample) were identified during the 8 years of follow up. Four clustered Fat-Fit patterns (Low fat-Fit, Medium fat-Fit, High fat-Unfit and Low fat-Unfit) and nine traditional Fat-Fit groups emerged. Using the Low fat-Fit pattern as the reference, significantly increased mortality was noted in High fat-Unfit (HR: 1.68, CI: 1.06 - 2.66) and Low fat-Unfit (HR: 2.01, CI: 1.28 - 3.16) groups. All the traditional Fit groups showed lower mortality risk when compared to the reference group (obese-unfit group).

CONCLUSIONS

Physical fitness is a determinant factor in terms of survival in community-dwelling older adults, independently of adiposity levels.

Plasma Interleukin-10 and Cholesterol Levels May Inform about Interdependences between Fitness and Fatness in Healthy Individuals

Relationships between demographic, anthropometric, inflammatory, lipid and glucose tolerance markers in connection with the fat but fit paradigm were investigated by supervised and unsupervised learning. Data from 81 apparently healthy participants (87% females) were used to generate four classes of fatness and fitness. Principal Component Analysis (PCA) revealed that the principal component was preponderantly composed of glucose tolerance parameters. IL-10 and high-density lipoprotein, low-density lipoprotein (LDL), and total cholesterol, along with body mass index (BMI), were the most important features according to Random Forest based recursive feature elimination. Decision Tree classification showed that these play a key role into assigning each individual in one of the four classes, with 70% accuracy, and acceptable classification agreement, κ = 0.54. However, the best classifier with 88% accuracy and κ = 0.79 was the Naïve Bayes. LDL and BMI partially mediated the relationship between fitness and fatness. Although unsupervised learning showed that the glucose tolerance cluster explains the highest quote of the variance, supervised learning revealed that the importance of IL-10, cholesterol levels and BMI was greater than the glucose tolerance PCA cluster. These results suggest that fitness and fatness may be interconnected by anti-inflammatory responses and cholesterol levels. Randomized controlled trials are needed to confirm these preliminary outcomes.

Resistance Training Improves a Cellular Health Parameter in Obese Older Women: A Randomized Controlled Trial

Ribeiro, AS, Schoenfeld, BJ, dos Santos, L, Nunes, JP, Tomeleri, CM, Cunha, PM, Sardinha, LB, and Cyrino, ES. Resistance training improves a cellular health parameter in obese older women: a randomized controlled trial. J Strength Cond Res 34(10): 2996-3002, 2020-Phase angle (PhA) is a viable indicator of cellular health, with higher values reflecting better cellularity, cell membrane integrity, and cell function. Adaptive responses to resistance training (RT) on PhA may be important in obese older people. The main purpose of the present study was to investigate the effects of 8 weeks of RT on PhA in obese older women. Thirty-three obese older women (68.1 ± 5.7 years, 71.6 ± 10.1 kg, 154.5 ± 6.7 cm, 30.0 ± 4.1 kg·m, and 45.0 ± 6.0% body fat) were randomly allocated into 1 of 2 groups: a training group that performed the RT program (TG, n = 18) or a nonexercise control group (CG, n = 15). The whole-body RT consisted of an 8-week RT program involving 8 exercises performed for 3 sets of 8-12 repetitions 3 times a week. Anthropometric, body fat and fat-free mass, PhA, total body water (TBW), intracellular water (ICW), and extracellular water compartments were performed at before and after training. After the intervention period, the TG presented greater increases (p < 0.05) than CG for fat-free mass (TG = +1.3% and CG = -0.3%), TBW (TG = +2.0% and CG = -1.7%), ICW (TG = +3.1% and CG = -1.9%), and PhA (TG = +3.4% and CG = -1.4%), and lower values for percentage of body fat (TG = -1.3% and CG = +0.9%) and bioimpedance resistance (TG = -4.6% and CG = +2.3%). Our results suggest that 8 weeks of RT improves PhA-a cellular health parameter-in obese older women.

Sarcopenia, Diet, Physical Activity and Obesity in European Middle-Aged and Older Adults: The LifeAge Study

The revised European consensus defined sarcopenia as a progressive and generalized skeletal muscle disorder that is associated with an increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality. The aim of this study was to determine the prevalence of sarcopenia and analyse the influence of diet, physical activity (PA) and obesity index as risk factors of each criteria of sarcopenia. A total of 629 European middle-aged and older adults were enrolled in this cross-sectional study. Anthropometrics were assessed. Self-reported PA and adherence to the Mediterranean diet were evaluated with the Global Physical Activity Questionnaire (GPAQ) and Prevention with Mediterranean Diet questionnaire (PREDIMED), respectively. The functional assessment included handgrip strength, lower body muscle strength, gait speed and agility/dynamic balance. Of the participants, 4.84% to 7.33% showed probable sarcopenia. Sarcopenia was confirmed in 1.16% to 2.93% of participants. Severe sarcopenia was shown by 0.86% to 1.49% of participants. Male; age group ≤65 years; lower body mass index (BMI); high levels of vigorous PA; and the consumption of more than one portion per day of red meat, hamburgers, sausages or cold cuts and/or preferential consumption of rabbit, chicken or turkey instead of beef, pork, hamburgers or sausages (OR = 0.126-0.454; all p < 0.013) resulted as protective factors, and more time of sedentary time (OR = 1.608-2.368; p = 0.032-0.041) resulted as a risk factor for some criteria of sarcopenia. In conclusion, age, diet, PA, and obesity can affect the risk of having low muscle strength, low muscle mass or low functional performance, factors connected with sarcopenia.

Examining the obesity paradox: A moderating effect of fitness on adipose endocrine function in older adults

Despite evidence linking obesity with increased mortality, older adults with excessive adiposity seem protected, resulting in a so-called obesity paradox. Obesity is characterized by leptin resistance, which contributes to increased risk of all-cause mortality. Therefore, lifestyle factors, such as physical fitness, that lower leptin independent of adiposity may be confounding the obesity paradox. To investigate this, we evaluated whether physical fitness moderated the relationship between leptin and adiposity. We found older adults with higher fitness had lower body mass (r(39) = -0.43, p < 0.01), leptin (r(39) = -0.29, p = 0.03) and inflammation (IL-1β: (r(39) = -0.69, p < 0.01); TNF-α: (r(39) = -0.30, p = 0.03)). Fitness moderated the relationship between leptin and adiposity (F(5, 37) = 3.73, p < 0.01, R² = 0.33) to reveal the obesity paradox in moderately and high fit individuals (b = 216.24, t(37) = 1.46, p = 0.15; b= -88.10, t(37) = -0.49, p = 0.63) but not in low fit individuals. These results show the link between obesity and mortality may not be dependent on total adiposity, but rather on endocrine function and adipocyte leptin secretion. These results have important implications for older adults struggling to maintain healthy body composition and suggest that fitness may promote overall wellbeing.

Body mass index and all-cause mortality in older adults: A scoping review of observational studies

In older age, body composition changes as fat mass increases and redistributes. Therefore, the current body mass index (BMI) classification may not accurately reflect risk in older adults (65+). This study aimed to review the evidence on the association between BMI and all-cause mortality in older adults and specifically, the findings regarding overweight and obese BMI. A systematic search of the OVID MEDLINE and Embase databases was conducted between 2013 and September 2018. Observational studies examining the association between BMI and all-cause mortality within a community-dwelling population aged 65+ were included. Seventy-one articles were included. Studies operationalized BMI categorically (n = 60), continuously (n = 8) or as a numerical change/group transition (n = 7). Reduced risk of mortality was observed for the overweight BMI class compared with the normal BMI class (hazard ratios [HR] ranged 0.41-0.96) and for class 1 or 2 obesity in some studies. Among studies examining BMI change, increases in BMI demonstrated lower mortality risks compared with decreases in BMI (HR: 0.83-0.95). Overweight BMI classification or a higher BMI value may be protective with regard to all-cause mortality, relative to normal BMI, in older adults. These findings demonstrate the potential need for age-specific BMI cut-points in older adults.

Edentulism and all-cause mortality among Brazilian older adults: 11-years follow-up

We assessed the association between edentulism and all-cause mortality among community-dwelling older adults from São Paulo, Brazil, from 2006 to 2017. This prospective cohort study used data from the Health, Well-being and Aging Study (SABE, Portuguese acronym). Edentulism was evaluated by means of clinical oral examination and all-cause mortality data were obtained from state official records. Covariates included socioeconomic factors (age, sex, and schooling); health behavior (smoking, alcohol intake, and physical activity); dental care (prostheses use); general health (multimorbidity); and nutritional status (underweight). Kaplan-Meier survival curves were stratified by edentulism and compared using the log-rank test. Cox proportional hazards model was applied to calculate hazard ratios (HRs) for the association between edentulism and mortality after adjusting for covariates. The study sample included 1,687 participants (age, 60-102 years; edentulous: 47.2%). In the 11 years of follow-up, we analyzed 10,494 person-years and 566 deaths. In bivariate analysis, edentulous older adults were found to be at a higher risk of dying from all causes than the dentate participants (HR: 1.81; 95%CI: 1.53-2.15). After sequential adjustment for socioeconomic factors, health behavior, dental care, general health, and nutritional status, this association was attenuated, but remained significant (HR: 1.34; 95%CI: 1.10-1.63). In conclusion, edentulism is a significant predictor of all-cause mortality among older adults.

Is fatness or fitness key for survival in older adults with intellectual disabilities?

BACKGROUND

Overweight/obesity and poor physical fitness are two prevalent lifestyle-related problems in older adults with intellectual disabilities, which each require a different approach. To improve healthy ageing, we assessed whether fatness or fitness is more important for survival in older adults with intellectual disabilities.

METHODS

In the HA-ID study, we measured obesity and fitness of 874 older adults with intellectual disabilities (61.4 ± 7.8 years). All-cause mortality was assessed over a 5-year follow-up period.

RESULTS

Fitness, but not obesity, was significantly related to survival (HR range of 0.17-0.22). People who were unfit were 3.58 (95% CI = 1.72-7.46) to 4.59 (95% CI = 1.97-10.68) times more likely to die within the follow-up period than people who were fit, regardless of obesity.

CONCLUSION

This was the first study to show that being fit is more important for survival than fatness in older adults with intellectual disabilities. The emphasis should, therefore, shift from weight reduction to improving physical fitness.

Mortality risk remains higher in individuals with type 1 diabetes: A population-based cohort study (the Ayrshire diabetes follow-up cohort [ADOC])

AIMS

Type 1 diabetes is associated with an increased risk of cardiovascular disease and all-cause mortality. Numerous studies have demonstrated that outcomes for diabetes are improved by intensive glycaemic control, blood pressure control, and treatment of dyslipidaemia in addition to cessation of smoking. The aim of this study was to compare mortalities in individuals with type 1 diabetes with that in non-diabetic individuals, and to investigate the effects of age, gender, glycaemic control, socio-economic status, hypertension, ischaemic heart disease (IHD), smoking status, body mass index (BMI) and dyslipidaemia.

METHODS

A population-based analysis in Ayrshire and Arran, Scotland included 253 304 non-diabetic individuals and 1324 individuals with type 1 diabetes who were tracked from 2009 to 2014.

RESULTS

Patients with type 1 diabetes had higher mortality rates than non-diabetic individuals (HR, 3.20; P < .01), with relative mortality in female individuals with type 1 diabetes being higher than that in males (OR, 2.38 vs 1.52; P < .01). Increasing age (HR, 2.37), smoking (HR, 1.85), IHD (HR, 1.62) and hypertension (HR, 1.21) (all P < .01) increased mortality risk. A hypertensive female with type 1 diabetes and IHD who smoked had an HR of 11.6 compared with a non-smoking, normotensive non-diabetic female without IHD. For a hypertensive male with type 1 diabetes and IHD who smoked, HR was 6.96. BMI > 30 kg/m² was associated with reduced mortality risk in both non-diabetic (HR, 0.61) and diabetic subjects (HR, 0.40).

CONCLUSIONS

This study confirmed that the risk of mortality in individuals with type 1 diabetes remains elevated. Further studies are required to understand how gender affects the disparity in mortality and why obesity appears to be protective.

Joint association between body fat and its distribution with all-cause mortality: A data linkage cohort study based on NHANES (1988-2011)

Objective

Although obesity is recognized as an important risk of mortality, how the amount and distribution of body fat affect mortality risk is unclear. Furthermore, whether fat distribution confers any additional risk of mortality in addition to fat amount is not understood.

Methods

This data linkage cohort study included 16415 participants (8554 females) aged 18 to 89 years from National Health and Nutrition Examination Survey III (1988–1994) and its linked mortality data (31 December 2011). Cox proportional hazard models and parametric survival models were used to estimate the association between body fat percentage (BF%), based on bioelectrical impedance analysis, and waist-hip ratio (WHR) with mortality.

Results

A total of 4999 deaths occurred during 19-year follow-up. A U-shaped association between BF% and mortality was found in both sexes, with the adjusted hazard ratios for other groups between 1.02 (95% confidence interval: 0.89, 1.18) and 2.10 (1.47, 3.01) when BF% groups of 25–30% in males and 30–35% in females were used as references. A non-linear relationship between WHR and mortality was detected in males, with the adjusted hazard ratios among other groups ranging from 1.05 (0.94, 1.18) to 1.52 (1.15, 2.00) compared with the WHR category of 0.95–1.0. However in females, the death risk constantly increased across the WHR spectrum. Joint impact of BF% and WHR suggested males with BF% of 25–30% and WHR of 0.95–1.0 and females with BF% of 30–35% and WHR <0.9 were associated with the lowest mortality risk and longest survival age compared with their counterparts in other categories.

Conclusions

This study supported the use of body fat distribution in addition to fat amount in assessing the risk of all-cause mortality.

Abdominal Obesity and Mobility Disability in Older Adults: A 4-Year Follow-Up the International Mobility in Aging Study

BACKGROUND

Abdominal obesity is related to the disability process in older adults, however, little is known about this relationship when adjusted for important confounders such as depression and physical performance measures in a diverse international aged population.

OBJECTIVES

To explore the longitudinal relationship between abdominal obesity and mobility disability controlling for physical performance and depression.

DESIGN AND SETTING

Longitudinal observational study using data from the International Mobility in Aging Study (IMIAS) Study.

PARTICIPANTS

1104 out of 2002 older adults aged 64-74 years old free of mobility disability at baseline (2012) and then reassessed in 2016.

MEASUREMENTS

Mobility disability was defined as reporting difficulty in walking 400 m or climbing stairs. Activities of daily living (ADL) disability was based on any self-reported difficulty in five mobility-related ADLs. Abdominal obesity was defined as waist circumference ≥ 88cm for women or ≥ 102 cm for men. Four meters gait speed, handgrip strength and depressive symptoms (CES-D) were assessed. Generalized Estimating Equations (GEE) and multinomial regressions were used to estimate associations between disability and abdominal obesity.

RESULTS

1104 free of disability participants were followed over 4 years, the mean age was 68.9 (±2.9) years among men and 68.7 (±2.6) years among women. Prevalence and incidence rates of mobility disability varied widely across research site and sex. The longitudinal associations between mobility disability and abdominal obesity remained significant even when adjusted by depressive symptoms, handgrip strength, gait speed, age, sex, education and research site. Participants with abdominal obesity had higher mobility disability (OR=1.68, 95% CI 1.23-1.76, p-value=0.01) and also increased risk for ADL disability (OR: 1.47, 95% CI 1.23-1.76, p-value=0.01). Abdominal obesity in baseline was also predictor of mobility disability in 2016 (OR: 1.93, 95% CI 1.17-3.17, p-value <0.01) but not for ADL disability (OR: 1.59, 95% CI 0.93-2.71, p-value =0.09) with accounting mortality.

CONCLUSION

Abdominal obesity is associated longitudinally and predicts mobility disability, even over a short period (4 years) in community-dwelling older adults from different epidemiological contexts.

Beyond Body Mass Index: Using Anthropometric Measures and Body Composition Indicators to Assess Odds of an Endometriosis Diagnosis

BACKGROUND

Body mass index (BMI) and endometriosis have been inversely associated. To address gaps in this research, we examined associations among body composition, endometriosis, and physical activity.

MATERIALS AND METHODS

Women from 14 clinical sites in the Salt Lake City, Utah and San Francisco, California areas and scheduled for laparoscopy/laparotomy were recruited during 2007-2009. Participants (N = 473) underwent standardized anthropometric assessments to estimate body composition before surgery. Using a cross-sectional design, odds of an endometriosis diagnosis (adjusted odds ratio [aOR]; 95% confidence interval [CI]) were calculated for anthropometric and body composition measures (weight in kg; height in cm; mid upper arm, waist, hip, and chest circumferences in cm; subscapular, suprailiac, and triceps skinfold thicknesses in mm; arm muscle and fat areas in cm²; centripetal fat, chest-to-waist, chest-to-hip, waist-to-hip, and waist-to-height ratios; arm fat index; and BMI in kg/m²). Physical activity (metabolic equivalent of task-minutes/week) and sedentariness (average minutes sitting on a weekday) were assessed using the International Physical Activity Questionnaire-Short Form. Measures were modeled continuously and in quartiles based on sample estimates. Adjusted models were controlled for age (years, continuous), site (Utah/California), smoking history (never, former, or current smoker), and income (below, within 180%, and above of the poverty line). Findings were standardized by dividing variables by their respective standard deviations. We used adjusted models to examine whether odds of an endometriosis diagnosis were moderated by physical activity or sedentariness.

RESULTS

Inverse relationships were observed between endometriosis and standardized: weight (aOR = 0.71, 95% CI 0.57-0.88); subscapular skinfold thickness (aOR = 0.79, 95% CI 0.65-0.98); waist and hip circumferences (aOR = 0.79, 95% CI 0.64-0.98 and aOR = 0.76, 95% CI 0.61-0.94, respectively); total upper arm and upper arm muscle areas (aOR = 0.76, 95% CI 0.61-0.94 and aOR = 0.74, 95% CI 0.59-0.93, respectively); and BMI (aOR = 0.75, 95% CI 0.60-0.93), despite similar heights. Women in the highest versus lowest quartile had lower adjusted odds of an endometriosis diagnosis for: weight; mid-upper arm, hip, and waist circumferences; total upper arm and upper arm muscle areas; BMI; and centripetal fat ratio. There was no evidence of a main effect or moderation of physical activity or sedentariness.

CONCLUSION

In a surgical cohort, endometriosis was inversely associated with anthropometric measures and body composition indicators.

Body Mass Index and Mortality

Although the prevalence of obesity, a well-known risk factor for various chronic diseases such as hypertension, type 2 diabetes and dyslipidemia, is rapidly increasing worldwide, the association of obesity with all-cause mortality remains controversial. Many previous epidemiologic studies have demonstrated a U-shaped relationship between obesity and mortality, suggesting that there is an obesity paradox. However, recent large-scale meta-analyses found contradictory results that both overweight and obese subjects exhibited a significant increase in all-cause mortality. This review summarizes the key epidemiologic studies on the association of obesity with mortality and thoroughly examines the causes of the obesity paradox and the precautions needed in the interpretation of this clinical evidence.

The protective effects of a novel fitness-fatness index on all-cause mortality among adults with cardiovascular disease

BACKGROUND

We evaluated the specific association between a fitness-fatness index (FFI) and all-cause mortality among a national sample of US adults with coronary artery disease, congestive heart failure, or myocardial infarction. This FFI has recently emerged in the literature as a novel index of health.

HYPOTHESIS

We hypothesize that FFI will be inversely associated with mortality risk.

METHODS

The FFI was calculated as cardiorespiratory fitness divided by waist-to-height ratio. Data from the 1999-2006 National Health and Nutrition Examination Survey were used to identify 1206 participants, ages 20 to 85. Person-months of follow-up were calculated from the date of interview until date of death or censoring on December 31, 2011, whichever came first.

RESULTS

In a Cox proportional hazards model, for every 1-FFI-unit increase, participants had a 6% reduced all-cause mortality rate (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.91-0.97, P = 0.001; N = 1206). Results were similar among those diagnosed with coronary artery disease (HR: 0.94, 95% CI: 0.90-0.98, P = 0.007), congestive heart failure (HR: 0.95, 95% CI: 0.91-0.99, P = 0.02), or myocardial infarction (HR: 0.96, 95% CI: 0.92-0.99, P = 0.04). When examined in isolation, only fitness (and not fatness) was linked with survival benefits.

CONCLUSIONS

In this national sample, increased FFI was associated with reduced risk of all-cause mortality; this association was driven by the beneficial effects of fitness. This underscores the importance of tailored cardiac rehabilitation programs designed to promote fitness, in particular, among cardiac populations.

The obesity paradox: is it really a paradox? Hypertension

This article is a narrative overview of the role of hypertension on the relationships between obesity, morbidity, and mortality. We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from inception to March 2016. Key words include overweight, obesity, visceral obesity, obesity paradox, and hypertension. In addition, we hand-searched references from the retrieved articles. This work is one of the works of the topical collection "Obesity Paradox". The positive association between overweight, obesity, and cardiovascular diseases is well established, though this relation is typically U shaped with an increased risk in low-weight subjects or even a beneficial effect of overweight and obesity, the so-called "obesity paradox". In addition, the relationship between obesity and arterial hypertension has been demonstrated in both children and adults by many epidemiological studies. Moreover, weight reduction is followed by a decrease in blood pressure in many patients and ameliorates the cardiovascular risk profile. Recent studies using more appropriate obesity indices raise some doubt about the real significance of obesity paradox and there are several studies that central obesity shows either no protective or even a worse effect. These observations raise the question: what kind of obesity is protective and what kind of obesity is harmful? The studies of obesity paradox suffer from several methodological limitations: most of these are retrospective analyses or were not specifically designed to study obesity paradox as a primary goal; a few studies have data on preceding unintentional weight loss and on some particular confounding variables. In conclusion, more prospective and accurate studies are necessary to better elucidate the clinical importance of obesity paradox. When weight loss is functional to reduce hypertension and cardiovascular risk, it should be encouraged, while an unintentional weight in a patient with chronic diseases may indicate an unfavorable course.

From the BMI paradox to the obesity paradox: the obesity-mortality association in coronary heart disease

Despite a strong association between body weight and mortality in the general population, clinical evidence suggests better clinical outcome of overweight or obese individuals with established coronary heart disease. This finding has been termed the 'obesity paradox', but its existence remains a point of debate, because it is mostly observed when body mass index (BMI) is used to define obesity. Inherent limitations of BMI as an index of adiposity, as well as methodological biases and the presence of confounding factors, may account for the observed findings of clinical studies. In this review, our aim is to present the data that support the presence of a BMI paradox in coronary heart disease and then explore whether next to a BMI paradox a true obesity paradox exists as well. We conclude by attempting to link the obesity paradox notion to available translational research data supporting a 'healthy', protective adipose tissue phenotype. © 2016 World Obesity.