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Carlin L, McPherson G, Davison R. The International Classification of Functioning Disability and Health Framework (ICF): a new approach to enhance sport and physical activity participation among people with disabilities in Scotland. Front Sports Act Living 2024; 6:1225198. [PMID: 38558859 PMCID: PMC10978736 DOI: 10.3389/fspor.2024.1225198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
This research provides a pilot study of the International Classification of Functioning Disability and Health Framework (ICF) involving persons with disabilities (PWD) with and without lived experience of sport participation in Scotland. National surveys in Scotland provide limited information on the nature of individual disability restricting the understanding of the relationship between disability and sport and physical activity participation. The ICF is a framework that aims to describe and classify functioning and thus can be used as a tool to provide a more detailed description of impairment for PWDs beyond their clinical condition. This knowledge has the potential to enhance the development of policies to increase the participation levels in this group. The ICF has also been used to inform the current IPC classification system at a competitive and elite level. As part of a larger study, 450 participants aged between 12 and 70 years completed an online questionnaire examining attitudes to, and participation in, sport and physical activity as well as completing the structural and functional components of the ICF. Subsequently, 18 people participated in focus groups aged between 13 and 61 years. The focus groups examined four meta-theme areas: physical, social, psychological, and sport-specific factors. The results confirm that the ICF provided a more detailed indicator of the key impairments that could have an impact on sport and physical activity participation. There was a clear lack of awareness of the links between the ICF and the classification system for competitive parasport. We concluded that a modified ICF-based assessment tool, incorporating social and environmental factors, has the potential to predict the likelihood of participation and offers a more comprehensive picture of both individual and national disability characteristics. This allows for the development of targeted policies and strategies to assist those with a disability to participate in sport. The overall framework presents a shift in thinking, in policy terms, for those in public health and in sport governance and delivery. The significance of this work is especially concerned with public health and wellbeing and sport development policy as pathways from recreational sport user to elite athlete parasport classification and performance.
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Affiliation(s)
- Liz Carlin
- Centre for Culture Sport and Events, University of the West of Scotland, Paisley, United Kingdom
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Yao Y, Liu W, Zhang X, Su N, Huang L, Nong Y, Xiao X, Liu F. Normal weight obesity is associated with lower AFC and adverse IVF outcomes. Front Endocrinol (Lausanne) 2024; 15:1332995. [PMID: 38455649 PMCID: PMC10917978 DOI: 10.3389/fendo.2024.1332995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/08/2024] [Indexed: 03/09/2024] Open
Abstract
Background Body weight could be classified into underweight, normal weight and overweight according to percentage of body fat (%BF), and normal weight obesity (NWO) is defined as a normal BMI but a high %BF. While the impact of NWO in women fecundity remain unknow. Therefore, this study aimed to investigate the associations between %BF and reproductive outcomes among in vitro fertilization (IVF) women with normal BMI. Methods A total of 469 women were included in this study and were classified into low %BF, normal %BF and high %BF according to previous study. Multivariate generalized regression models were employed to evaluate the associations of %BF with ovarian reserve parameters, IVF outcomes and early pregnancy outcomes. We further run sensitivity analyses by restricted the analysis to young women and those only with tubal factor, respectively. Results About 32.2% of normal BMI women were misclassified according %BF, with 16.4% of them were low %BF and 15.8% were high %BF. The high %BF group had significantly lower antral follicle count (AFC) than normal %BF groups, and the AFC showed a tendency of decrease as %BF increased. In sensitivity analysis in young women, high %BF group also had significantly lower number of good-quality embryos when compared to normal %BF groups. The results expanded to all IVF outcomes when analysis restricted to tubal factor women. Conclusion In summary, misclassifications of body weight status based on BMI are common according to %BF, and NWO is associated with adverse reproductive outcomes.
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Affiliation(s)
- Yangcheng Yao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wenjuan Liu
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xiqian Zhang
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
| | - Nianjun Su
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
| | - Li Huang
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
| | - Yingqi Nong
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xiaomin Xiao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Fenghua Liu
- Center for Reproductive Medicine, Guangdong Women and Children Hospital, Guangzhou, China
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Bechlioulis A, Markozannes G, Chionidi I, Liberopoulos E, Naka KK, Ntzani EE, Liatis S, Rizzo M, Rizos EC. The effect of SGLT2 inhibitors, GLP1 agonists, and their sequential combination on cardiometabolic parameters: A randomized, prospective, intervention study. J Diabetes Complications 2023; 37:108436. [PMID: 36842186 DOI: 10.1016/j.jdiacomp.2023.108436] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/02/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Pulse wave velocity (PWV) and augmentation index (AIx) are indices used to assess arterial stiffness. We aim to compare the effect of empagliflozin, liraglutide and their sequential combination on arterial stiffness indices in patients with type 2 diabetes (T2D). METHODS This was a randomized single blind study evaluating the effect of empagliflozin vs liraglutide in adult patients with T2D. Patients were randomized to liraglutide titrated gradually to 1.8 mg or empagliflozin 25 mg in 1:1 ratio. Three months later empagliflozin was added to the liraglutide group, and liraglutide was added to the empagliflozin group. Patients were assessed with non-invasive tests for arterial stiffness (i.e., carotid-femoral PWV and AIx of aortic pressure) at baseline, 3-month and 9-month visits (final visit was extended for 3 months from the initial design due to Covid 19 pandemic). The primary outcome was the between-group difference of PWV change (ΔPWV) and ΔAIx at 3 months. Secondary outcomes included the between-group difference of ΔPWV and ΔAIx at 9 months, as well as the ΔPWV and ΔAIx between baseline and 9-month visit when total study population was assessed. RESULTS A total of 62 patients with T2D (30 started liraglutide; 32 empagliflozin, mean age 63 years, 25 % with established cardiovascular disease) participated in the study. We failed to show any significant between-group differences of ΔPWV and ΔΑΙx at 3 and 9 months, as well as between-group difference of ΔPWV and ΔAIx for the total study population between baseline and 9-month visit. In contrast, systemic vascular resistance and lipoprotein(a) levels improved, showing better results with liraglutide than empagliflozin. Favorable effects were also observed on body weight, body mass index, body and visceral fat, blood pressure, HbA1c, and uric acid levels. CONCLUSION No evidence of a favorable change in arterial stiffness indices was seen with empagliflozin or liraglutide or their combination in this study. Well-designed powerful studies are needed to address any potential effects on arterial stiffness in selected populations.
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Affiliation(s)
- Aris Bechlioulis
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Georgios Markozannes
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Ifigeneia Chionidi
- Diabetes Outpatient Clinic, University Hospital of Ioannina, Ioannina, Greece
| | - Evangelos Liberopoulos
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina K Naka
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Evangelia E Ntzani
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; Center for Evidence-Based Medicine, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Stavros Liatis
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Manfredi Rizzo
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Palermo, Palermo, Italy
| | - Evangelos C Rizos
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece; School of Medicine, European University Cyprus, Nicosia, Cyprus.
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Kivlehan E, Gaebler-Spira D, Chen L, Garrett A, Wysocki N, Marciniak C. Relationship of anthropometric measurements and percent body fat mass to cardiovascular disease risk factors in adults with cerebral palsy. PM R 2023; 15:192-202. [PMID: 35235238 DOI: 10.1002/pmrj.12797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Adults with cerebral palsy (CP) face high morbidity from cardiovascular disease (CVD). Of concern, classic screening parameters are inconsistent in identifying CVD risk in this population. Dual-energy x-ray absorptiometry (DEXA), which provides direct measurements of fat mass (FM), may be an alternative screening method. OBJECTIVE To evaluate whether FM measurement with DEXA is feasible in screening adults with CP and compare FM and anthropometric measures to CVD risk factors. DESIGN Cross-sectional study. SETTING Outpatient rehabilitation hospital. PARTICIPANTS Forty-seven adults with CP. MAIN OUTCOME MEASURES Weight, height, waist circumference (WC), and hip circumference (HC) were measured; waist-to-hip ratio (WHR) and body mass index (BMI) were calculated. Blood pressure (BP), FM by DEXA, hemoglobin A1c (HbA1c), and lipid measurements were obtained. Logistic regression models investigated odds ratios (ORs) and 95% confidence intervals (CIs) between anthropometric measurements/FM and CVD risk factors; correlations were assessed using Pearson correlation coefficients. RESULTS Elevated BP or hypertension diagnosis was present in 47.8%; HbA1c ≥5.7% in 22.2%; and high-density lipoprotein (HDL) level below optimal for 33.3%. DEXA FM was obtained in 29 of 47 participants, as surgical metal and positioning limited many studies. Excess FM was noted in 75.9% versus 41.3% overweight/obese by BMI. WC correlated with HbA1c (r = 0.46, p = .002), HDL (r = -0.36, p = .018), and triglyceride (TG) levels (r = 0.30, p = .045); however at-risk WC values were associated only with odds of elevated HbA1c (OR 8.53, 95% CI 1.46-50.05; p = .018). HC correlated with HbA1c levels (r = 0.38, p = .011) and systolic BPs (r = 0.35, p = .019); similarly, ORs for elevated HC were weakly associated with elevated HbA1c and BPs (OR 1.08, 95% CI 1.01-1.16; p = .024 and OR 1.07, 95% CI 1.01-1.14; p = .024, respectively). WHR correlated with TGs; however few TG levels were elevated. FM measures were not associated with at-risk lab values or BPs. CONCLUSIONS DEXA FM measurements may not be feasible for CVD screening in many adults with CP. Although CVD risk factors are frequently present, anthropometric measurements commonly used for general population screening may not translate well to adults with CP.
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Affiliation(s)
- Emily Kivlehan
- Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Gaebler-Spira
- Shirley Ryan AbilityLab, Chicago, Illinois, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Pediatric Rehabilitation, Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | - Liqi Chen
- Biostatistics Collaboration Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Nicole Wysocki
- Shirley Ryan AbilityLab, Chicago, Illinois, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christina Marciniak
- Shirley Ryan AbilityLab, Chicago, Illinois, USA.,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Zyoud SH, Shakhshir M, Abushanab AS, Koni A, Shahwan M, Jairoun AA, Al-Jabi SW. Global research trends on the links between insulin resistance and obesity: a visualization analysis. TRANSLATIONAL MEDICINE COMMUNICATIONS 2022; 7:18. [DOI: 10.1186/s41231-022-00124-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/16/2022] [Indexed: 12/01/2023]
Abstract
AbstractBackgroundObesity increases the chance of developing insulin resistance. Numerous inflammatory markers have been linked to an increased risk of insulin resistance in obese individuals. Therefore, we performed a bibliometric analysis to determine global research activity and current trends in the field of obesity and insulin resistance.MethodsScopus was used between 2002 and 2021 to retrieve publications related to terms related to obesity and insulin resistance. Data were exported to Microsoft Excel. Additionally, we use VOSviewer software to create visualization maps that describe international collaborations and research hotspots.ResultsWe identified 6626 publications, including 5754 journal articles, 498 review articles, and 109 letters to the editor. The most productive countries were the United States (n = 995, 30.11%), followed by China (n = 650, 9.81%), Italy (n = 412, 6.22%) and Spain (n = 386, 5.83%). Previously to 2012, this field was mainly focused on ‘adipocyte dysfunctions that link obesity with insulin resistance”; and ‘relationship between obesity, insulin resistance, and risk of cardiovascular disease’. ‘Supplements improve insulin sensitivity‘, and ‘obesity-induced inflammation and insulin resistance’ were found more recently (after 2014), indicating that research in this field has acquired significant interest and emphasis in recent years.ConclusionsThis is the first bibliometric study to focus on publications related to insulin resistance and obesity at the global level. Our reporting of quantifiable knowledge in this field may be useful in providing evidence and direction for future research, clinical practice, and educational initiatives.
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Dogruoz Karatekin B, İcagasioglu A, Sahin SN, Akbulut İH, Pasin O. Multimorbidities and quality of life in adult cerebral palsy over 40 years. Acta Neurol Belg 2022; 122:1261-1267. [PMID: 35780206 DOI: 10.1007/s13760-022-01958-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/13/2022] [Indexed: 11/24/2022]
Abstract
AIM This study aimed to describe the most common combinations of comorbidities and their relationship to quality of life in a sample of adults over 40 years of age with cerebral palsy. METHODS Patients who are 40 years or older and admitted to the hospital in the last 5 years and were diagnosed with cerebral palsy were included. Demographic data and comorbidities were both questioned through the Patient Information Management System and confirmed by asking the individual about their diseases. The patients' quality of life was evaluated with the EQ-5D-3L Telephone interview version. Principal component analysis was used to determine comorbidity combinations for multiple morbidity. RESULTS Comorbidity was found in 72.1% of the participants and multimorbidity was found in 47.5%. The 5 most common comorbidities were musculoskeletal diseases (34.4%), psychiatric diseases (21.3%), essential hypertension (21.3%), osteoporosis (18%) and hyperlipidemia (18%). As a result of principal component analysis, a total of five components are formed and this most common comorbidity combinations in the sample explained 66.78% of the total variance. CONCLUSIONS New combinations of comorbidities have been demonstrated that may perhaps serve as a starting point for identifying new association of pathways. Future efforts are needed to identify modifiable factors for early intervention and prevention of chronic health problems in this population.
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Affiliation(s)
- Bilinc Dogruoz Karatekin
- Istanbul Medeniyet University, Goztepe Prof Dr Suleyman Yalcin City Hospital, Physical Medicine and Rehabilitation, Istanbul, Turkey.
| | - Afitap İcagasioglu
- Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul Medeniyet University, Istanbul, Turkey
| | - Seyma Nur Sahin
- Istanbul Medeniyet University, Goztepe Prof Dr Suleyman Yalcin City Hospital, Physical Medicine and Rehabilitation, Istanbul, Turkey
| | - İsmail Hakan Akbulut
- Istanbul Medeniyet University, Goztepe Prof Dr Suleyman Yalcin City Hospital, Physical Medicine and Rehabilitation, Istanbul, Turkey
| | - Ozge Pasin
- Faculty of Medicine, Department of Biostatistics, Bezmialem Foundation University, Istanbul, Turkey
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Peterson MD, Lin P, Kamdar N, Marsack-Topolewski CN, Mahmoudi E. Physical and Mental Health Comorbidities Among Adults With Multiple Sclerosis. Mayo Clin Proc Innov Qual Outcomes 2022; 6:55-68. [PMID: 35005438 PMCID: PMC8715377 DOI: 10.1016/j.mayocpiqo.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To compare the incidence of and adjusted hazard ratios for common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities among adults with and without multiple sclerosis (MS). PATIENTS AND METHODS Beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for MS (n=9815) from a national private insurance claims database (Clinformatics Data Mart; OptumInsight). Adults without MS were also included (n=1,474,232) as a control group. Incidence estimates of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities were compared at 5 years of continuous enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident morbidities. RESULTS Adults with MS had a higher incidence of any common cardiometabolic disease (51.6% [2663 of 5164] vs 36.4% [328,690 of 904,227]), musculoskeletal disorder (68.8% [3411 of 4959] vs 47.5% [512,422 of 1,077,737]), and psychological morbidity (49.4% [3305 of 6691] vs 30.8% [380,893 of 1,235,388]) than adults without MS, and differences were clinically meaningful (all P<.001). Fully adjusted survival models revealed that adults with MS had a greater risk for any (hazard ratio [HR], 1.37; 95% CI, 1.32 to 1.43) and all (HR, 1.19 to 1.48) common cardiometabolic diseases, any (HR, 1.59; 95% CI, 1.53 to 1.64) and all (HR, 1.22 to 2.77) musculoskeletal disorders, and any (HR, 1.57; 95% CI, 1.51 to 1.62) and all (HR, 1.20 to 2.51) but one (impulse control disorders) psychological morbidity. CONCLUSION Adults with MS have a significantly higher risk for development of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities (all P<.001) than adults without MS. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of chronic physical and mental disease onset/progression in this higher risk population.
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Affiliation(s)
- Mark D. Peterson
- Department of Physical Medicine and Rehabilitation
- Institute for Healthcare Policy and Innovation
| | - Paul Lin
- Institute for Healthcare Policy and Innovation
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation
- Department of Obstetrics and Gynecology
- Department of Emergency Medicine
- Department of Surgery
| | | | - Elham Mahmoudi
- Institute for Healthcare Policy and Innovation
- Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor
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Brown MC, Marciniak CM, Garrett AM, Gaebler-Spira DJ. Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention. Dev Med Child Neurol 2021; 63:1221-1228. [PMID: 33959958 DOI: 10.1111/dmcn.14913] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2021] [Indexed: 12/13/2022]
Abstract
AIM To assess diet quality and its relationship with cardiovascular health measures for adults with cerebral palsy (CP). METHOD A convenience sample of 45 adults with CP (26 females, 19 males; mean age 35y 10mo [SD 14y 9mo]). were recruited for this cross-sectional study. Demographic, medical, and Gross Motor Function Classification System (GMFCS) information were obtained through in-person visits. Participants completed two 24-hour dietary recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool. Specific macronutrient intake was compared to 2015 to 2020 US Department of Agriculture (USDA) guidelines. Other data included body mass index (BMI), waist-to-hip ratio (WHR), blood pressure, and hemoglobin A1c (HgA1c;n=43). RESULTS Adults across GMFCS levels I to V were enrolled, 20 participants were in GMFCS levels IV or V. Mean calorie intake was 1777.91/day (SD 610.54), while sodium intake was 3261.75mg/day (SD 1484.92). Five participants met USDA vegetable and seven fruit guidelines. None met whole grain targets. Sixteen were overweight/obese by BMI. Sixteen participants without hypertension diagnoses had elevated blood pressure and nine had abnormal HgA1c without prediabetes/diabetes history. Percent calories from saturated fat was inversely associated with WHR in unadjusted and adjusted models (p=0.002 and p=0.003 respectively); all other dietary recommendations assessed (total calories, sodium, and sugar) were non-significant. Post hoc analyses were unchanged using 2020 to 2025 USDA guidelines. INTERPRETATION Assessment of nutrient intake and diet quality is feasible and warrants further study in adults with CP, as USDA guidelines are largely unmet. What this paper adds Adults with cerebral palsy (CP) do not meet US Department of Agriculture dietary quality recommendations. Prediabetes and hypertension may be common, but unrecognized, in adults with CP. Screening for nutrient intake and diet quality should be performed to facilitate nutritional counseling.
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Affiliation(s)
- Meagan C Brown
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Christina M Marciniak
- Department of Physical Medicine and Rehabilitation, Feinberg Medical School, Northwestern University, Chicago, IL, USA.,Department of Neurology, Feinberg Medical School, Northwestern University, Chicago, IL, USA.,Shirley Ryan AbilityLab, Chicago, IL, USA
| | | | - Deborah J Gaebler-Spira
- Department of Physical Medicine and Rehabilitation, Feinberg Medical School, Northwestern University, Chicago, IL, USA.,Shirley Ryan AbilityLab, Chicago, IL, USA.,Department of Pediatrics, Feinberg Medical School, Northwestern University, Chicago, IL, USA
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Hurvitz EA, Whitney DG, Waldron-Perrine B, Ryan D, Haapala HJ, Schmidt M, Gray C, Peterson MD. Navigating the Pathway to Care in Adults With Cerebral Palsy. Front Neurol 2021; 12:734139. [PMID: 34603186 PMCID: PMC8482767 DOI: 10.3389/fneur.2021.734139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022] Open
Abstract
As individuals with cerebral palsy (CP) age, they face unique challenges which complicate their ability to access and receive appropriate health care. These problems exist at the level of the health care system, the clinician, and the individual. At the system level, there is an inadequate number of professionals who are informed of and interested in the care of adults with CP. Pediatric clinicians prefer treating children, and adult caregivers are not knowledgeable about and may feel less competent about CP. Pediatric care does not translate well to the adult population, and information about best practices for adults is just starting to develop. Differences in the physiologic development of individuals with CP render well-established clinical protocols for risk screening of chronic diseases less effective. Moreover, lack of supportive resources decreases a caregiver's sense of self-efficacy in treating this population. The patient's ability to navigate these barriers is complicated by the high prevalence of comorbid cognitive impairment and mental health issues including anxiety, depression, and other psychiatric disorders; a bidirectional relationship between challenges in navigating care/needs and comorbid mental health conditions appears likely. Many patients have additional barriers related to social determinants of health, such as access to transportation, accessible health care facilities, and other personal and environmental factors that may impede health maintenance and wellness. Increasing and disseminating knowledge, harnessing the power of new technologies such as telemedicine, and addressing mental health issues are some of the methods that are available to help adults with CP navigate this road.
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Affiliation(s)
- Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brigid Waldron-Perrine
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Dayna Ryan
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Heidi J. Haapala
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mary Schmidt
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Cathryn Gray
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mark D. Peterson
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
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Xu W, Hu X, Anwaier A, Wang J, Liu W, Tian X, Zhu W, Ma C, Wan F, Shi G, Qu YY, Zhang H, Ye D. Fatty Acid Synthase Correlates With Prognosis-Related Abdominal Adipose Distribution and Metabolic Disorders of Clear Cell Renal Cell Carcinoma. Front Mol Biosci 2021; 7:610229. [PMID: 33569391 PMCID: PMC7868388 DOI: 10.3389/fmolb.2020.610229] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/04/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose: Lipid metabolism reprogramming is a major pathway in tumor evolution. This study investigated fatty acid synthase (FASN) mRNA expression in anthropometric adipose tissue and elucidated the prognostic value and potential mechanism of clear cell renal cell carcinoma (ccRCC). Materials and Methods: Transcription profiles were obtained from 533 ccRCC samples in The Cancer Genome Atlas (TCGA) cohorts. Real-time quantitative PCR (RT-qPCR) and immunohistochemistry were performed to detect FASN expression in 380 paired ccRCC and normal tissues from the Fudan University Shanghai Cancer Center (FUSCC). Visceral adipose tissue (VAT) and subcutaneous adipose tissue were at the level of the umbilicus as measured by magnetic resonance imaging (MRI). Non-targeted metabolomics and in vitro experiments were used to reveal the biological functions of FASN. Results: Increased FASN expression was significantly relevant to advanced T, N, and American Joint Committee on Cancer (AJCC) stages (p < 0.01) and significantly correlated to poor progression-free survival (PFS) and overall survival (OS) of 913 ccRCC patients in FUSCC and TCGA cohorts. Pearson's correlation coefficient indicated that FASN amplification was positively correlated to VAT% (r = 0.772, p < 0.001), which significantly correlated to poor PFS (HR = 2.066, p = 0.028) and OS (HR = 2.773, p = 0.023) in the FUSCC cohort. Transient inhibition or overexpression of FASN significantly regulated A498 and 786O cell proliferation and migration by regulating epithelial–mesenchymal transition. Inhibition of FASN led to a higher apoptotic rate and decreased lipid droplet formation compared with normal control in ccRCC cells. Non-targeted metabolomics showed that decreased de novo lipogenesis might be required to sustain an elevation of glycolytic activity in 786O cells by regulating galactinol, dl-lactate, N-acetylaspartylglutamate, and sucrose, thereby participating in carcinogenesis and progression of ccRCC. Conclusion: This study demonstrated that FASN expression is positively related to aggressive cell proliferation, migration, apoptosis, and lipid droplet formation and regulates metabolic disorders of the ccRCC microenvironment. Additionally, elevated FASN mRNA expression is significantly correlated to the abdominal obesity distribution, especially VAT%, which is a significant predictor of a poor prognosis for ccRCC patients.
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Affiliation(s)
- Wenhao Xu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Xiaoxin Hu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Aihetaimujiang Anwaier
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Jun Wang
- Department of Urology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in Southern China, Guangzhou, China
| | - Wangrui Liu
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xi Tian
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Wenkai Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Chunguang Ma
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Fangning Wan
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Guohai Shi
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Yuan-Yuan Qu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Hailiang Zhang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Dingwei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
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11
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Armandi A, Rosso C, Caviglia GP, Ribaldone DG, Bugianesi E. The Impact of Dysmetabolic Sarcopenia Among Insulin Sensitive Tissues: A Narrative Review. Front Endocrinol (Lausanne) 2021; 12:716533. [PMID: 34858322 PMCID: PMC8631324 DOI: 10.3389/fendo.2021.716533] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022] Open
Abstract
Sarcopenia is a common muscular affection among elderly individuals. More recently, it has been recognized as the skeletal muscle (SM) expression of the metabolic syndrome. The prevalence of sarcopenia is increasing along with visceral obesity, to which it is tightly associated. Nonetheless, it is a still underreported entity by clinicians, despite the worsening in disease burden and reduced patient quality of life. Recognition of sarcopenia is clinically challenging, and variability in study populations and diagnostic methods across the clinical studies makes it hard to reach a strong evidence. Impaired insulin activity in SM is responsible for the altered molecular pathways and clinical manifestations of sarcopenia, which is morphologically expressed by myosteatosis. Lipotoxicity, oxidative stress and adipose tissue-derived inflammation lead to both alterations in glucose disposal and protein synthesis in SM, with raising insulin resistance (IR) and SM atrophy. In particular, hyperleptinemia and leptin resistance interfere directly with SM activity, but also with the release of Growth Hormone from the hypohysis, leading to a lack in its anabolic effect on SM. Moreover, sarcopenia is independently associated to liver fibrosis in Non-Alcoholic Fatty Liver Disease (NAFLD), which in turn worsens SM functionality through the secretion of proinflammatory heptokines. The cross-talk between the liver and SM in the IR setting is of crucial relevance, given the high prevalence of NAFLD and the reciprocal impact of insulin-sensitive tissues on the overall disease burden. Along with the efforts of non-invasive diagnostic approaches, irisin and myostatin are two myokines currently evaluated as potential biomarkers for diagnosis and prognostication. Decreased irisin levels seem to be potentially associated to sarcopenia, whereas increased myostatin has shown to negatively impact on sarcopenia in pre-clinical studies. Gene variants in irisin have been explored with regard to the impact on the liver disease phenotype, with conflicting results. The gut-muscle axis has gain relevance with the evidence that insulin resistance-derived gut dysbiosis is responsible for increased endotoxemia and reduction in short-chain free fatty acids, directly affecting and predisposing to sarcopenia. Based on the current evidence, more efforts are needed to increase awareness and improve the management of sarcopenic patients.
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12
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Peterson MD, Lin P, Kamdar N, Mahmoudi E, Schmidt MM, Haapala HJ, Hurvitz EA. Cardiometabolic Morbidity in Adults With Cerebral Palsy and Spina Bifida. Am J Med 2020; 133:e695-e705. [PMID: 32687812 PMCID: PMC9645295 DOI: 10.1016/j.amjmed.2020.05.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to compare the incidence of, and adjusted hazards for, cardiometabolic morbidities among adults with and without cerebral palsy or spina bifida. METHODS Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code for cerebral palsy or spina bifida (n = 15,302). Adults without cerebral palsy or spina bifida were also included (n = 1,935,480). Incidence estimates of common cardiometabolic morbidities were compared at 4 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios (HRs) for incident cardiometabolic morbidities. RESULTS Adults living with cerebral palsy or spina bifida had a higher 4-year incidence of any cardiometabolic morbidity (41.5% vs 30.6%) as compared to adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with cerebral palsy or spina bifida had a greater hazard for any cardiometabolic morbidity (HR: 1.52; 95% confidence interval [CI]: 1.47, 1.57), and all but 1 cardiometabolic disorder (nonalcoholic fatty liver disease) and ranged from HR: 1.20 (1.15, 1.25) for hypercholesterolemia to HR: 1.86 (1.74, 1.98) for heart failure. CONCLUSIONS Adults with cerebral palsy or spina bifida have a significantly higher incidence of, and risk for, common cardiometabolic morbidities, as compared to adults without cerebral palsy or spina bifida. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of cardiometabolic disease onset and progression in these higher-risk populations.
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Affiliation(s)
- Mark D Peterson
- Department of Physical Medicine and Rehabilitation; Institute for Healthcare Policy and Innovation.
| | - Paul Lin
- Institute for Healthcare Policy and Innovation
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation; Department of Obstetrics and Gynecology; Department of Emergency Medicine; Department of Surgery
| | - Elham Mahmoudi
- Institute for Healthcare Policy and Innovation; Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor
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13
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Sommer I, Teufer B, Szelag M, Nussbaumer-Streit B, Titscher V, Klerings I, Gartlehner G. The performance of anthropometric tools to determine obesity: a systematic review and meta-analysis. Sci Rep 2020; 10:12699. [PMID: 32728050 PMCID: PMC7391719 DOI: 10.1038/s41598-020-69498-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 07/13/2020] [Indexed: 02/07/2023] Open
Abstract
The aim of this systematic review was to assess the performance of anthropometric tools to determine obesity in the general population (CRD42018086888). Our review included 32 studies. To detect obesity with body mass index (BMI), the meta-analyses rendered a sensitivity of 51.4% (95% CI 38.5-64.2%) and a specificity of 95.4% (95% CI 90.7-97.8%) in women, and 49.6% (95% CI 34.8-64.5%) and 97.3% (95% CI 92.1-99.1%), respectively, in men. For waist circumference (WC), the summary estimates for the sensitivity were 62.4% (95% CI 49.2-73.9%) and 88.1% for the specificity (95% CI 77.0-94.2%) in men, and 57.0% (95% CI 32.2-79.0%) and 94.8% (95% CI 85.8-98.2%), respectively, in women. The data were insufficient to pool the results for waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) but were similar to BMI and WC. In conclusion, BMI and WC have serious limitations for use as obesity screening tools in clinical practice despite their widespread use. No evidence supports that WHR and WHtR are more suitable than BMI or WC to assess body fat. However, due to the lack of more accurate and feasible alternatives, BMI and WC might still have a role as initial tools for assessing individuals for excess adiposity until new evidence emerges.
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Affiliation(s)
- Isolde Sommer
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria.
| | - Birgit Teufer
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Monika Szelag
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Barbara Nussbaumer-Streit
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Viktoria Titscher
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Irma Klerings
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Gerald Gartlehner
- Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
- RTI-UNC Evidence-Based Practice Center, Research Triangle Institute International, East Cornwallis Road, Post Office Box 12194, Research Triangle Park, NC, 27709-2194, USA
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14
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Soares RR, Salgado PDO, Rocha KO, Lima LM. Functional capacity and risk of falls in the elderly with metabolic syndrome. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2020. [DOI: 10.5712/rbmfc15(42)2228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Metabolic syndrome (MetS) is the most common metabolic abnormality in the population that predisposes to cardiovascular events and may be related to poor physical fitness and low functional capacity in the elderly. The objective of this study was to evaluate the interference of metabolic changes in functional capacity and risk of falls in the elderly. Methods: A cross-sectional study was carried out with 126 elderly subjects, 58 presented MetS and 68 without MetS, according to the criteria of the International Diabetes Federation. Katz Index, Tinetti Index, Timed Up and Go test and Berg Scale were applied to evaluate the functional capacity. Falls Efficacy Scale-International scale (FES-I-Brazil) was used to evaluate the fear of falling. For statistical analysis, the Mann-Whitney, Chi-square and Spearman correlation tests were used. Results: There was an association between the MetS and non-MetS groups in relation to the risk strata of the TUG index [p=0.02; OR=0.38; 95%CI (0.16-0.91)]. Between these two groups, there was a significant difference in the mean of the following markers: Berg scale (p=0.03); TUG (p=0.03); FES-I-Brazil (p=0.02). The Kats and IPAQ index did not show any significant association. Conclusions: Elderly patients with MetS presented higher risk and fear of falls when compared to patients without MetS. However, there was no variation in walking ability or balance.
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15
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Xu WH, Qu YY, Wang J, Wang HK, Wan FN, Zhao JY, Zhang HL, Ye DW. Elevated CD36 expression correlates with increased visceral adipose tissue and predicts poor prognosis in ccRCC patients. J Cancer 2019; 10:4522-4531. [PMID: 31528216 PMCID: PMC6746135 DOI: 10.7150/jca.30989] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/22/2019] [Indexed: 02/06/2023] Open
Abstract
Objective: Growing evidence has proved obesity one of the confirmed important etiologic indicators for renal cell carcinoma (RCC). CD36 is underpinned to be involved in adipose absorption, but its role in clear cell renal cell carcinoma (ccRCC) remains unclear. This study aimed to investigate the mRNA expression of CD36 in anthropometric measures of adipose tissue and defining its value in predicting prognosis in ccRCC patients. Methods: Real-Time qPCR gene expression analysis was detected from 367 paired ccRCC and adjacent normal tissues. Distributions of categorical clinical-pathological data together with levels of CD36 expression were compared with χ2-test in a contingency table. Subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were measured by magnetic resonance imaging (MRI) and identified at the level of the umbilicus. Pearson's correlation coefficient was utilized to quantify relations between body mass index (BMI), VAT%, SAT and CD36 expression respectively. Partial likelihood test from univariate and multivariate Cox regression analysis were developed to address the influence of independent factors on progression-free survival (PFS) and overall survival (OS). The Kaplan-Meier method and log-rank test were performed to assess the survival benefits between discrete levels. Results: In the current study, CD36 mRNA was demonstrated highly expressed in ccRCC compared with normal tissues. In addition, CD36 mRNA expression was significantly increased in patients with advanced TNM stage (p=0.003, p<0.001, p<0.001), and high VAT% (p=0.004). Pearson's correlation coefficient indicated that CD36 amplification positively correlated with BMI (r=0.117, p=0.025), VAT% (r=0.465, p<0.001), while negatively associated with SAT (r=-0.296, p=0.002). Median PFS was 60 months and OS was 99 months. Meanwhile, ccRCC patients with elevated CD36 expression held shorter PFS and OS, with hazard ratios [HR; 95% confidence interval (CI)] of 4.873 (3.300-7.196, p<0.001) and 4.610 (2.956-7.189, p<0.001). In 104 cases with available MRI scans, VAT was significantly correlated with poor PFS and OS, with HR of 2.556 (1.036-6.310, p<0.042) and 3.291 (1.034-10.477, p<0.044). A total of 100 significant genes were obtained from GSEA, and CD36 was found involved in the most significant pathways including fatty acid metabolism, UV response, angiogenesis and transforming growth factor beta (TGF-β) signaling pathways. Conclusion: In conclusion, our study first reveal that elevated CD36 mRNA expression is positively correlated to distribution of abdominal adipose, particularly VAT%, which, in addition, notably predicts poor prognosis in ccRCC patients.
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Affiliation(s)
- Wen-Hao Xu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
| | - Yuan-Yuan Qu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
| | - Jun Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
| | - Hong-Kai Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
| | - Fang-Ning Wan
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
| | - Jian-Yuan Zhao
- The Obstetrics & Gynecology Hospital of Fudan University, State Key Lab of Genetic Engineering, School of Life Sciences and Collaborative Innovation Center of Genetics & Development, Fudan University, Shanghai 200032, P.R. China
| | - Hai-Liang Zhang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
| | - Ding-Wei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai 200032.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 20032, P.R. China
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16
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Gaynor B, Wright R, Shin JY. Community-Based Older Adults' Acceptance of and Willingness Toward Waist Circumference Measurement. J Gerontol Nurs 2019; 45:11-15. [PMID: 31026327 DOI: 10.3928/00989134-20190305-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 02/04/2019] [Indexed: 11/20/2022]
Abstract
Older adults have higher rates of central obesity and greater risk for central obesity-related diseases compared to younger adults. Waist circumference measurement is a reliable indicator of preventable, central obesity-related disease risk. Despite its value, it is rarely measured in primary care settings due to providers' perceived patient discomfort with waist measurement. The current study examined community-based older adults' (N = 99) experience with, acceptance of, and willingness toward waist measurement. Ninety-two percent of participants reported never having waist measurement in primary care settings. Despite lack of waist measurement experience, 62.6% reported feeling "very" comfortable and 82.8% were "very willing" to have waist measurement. High acceptance of and willingness toward waist measurement in the absence of experience supports acceptability of waist measurement among older adults. Thus, providers are encouraged to use waist measurement to screen older adults for central obesity and associated disease risk. [Journal of Gerontological Nursing, 45(5), 11-15.].
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17
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Ryan JM, Allen E, Gormley J, Hurvitz EA, Peterson MD. The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review. Dev Med Child Neurol 2018; 60:753-764. [PMID: 29572812 DOI: 10.1111/dmcn.13737] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2018] [Indexed: 12/26/2022]
Abstract
AIM To examine the risk, burden, and management of non-communicable diseases (NCDs) among people with cerebral palsy (CP). METHOD Databases (Ovid MEDLINE, Embase Ovid, CINAHL Plus) were systematically searched up to August 2017. Data on the prevalence of risk factors for, and the burden and management of, cardiovascular diseases, diabetes, cancers, and respiratory diseases were extracted. RESULTS Thirty-six studies that examined the prevalence of risk factors among people with CP were identified. There was inconsistent evidence that people with CP had higher prevalence of metabolic risk factors such as hypertension, hyperlipidaemia, and obesity, but strong evidence that they participated in low levels of physical activity, compared with people without CP. Seven studies reported on the burden of NCDs. Adults with CP had a higher risk of NCDs, including stroke, chronic obstructive pulmonary disease, and other heart conditions, and death due to NCDs, including cancers, chronic obstructive pulmonary disease, stroke, and ischaemic heart disease, compared with the general population. Only one study reported on the management of NCD, specifically the uptake of breast cancer screening among females. INTERPRETATION The burden of NCDs is higher among adults with CP compared with the general population. Further research is required to determine the prevalence of metabolic risk factors and management of NCDs among people with CP. WHAT THIS PAPER ADDS Adults with cerebral palsy (CP) have an increased risk of non-communicable diseases (NCDs) and increased risk of death because of NCDs. Evidence is inconsistent about the elevated prevalence of metabolic risk factors for NCDs. Evidence is consistent that people with CP participate in reduced physical activity. Only one study reported on management of NCD among people with CP. Available evidence suggests people with CP are less likely to receive preventive medicine.
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Affiliation(s)
- Jennifer M Ryan
- College of Health and Life Sciences, Brunel University, London, UK.,Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - John Gormley
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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18
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Relationship between body mass index and renal function deterioration among the Taiwanese chronic kidney disease population. Sci Rep 2018; 8:6908. [PMID: 29720598 PMCID: PMC5932053 DOI: 10.1038/s41598-018-24757-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/22/2018] [Indexed: 01/06/2023] Open
Abstract
This study investigated the characteristics of patients with different chronic kidney disease (CKD) stages according to various body mass index (BMI) categories and determined the influence of BMI in renal function deterioration. We conducted a multicenter, longitudinal cohort study based on the Epidemiology and Risk Factors Surveillance of CKD project (2008–2013) and National Health Insurance Research Database (2001–2013). A total of 7357 patients with CKD aged 20–85 years from 14 hospitals were included in the study. A higher male sex, diabetes mellitus (DM) and hypertension were noted among overweight and obese CKD patients, while more cancer prevalence was noted among underweight CKD patients. Charlson comorbidity index was significantly higher and correlated with BMI among late CKD patients. Patients with BMI < 18.5 kg/m2 exhibited non-significantly higher events of eGFR decline events in both early and late CKD stages than other BMI groups. BMI alone is not a determinant of CKD progression among our Taiwanese CKD patients. Obesity should be re-defined and body weight manipulation should be individualized in CKD patients.
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19
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Jo A, Mainous AG. Informational value of percent body fat with body mass index for the risk of abnormal blood glucose: a nationally representative cross-sectional study. BMJ Open 2018; 8:e019200. [PMID: 29654009 PMCID: PMC5905746 DOI: 10.1136/bmjopen-2017-019200] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 03/09/2018] [Accepted: 03/21/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To examine the value of percent body fat (%BF) with body mass index (BMI) to assess the risk of abnormal blood glucose (ABG) among US adults who are normal weight or overweight. We hypothesised that normal-weight population with higher %BF is more likely to have ABG. DESIGN A cross-sectional study. SETTING National Health and Nutrition Examination Survey, 1999-2006, conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention. PARTICIPANTS Participants were US adults aged 40 and older who have never been diagnosed with type 2 diabetes by a doctor (unweighted n=6335, weighted n=65 705 694). The study population was classified into four groups: (1) normal weight with normal %BF, (2) normal weight with high %BF, (3) overweight with normal %BF and (4) overweight with high %BF. MAIN OUTCOME MEASURES ORs for ABG including pre-diabetes and undiagnosed diabetes (HbA1c ≥5.7%, ≥39 mmol/mol). RESULTS 64% of population with normal BMI classification had a high %BF. Prevalence of ABG in normal-weight group with high %BF (13.5%) is significantly higher than the overweight group with low %BF (10.5%, P<0.001). In an unadjusted model, the OR of ABG was significantly greater in adults at normal BMI with high %BF compared with individuals at normal weight with low %BF. In an adjusted model controlling for age, sex, race/ethnicity, first-degree-relative diabetes, vigorous-intensity activities and muscle strengthening activities, risks of ABG were greater in population with normal weight and high %BF (OR 1.55, 95% CI 1.01 to 2.38) and with overweight and low %BF (OR 1.17, 95% CI 0.69 to 1.98, P<0.05). CONCLUSIONS Integrating BMI with %BF can improve in classification to direct screening and prevention efforts to a group currently considered healthy and avoid penalties and stigmatisation of other groups that are classified as high risk of ABG.
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Affiliation(s)
- Ara Jo
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Arch G Mainous
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
- Department of Family Medicine and Community Health, College of Medicine, University of Florida, Gainesville, Florida, USA
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20
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Zwinkels M, Verschuren O, Balemans A, Lankhorst K, Te Velde S, van Gaalen L, de Groot J, Visser-Meily A, Takken T. Effects of a School-Based Sports Program on Physical Fitness, Physical Activity, and Cardiometabolic Health in Youth With Physical Disabilities: Data From the Sport-2-Stay-Fit Study. Front Pediatr 2018; 6:75. [PMID: 29632853 PMCID: PMC5879083 DOI: 10.3389/fped.2018.00075] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/12/2018] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To investigate the effects of a school-based once-a-week sports program on physical fitness, physical activity, and cardiometabolic health in children and adolescents with a physical disability. METHODS This controlled clinical trial included 71 children and adolescents from four schools for special education [mean age 13.7 (2.9) years, range 8-19, 55% boys]. Participants had various chronic health conditions including cerebral palsy (37%), other neuromuscular (44%), metabolic (8%), musculoskeletal (7%), and cardiovascular (4%) disorders. Before recruitment and based on the presence of school-based sports, schools were assigned as sport or control group. School-based sports were initiated and provided by motivated experienced physical educators. The sport group (n = 31) participated in a once-a-week school-based sports program for 6 months, which included team sports. The control group (n = 40) followed the regular curriculum. Anaerobic performance was assessed by the Muscle Power Sprint Test. Secondary outcome measures included aerobic performance, VO2 peak, strength, physical activity, blood pressure, arterial stiffness, body composition, and the metabolic profile. RESULTS A significant improvement of 16% in favor of the sport group was found for anaerobic performance (p = 0.003). In addition, the sport group lost 2.8% more fat mass compared to the control group (p = 0.007). No changes were found for aerobic performance, VO2 peak, physical activity, blood pressure, arterial stiffness, and the metabolic profile. CONCLUSION Anaerobic performance and fat mass improved following a school-based sports program. These effects are promising for long-term fitness and health promotion, because sports sessions at school eliminate certain barriers for sports participation and adding a once-a-week sports session showed already positive effects for 6 months. CLINICAL TRIAL REGISTRATION This trial was registered with the Dutch Trial Registry (NTR4698).
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Affiliation(s)
- Maremka Zwinkels
- Center of Excellence for Rehabilitation Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University and De Hoogstraat Rehabilitation, Utrecht, Netherlands.,Department of Sports, De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Olaf Verschuren
- Center of Excellence for Rehabilitation Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University and De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Astrid Balemans
- Center of Excellence for Rehabilitation Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University and De Hoogstraat Rehabilitation, Utrecht, Netherlands.,Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Public Health, VU University Amsterdam, Amsterdam, Netherlands
| | | | - Saskia Te Velde
- HU University of Applied Sciences Utrecht, Utrecht, Netherlands
| | | | - Janke de Groot
- HU University of Applied Sciences Utrecht, Utrecht, Netherlands.,Netherlands Institute for Health Services Research, Utrecht, Netherlands.,Child Development and Exercise Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anne Visser-Meily
- Center of Excellence for Rehabilitation Medicine, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University and De Hoogstraat Rehabilitation, Utrecht, Netherlands.,Department of Rehabilitation, Physical Therapy Science and Sports, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Tim Takken
- Child Development and Exercise Center, University Medical Center Utrecht, Utrecht, Netherlands
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Windham BG, Griswold ME, Wang W, Kucharska-Newton A, Demerath EW, Gabriel KP, Pompeii LA, Butler K, Wagenknecht L, Kritchevsky S, Mosley TH. The Importance of Mid-to-Late-Life Body Mass Index Trajectories on Late-Life Gait Speed. J Gerontol A Biol Sci Med Sci 2017; 72:1130-1136. [PMID: 27811156 PMCID: PMC5861851 DOI: 10.1093/gerona/glw200] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 09/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prior studies suggest being overweight may be protective against poor functional outcomes in older adults. METHODS Body mass index (BMI, kg/m2) was measured over 25 years across five visits (1987-2011) among Atherosclerosis Risk in Communities Study participants (baseline Visit 1 n = 15,720, aged 45-64 years). Gait speed was measured at Visit 5 ("late-life", aged ≥65 years, n = 6,229). BMI trajectories were examined using clinical cutpoints and continuous mixed models to estimate effects of patterns of BMI change on gait speed, adjusting for demographics and comorbidities. RESULTS Mid-life BMI (baseline visit; 55% women; 27% black) was associated with late-life gait speed 25 years later; gait speeds were 94.3, 89.6, and 82.1 cm/s for participants with baseline normal BMI (<25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30) (p < .001). In longitudinal analyses, late-life gait speeds were 96.9, 88.8, and 81.3 cm/s for participants who maintained normal, overweight, and obese weight status, respectively, across 25 years (p < .01). Increasing BMI over 25 years was associated with poorer late-life gait speeds; a 1%/year BMI increase for a participant with a baseline BMI of 22.5 (final BMI 28.5) was associated with a 4.6-cm/s (95% confidence interval: -7.0, -1.8) slower late-life gait speed than a participant who maintained a baseline BMI of 22.5. CONCLUSION Being overweight in older age was not protective of mobility function. Maintaining a normal BMI in mid- and late-life may help preserve late-life mobility.
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Affiliation(s)
| | - Michael E Griswold
- Department of Data Science, University of Mississippi Medical Center, Jackson
| | - Wanmei Wang
- Department of Data Science, University of Mississippi Medical Center, Jackson
| | | | - Ellen W Demerath
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis
| | - Kelley Pettee Gabriel
- University of Texas School of Public Health in Austin, Department of Epidemiology, Human Genetics, and Environmental Sciences
| | - Lisa A Pompeii
- University of Texas School of Public Health, Department of Epidemiology, Human Genetics, and Environmental Sciences
| | | | - Lynne Wagenknecht
- Center on Diabetes, Obesity, and Metabolism; Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen Kritchevsky
- Sticht Center on Aging; Wake Forest School of Medicine, Winston-Salem, North Carolina
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Cremer N, Hurvitz EA, Peterson MD. Multimorbidity in Middle-Aged Adults with Cerebral Palsy. Am J Med 2017; 130:744.e9-744.e15. [PMID: 28065772 PMCID: PMC5502778 DOI: 10.1016/j.amjmed.2016.11.044] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Individuals with cerebral palsy have less lean body mass, greater relative adiposity, and lower fitness and physical activity participation, and yet the prevalence of age-related multimorbidity in this population has yet to be established. The study objective was to examine the prevalence of lifestyle-related chronic conditions and multimorbidity in a sample of middle-aged adults with cerebral palsy. METHODS A clinic-based sample of middle-aged adults with cerebral palsy was examined using Electronic Medical Records Search Engine software. Our cohort included 435 individuals aged 40 to 60 years, with an International Classification of Diseases, Clinical Modification, 9th and 10th Revisions Diagnosis Code for cerebral palsy. Prevalence of 12 chronic conditions was evaluated, including existing diagnoses or historical record of osteopenia/osteoporosis, myocardial infarction, stroke, coronary artery disease, impaired glucose tolerance/type 2 diabetes, other cardiovascular conditions, rheumatoid arthritis, osteoarthritis, asthma, emphysema, prehypertension/hypertension, and hyperlipidemia. Multivariate logistic models were used to estimate multimorbidity (ie, ≥2 chronic conditions), adjusting for age, sex, smoking status, obesity, and Gross Motor Function Classification System (GMFCS). RESULTS There were 137 unique multimorbidity combinations. Multimorbidity was significantly more prevalent among obese versus nonobese individuals for both GMFCS I-III (75.8% vs 53.6%) and GMFCS IV-V (79.0% vs 64.2%), but was also significantly higher in nonobese individuals with GMFCS IV-V (64.2%) compared with nonobese individuals with GMFCS I-III (53.6%). Both the obesity status (odds ratio, 2.20; 95% confidence interval, 1.32-2.79) and the GMFCS IV-V category (odds ratio, 1.81; 95% confidence interval, 1.32-3.68) were independently associated with multimorbidity. CONCLUSIONS Middle-aged adults with cerebral palsy have high estimates of multimorbidity; both obesity and higher GMFCS levels are independently associated with greater risk.
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Affiliation(s)
- Nicole Cremer
- University of Michigan, University of Michigan Medical School, Ann Arbor
| | - Edward A Hurvitz
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor
| | - Mark D Peterson
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor.
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Ilvig PM, Christensen JR. Degree of disability among female healthcare workers who are overweight or obese. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1282032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Pia Maria Ilvig
- Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
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Wanner M, Martin BW, Autenrieth CS, Schaffner E, Meier F, Brombach C, Stolz D, Bauman A, Rochat T, Schindler C, Kriemler S, Probst-Hensch N. Associations between domains of physical activity, sitting time, and different measures of overweight and obesity. Prev Med Rep 2016; 3:177-84. [PMID: 27419012 PMCID: PMC4929209 DOI: 10.1016/j.pmedr.2016.01.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To describe 1) cross-sectional associations between domain-specific physical activity, sitting time and different measures of overweight/obesity and 2) longitudinal associations between patterns of change in physical activity and overweight/obesity ten years later. METHODS Cross-sectional and longitudinal analyses based on the first and second follow-up of the Swiss cohort study SAPALDIA (SAP) were conducted (SAP2 in 2002/03, SAP3 in 2010/11). Physical activity was assessed by self-report using the long International Physical Activity Questionnaire (IPAQ) and four short questions regarding moderate and vigorous activities. Overweight/obesity were defined based on body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and percent body fat based on bioelectric impedance analysis (BIA), all measured objectively. Multivariable logistic regression was used for analyses. RESULTS Cross-sectionally, leisure-time and vigorous physical activity were inversely associated with all obesity parameters. Most consistent associations were found with BIA percent body fat. There were no associations between work-related and domestic activities and overweight/obesity. Sitting time was positively associated with BIA percent body fat, but not with BMI, WHR and WHtR. Longitudinally, remaining inactive from SAP2 to SAP3 was associated with obesity and BIA percent body fat at SAP3 and with weight increase, becoming inactive with BIA percent body fat and weight increase. CONCLUSIONS The results support associations between physical activity and overweight/obesity cross-sectionally and longitudinally. Most consistent associations were found for BIA percent body fat. For prevention purposes, the results indicate that physical activity can have an important contribution to weight management.
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Affiliation(s)
- Miriam Wanner
- Physical Activity and Health Unit, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Brian W. Martin
- Physical Activity and Health Unit, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Christine S. Autenrieth
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Emmanuel Schaffner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Flurina Meier
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | | | - Daiana Stolz
- Clinic of Pulmonary Medicine and Respiratory Cell Research, University Hospital Basel, Basel, Switzerland
| | - Adrian Bauman
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Thierry Rochat
- Division of Pulmonary Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Christian Schindler
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
| | - Susi Kriemler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Switzerland
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Batsis JA, Mackenzie TA, Bartels SJ, Sahakyan KR, Somers VK, Lopez-Jimenez F. Diagnostic accuracy of body mass index to identify obesity in older adults: NHANES 1999-2004. Int J Obes (Lond) 2016; 40:761-7. [PMID: 26620887 PMCID: PMC4854777 DOI: 10.1038/ijo.2015.243] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/21/2015] [Accepted: 09/21/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Body composition changes with aging lead to increased adiposity and decreased muscle mass, making the diagnosis of obesity challenging. Conventional anthropometry, including body mass index (BMI), while easy to use clinically may misrepresent adiposity. We determined the diagnostic accuracy of BMI using dual-energy X-ray absorptiometry (DEXA) in assessing the degree of obesity in older adults. METHODS The National Health and Nutrition Examination Surveys 1999-2004 were used to identify adults aged ⩾60 years with DEXA measures. They were categorized (yes/no) as having elevated body fat by gender (men: ⩾25%; women ⩾35%) and by BMI ⩾25 and ⩾30 kg m(-)(2). The diagnostic performance of BMI was assessed. Metabolic characteristics were compared in discordant cases of BMI/body fat. Weighting and analyses were performed per NHANES (National Health and Nutrition Examination Survey) guidelines. RESULTS We identified 4984 subjects (men: 2453; women: 2531). Mean BMI and % body fat was 28.0 kg m(-2) and 30.8% in men, and 28.5 kg m(-)(2) and 42.1% in women. A BMI ⩾30 kg m(-)(2) had a low sensitivity and moderately high specificity (men: 32.9 and 80.8%, concordance index 0.66; women: 38.5 and 78.5%, concordance 0.69) correctly classifying 41.0 and 45.1% of obese subjects. A BMI ⩾25 kg m(-2) had a moderately high sensitivity and specificity (men: 80.7 and 99.6%, concordance 0.81; women: 76.9 and 98.8%, concordance 0.84) correctly classifying 80.8 and 78.5% of obese subjects. In subjects with BMI <30 kg m(-)(2), body fat was considered elevated in 67.1% and 61.5% of men and women, respectively. For a BMI ⩾30 kg m(-)(2), sensitivity drops from 40.3% to 14.5% and 44.5% to 23.4%, whereas specificity remains elevated (>98%), in men and women, respectively, in those 60-69.9 years to subjects aged ⩾80 years. Correct classification of obesity using a cutoff of 30 kg m(-)(2) drops from 48.1 to 23.9% and 49.0 to 19.6%, in men and women in these two age groups. CONCLUSIONS Traditional measures poorly identify obesity in the elderly. In older adults, BMI may be a suboptimal marker for adiposity.
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Affiliation(s)
- John A. Batsis
- Section of General Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
- Dartmouth Centers for Health and Aging, Dartmouth College, Hanover, NH
- Health Promotion Research Center at Dartmouth, Lebanon, NH
- Dartmouth Weight & Wellness Center, Lebanon, NH
| | - Todd A. Mackenzie
- Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
| | - Stephen J. Bartels
- Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH
- Dartmouth Centers for Health and Aging, Dartmouth College, Hanover, NH
- Health Promotion Research Center at Dartmouth, Lebanon, NH
| | - Karine R. Sahakyan
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, MN, 55905
| | - Virend K. Somers
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, MN, 55905
| | - Francisco Lopez-Jimenez
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, MN, 55905
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Hao Q, Song X, Yang M, Dong B, Rockwood K. Understanding Risk in the Oldest Old: Frailty and the Metabolic Syndrome in a Chinese Community Sample Aged 90+ Years. J Nutr Health Aging 2016; 20:82-8. [PMID: 26728938 DOI: 10.1007/s12603-016-0680-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the relationship between frailty and the metabolic syndrome and to evaluate how these contribute to mortality in very old people. DESIGN Secondary analysis of data from the Project of Longevity and Aging in Dujiangyan. SETTING Community sample from Sichuan Province, China. PARTICIPANTS People aged 90+ years (n=767; baseline age=93.7±3.4 years; 68.0% women. MEASUREMENTS After a baseline health assessment, participants were followed for four years (54.0% died). A frailty index (FI) was calculated as the sum of deficits present, divided by the 35 health-related deficits considered. Relationships between the FI and the metabolic syndrome were tested; their effect on death was examined. RESULTS The mean FI was 0.26 ±0.11. Higher FI scores were associated with a greater risk of death, adjusted for age, sex, education, and metabolic syndrome items. The hazard ratio was 1.03 (95% confidence interval 1.02, 1.04) for each 1% percent increase of the FI. The mortality risk did not change with the metabolic syndrome (odds ratio=0.99; 0.71-1.36). CONCLUSIONS In the oldest old, frailty was a significant risk for near-term death, regardless of the metabolic syndrome. Even using age-adjusted models, the epidemiology of late life illness may need to account for frailty routinely.
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Affiliation(s)
- Q Hao
- Kenneth Rockwood, Division of Geriatric Medicine, Dalhousie University, Suite 1421-5955 Veterans Memorial Lane, Halifax, Nova Scotia, B3H 2E1, Canada, Tel: 1-902-473-8631; Fax: 1-902-473-1050,
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Camina-Martín MA, de Mateo-Silleras B, Malafarina V, Lopez-Mongil R, Niño-Martín V, López-Trigo JA, Redondo-Del-Río MP. [Nutritional status assessment in Geriatrics: Consensus declaration by the Spanish Society of Geriatrics and Gerontology NutritionWork Group]. Rev Esp Geriatr Gerontol 2016; 51:52-57. [PMID: 26388249 DOI: 10.1016/j.regg.2015.07.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/09/2015] [Accepted: 07/19/2015] [Indexed: 06/05/2023]
Abstract
Ongoing population ageing is one of the factors influencing the increase in the prevalence of undernutrition, as elderly people are a vulnerable group due to their biological, psychological and social characteristics. Despite its high prevalence, undernutrition is underdiagnosed in the geriatric sphere. For this reason, the aim of this consensus document is to devise a protocol for geriatric nutritional assessment. A multidisciplinary team has been set up within the Spanish Society of Geriatrics and Gerontology (in Spanish Sociedad Española de Geriatría y Gerontología [SEGG]) in order to address undernutrition and risk of undernutrition so that they can be diagnosed and treated in an effective manner. The MNA-SF is a practical tool amongst the many validated methods for nutritional screening. Following suspicion of undernutrition, or after establishing the presence of undernutrition, a full assessment will include a detailed nutritional history of the patient. The compilation of clinical-nutritional and dietetic histories is intended to help in identifying the possible risk factors at the root of a patient's undernutrition. Following this, an anthropometric assessment, combined with laboratory data, will describe the patient's physical and metabolic changes associated to undernutrition. Currently, the tendency is for further nutritional assessment through the use of non-invasive techniques to study body composition in association with functional status. The latter is an indirect index for nutritional status, which is very interesting from a geriatrician's point of view. To conclude, correct nutritional screening is the fundamental basis for an early undernutrition diagnosis and to assess the need for nutritional treatment. In order to achieve this, it is fundamental to foster research in the field of nutritional geriatrics, in order to expand our knowledge base and to increasingly practice evidence-based geriatrics.
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Affiliation(s)
| | - Beatriz de Mateo-Silleras
- Área de Nutrición y Bromatología, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
| | - Vincenzo Malafarina
- Área de Geriatría, Clínica Los Manzanos, Grupo Viamed, Logroño, La Rioja, España.
| | | | | | | | - María Paz Redondo-Del-Río
- Área de Nutrición y Bromatología, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
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Ilich JZ, Inglis JE, Kelly OJ, McGee DL. Osteosarcopenic obesity is associated with reduced handgrip strength, walking abilities, and balance in postmenopausal women. Osteoporos Int 2015; 26:2587-95. [PMID: 26025288 DOI: 10.1007/s00198-015-3186-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 05/20/2015] [Indexed: 12/12/2022]
Abstract
UNLABELLED We determined the prevalence of osteosarcopenic obesity (loss of bone and muscle coexistent with increased adiposity) in overweight/obese postmenopausal women and compared their functionality to obese-only women. Results showed that osteosarcopenic obese women were outperformed by obese-only women in handgrip strength and walking/balance abilities indicating their higher risk for mobility impairments. INTRODUCTION Osteosarcopenic obesity (OSO) is a recently defined triad of osteopenia/osteoporosis, sarcopenia, and adiposity. We identified women with OSO in overweight/obese postmenopausal women and evaluated their functionality comparing them with obese-only (OB) women. Additionally, women with osteopenic/osteoporotic obesity (OO), but no sarcopenia, and those with sarcopenic obesity (SO), but no osteopenia/osteoporosis, were identified and compared. We hypothesized that OSO women will have the lowest scores for each of the functionality measures. METHODS Participants (n = 258; % body fat ≥35) were assessed using a Lunar iDXA instrument for bone and body composition. Sarcopenia was determined from negative residuals of linear regression modeled on appendicular lean mass, height, and body fat, using 20th percentile as a cutoff. Participants with T-scores of L1-L4 vertebrae and/or total femur <-1, but without sarcopenia, were identified as OO (n = 99) and those with normal T-scores, but with sarcopenia, as SO (n = 28). OSO (n = 32) included women with both osteopenia/osteoporosis and sarcopenia, while those with normal bone and no sarcopenia were classified as OB (n = 99). Functionality measures such as handgrip strength, normal/brisk walking speed, and right/left leg stance were evaluated and compared among groups. RESULTS Women with OSO presented with the lowest handgrip scores, slowest normal and brisk walking speed, and shortest time for each leg stance, but these results were statistically significantly different only from the OB group. CONCLUSION These findings indicate a poorer functionality in women presenting with OSO, particularly compared to OB women, increasing the risk for bone fractures and immobility from the combined decline in bone and muscle mass, and increased fat mass.
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Affiliation(s)
- J Z Ilich
- Department of Nutrition, Food and Exercise Sciences, Florida State University, 120 Convocation Way, 418 Sandels Building, Tallahassee, FL, 32306-1493, USA.
| | - J E Inglis
- Department of Nutrition, Food and Exercise Sciences, Florida State University, 120 Convocation Way, 418 Sandels Building, Tallahassee, FL, 32306-1493, USA
| | - O J Kelly
- Abbott Nutrition, Scientific and Medical Affairs, Columbus, OH, 43219, USA
| | - D L McGee
- Department of Statistics, Florida State University, Tallahassee, FL, 32306, USA
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Peterson MD, Zhang P, Haapala HJ, Wang SC, Hurvitz EA. Greater Adipose Tissue Distribution and Diminished Spinal Musculoskeletal Density in Adults With Cerebral Palsy. Arch Phys Med Rehabil 2015; 96:1828-33. [PMID: 26140740 PMCID: PMC4601929 DOI: 10.1016/j.apmr.2015.06.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/12/2015] [Accepted: 06/13/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To examine differences in adipose tissue distribution, lumbar vertebral bone mineral density (BMD), and muscle attenuation in adults with and without cerebral palsy (CP), and to determine the associations between morphologic characteristics. DESIGN Cross-sectional, retrospective analyses of archived computed tomography scans. SETTING Clinical treatment and rehabilitation center. PARTICIPANTS Adults (N=352) with CP (age, 38.8±14.4y; body mass, 61.3±17.1kg; Gross Motor Function Classification System levels, I-V) and a matched cohort of neurotypical adults. Of the 41 adults with CP included in the study, 10 were not matchable because of low body masses. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Computed tomography scans were assessed for visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) areas, psoas major area and attenuation in Hounsfield units (Hu), and cortical and trabecular BMDs. RESULTS Adults with CP had lower cortical (β=-63.41 Hu, P<.001) and trabecular (β=-42.24 Hu, P<.001) BMDs and psoas major areas (β=-374.51mm(2), P<.001) and attenuation (β=-9.21 Hu, P<.001) after controlling for age, sex, and body mass. Adults with CP had greater VAT (β=3914.81mm(2), P<.001) and SAT (β=4615.68mm(2), P<.001). Muscle attenuation was significantly correlated with trabecular (r=.51, P=.002) and cortical (r=.46, P<.01) BMD, whereas VAT was negatively associated with cortical BMD (β=-.037 Hu/cm(2), r(2)=.13, P=.03). CONCLUSIONS Adults with CP had lower BMDs, smaller psoas major area, greater intermuscular adipose tissue, and greater trunk adiposity than neurotypical adults. VAT and cortical BMD were inversely associated.
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Affiliation(s)
- Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.
| | - Peng Zhang
- Department of Surgery, University of Michigan, Ann Arbor, MI; Morphomic Analysis Group, University of Michigan, Ann Arbor, MI
| | - Heidi J Haapala
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
| | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI; Morphomic Analysis Group, University of Michigan, Ann Arbor, MI
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI
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Camina Martín MA, De Mateo Silleras B, Miján De La Torre A, Barrera Ortega S, Domínguez Rodríguez L, Redondo Del Río MP. Body mass index and waist circumference are not good surrogate indicators of adiposity in psychogeriatric patients. Am J Hum Biol 2015; 28:233-5. [PMID: 26179833 DOI: 10.1002/ajhb.22765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 04/15/2015] [Accepted: 06/21/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE to assess the utility of body mass index (BMI) and waist circumference (WC) as surrogate indicators of adiposity with respect to the total body fat estimated with bioimpedance analysis in psychogeriatric patients. METHODS Anthropometric and hand-to-foot bioimpedance measurements were performed according to standard procedures in a sample of 128 psychogeriatric patients (87 males, 41 females). WC cutoffs proposed by the International Diabetes Federation were used to define abdominal obesity. Z-scores of fat and fat-free mass indices (Z-FMI and Z-FFMI) were calculated. RESULTS Males with WC values below the cutoff were normal weight, and showed normal levels of FM and low FFM (Z-FFMI below 1.5 SD). Males with WC values above the cutoff were overweight, showed high levels of FM (Z-FMI: 1.34 SD) and a slight depletion of FFM (Z-FFMI: -0.59 SD). In females with WC values below the cutoff, BMI was close to 20 kg/m(2) and both FM and FFM were depleted (Z-FMI: -0.7 SD; Z-FFMI: -1.76 SD). In females with WC above the cutoff, the average BMI was 25.6 kg/m(2) , Z-FMI was 0.48 SD, and Z-FFMI was -0.56 SD. CONCLUSIONS Our results indicate that it is necessary to establish age and sex-specific BMI and WC cutoffs, and also highlight the importance of focusing on body composition analysis to ensure an accurate nutritional diagnosis in older-adults and in psychogeriatric patients.
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Affiliation(s)
- M Alicia Camina Martín
- Area of Nutrition and Food Science, Faculty of Medicine, University of Valladolid, C/Ramón Y Cajal, 7., Valladolid, 47005, Spain
| | - Beatriz De Mateo Silleras
- Area of Nutrition and Food Science, Faculty of Medicine, University of Valladolid, C/Ramón Y Cajal, 7., Valladolid, 47005, Spain
| | - Alberto Miján De La Torre
- Area of Nutrition and Food Science, Faculty of Medicine, University of Valladolid, C/Ramón Y Cajal, 7., Valladolid, 47005, Spain
| | - Sara Barrera Ortega
- Residential Care Centre San Juan De Dios, Psychogeriatric Area, Palencia. Paseo Padre Faustino Calvo S/N. Apto. 66, Palencia, 34005, Spain
| | - Luis Domínguez Rodríguez
- Residential Care Centre San Juan De Dios, Psychogeriatric Area, Palencia. Paseo Padre Faustino Calvo S/N. Apto. 66, Palencia, 34005, Spain
| | - M Paz Redondo Del Río
- Area of Nutrition and Food Science, Faculty of Medicine, University of Valladolid, C/Ramón Y Cajal, 7., Valladolid, 47005, Spain
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Camina-Martín MA, de Mateo-Silleras B, Malafarina V, Lopez-Mongil R, Niño-Martín V, López-Trigo JA, Redondo-del-Río MP. Nutritional status assessment in geriatrics: Consensus declaration by the Spanish society of geriatrics and gerontology nutrition work group. Maturitas 2015; 81:414-9. [DOI: 10.1016/j.maturitas.2015.04.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 04/29/2015] [Indexed: 12/23/2022]
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Peterson MD, Mahmoudi E. Healthcare utilization associated with obesity and physical disabilities. Am J Prev Med 2015; 48:426-35. [PMID: 25716534 PMCID: PMC4380627 DOI: 10.1016/j.amepre.2014.11.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 11/07/2014] [Accepted: 11/12/2014] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Obesity incurs a substantial economic burden to healthcare systems. Little is known about the combined medical costs attributable to obesity among individuals with physical disabilities (PDs). PURPOSE To estimate the annual healthcare utilization and expenditure associated with overweight and obesity among adults with and without PDs. METHODS Weighted multivariate generalized linear models were used to estimate healthcare costs and utilization among adults with and without PDs, across standard BMI categories, using the 2002-2011 Medical Expenditure Panel Survey. The analyses, performed in 2013-2014, included a population representative sample of 215,107 individuals, aged ≥18 years. Overall, 36,349 adults reported moderate or significant PDs. The primary outcomes were total healthcare costs, physician office visits, and hospitalization. RESULTS After adjusting for sociodemographic variables, self-rated mental and physical health, physical activity, and year, adults with PDs incurred more than 1.96 times the adjusted total healthcare costs ($4,298, 95% CI=$3,980, $4,617) than adults without PDs. Obese individuals spent significantly more than those at normal weight ($726, p<0.001). Obese individuals with PDs spent 1.13 times more than normal-weight individuals with PDs ($1,107, p<0.001) and >2.2 times more than normal-weight individuals without PDs ($5,197, p<0.001). PDs plus obesity represents $23.9 billion/year, or roughly 50% of the total costs attributable to obesity in the U.S. CONCLUSIONS Across BMI categories, there was significantly greater healthcare utilization and cost among adults with PDs, independent of age, race, education, and SES. Health policies need to identify behavioral interventions that address both healthy weight achievement/maintenance and functional independence among all adults.
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Affiliation(s)
- Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Elham Mahmoudi
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Ruff RR, Zhen C. Estimating the effects of a calorie-based sugar-sweetened beverage tax on weight and obesity in New York City adults using dynamic loss models. Ann Epidemiol 2015; 25:350-7. [PMID: 25659449 DOI: 10.1016/j.annepidem.2014.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/27/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Sugar-sweetened beverages (SSBs) contribute to weight gain and increase the risk of obesity. In this article, we determine the effects of an innovative SSB tax on weight and obesity in New York City adults. METHODS Dynamic weight loss models were used to estimate the effects of an expected 5800-calorie reduction resulting from an SSB tax on weight and obesity. Baseline data were derived from the New York City Community Health Survey. One, five, and 10-year simulations of weight loss were performed. RESULTS Calorie reductions resulted in a per-person weight loss of 0.46 kg in year 1 and 0.92 kg in year 10. A total of 5,531,059 kg was expected to be lost over 10 years when weighted to the full New York City adult population. Approximately 50% of overall bodyweight loss occurred within the first year, and 95% within 5 years. Results showed consistent but nonsignificant decreases in obesity prevalence. CONCLUSIONS SSB taxes may be viable strategies to reduce obesity when combined with other interventions to maximize effects in the population.
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Affiliation(s)
- Ryan Richard Ruff
- Department of Epidemiology & Health Promotion, New York University College of Dentistry, New York University Global Institute of Public Health, New York.
| | - Chen Zhen
- Food and Nutrition Policy Research Program, RTI International, Research Triangle Park, NC
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Peterson MD, Haapala HJ, Chaddha A, Hurvitz EA. Abdominal obesity is an independent predictor of serum 25-hydroxyvitamin D deficiency in adults with cerebral palsy. Nutr Metab (Lond) 2014; 11:22. [PMID: 24883075 PMCID: PMC4039320 DOI: 10.1186/1743-7075-11-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
Background Individuals with cerebral palsy (CP) are at risk for nutritional insufficiency. The purpose of the study was to examine the vitamin D status of adults with CP, and to evaluate the association between vitamin D and functional level, age, race, and anthropometric indicators of adiposity. Methods Serum vitamin D levels, BMI, waist circumference (WC), and functional level (measured by Gross Motor Function Classification System (GMFCS)) were examined in 112 adults with CP. Vitamin D status was assessed by serum 25-hydroxyvitamin D level (25(OH)D). The influence of motor impairment and adiposity on 25(OH)D were assessed using general linear modeling and logistic regression, with age, sex, race, and season as covariates. Results Mean vitamin D was 28.1 ± 16.0 ng/ml. Only 45% of subjects had optimal levels of 25(OH)D, 21% were insufficient and 34% were deficient. Overweight or obesity was prevalent (52%), as was abdominal obesity in men (23.5% at 102 cm cutoff) and women (31.1% at 88 cm cutoff). There was a robust association between the indicator of visceral adiposity (WC) and 25(OH)D level (p <0.001), even after controlling for age, sex, race, season, and GMFCS. According to sex-specific WC cutoffs, the odds of being deficient in vitamin D increase by a factor of 3.5 (95% CI 1.12-11.0) for abdominal obesity. GMFCS was not associated with 25(OH)D. Conclusions Adults with CP are at risk for low vitamin D levels and overweight/obesity. Waist circumference is a strong independent predictor for low vitamin D levels.
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Affiliation(s)
- Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan Health Systems, 325 E. Eisenhower Parkway, Suite 300, Ann Arbor, Michigan 48108, USA
| | - Heidi J Haapala
- Department of Physical Medicine and Rehabilitation, University of Michigan Health Systems, 325 E. Eisenhower Parkway, Suite 300, Ann Arbor, Michigan 48108, USA
| | - Ashish Chaddha
- Department of Physical Medicine and Rehabilitation, University of Michigan Health Systems, 325 E. Eisenhower Parkway, Suite 300, Ann Arbor, Michigan 48108, USA
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan Health Systems, 325 E. Eisenhower Parkway, Suite 300, Ann Arbor, Michigan 48108, USA
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