relationships between leisure-time physical activity, obesity and disability in elderly men

Key words: Disability, elderly, obesity, physical activity.Correspondence: M. Zamboni, MD, Clinica Geriatrica, Ospedale Maggiore, Piazzale Stefani 1, 37126 Verona, Italy.E-mail: [email protected] February 27, 2004; accepted in revised form July 22, 2004.

Aging Clin Exp Res, Vol. 17, No. 3 201

ABSTRACT. Background and aims: Relationshipshave already been shown between leisure-time phys-ical activity, obesity and body composition in youngadults. However, this association needs to be con-firmed in the elderly. The aim of this study was to in-vestigate the relationship between leisure-time phys-ical activity, obesity, preservation of muscle massand disability in elderly men. Methods: Cross-sec-tional analysis of a sample of 85 community-dwellingmen, 68 to 79 years of age. Body mass index (BMI)was used to quantify obesity. Body composition wasevaluated using Dual Energy X-ray Absorptiometry.Disability was measured using a modified version ofthe Activities of Daily Living scale. Leisure-time phys-ical activity was evaluated by a validated self-admin-istered questionnaire. Results: A negative relation be-tween obesity and weekly walking was observed.Walking less than 30 minutes per day was associatedwith a 2.7 greater probability of being obese (95% CI1.1-6.7). High-intensity exercise, such as brisk walk-ing or gardening, was inversely correlated with bodyfat (R=–0.296, p<0.01) and directly correlated withappendicular skeletal mass (R=0.238, p<0.05). Theprevalence of disability was the highest (58%) amongoverweight elderly subjects at the lowest tertile of ex-ercise. Multiple logistic regression selected BMI as apositive predictor and high-intensity exercise as anegative predictor of disability. Conclusions: Ourstudy shows that, in elderly men, leisure-time physi-cal activity is inversely associated with body fat, BMI,and reported disability, but positively associated withappendicular fat-free mass. The highest prevalence ofreported disability was observed in sedentary sub-jects with BMI higher than 25 kg/m2.(Aging Clin Exp Res 2005; 17: 201-206)©2005, Editrice Kurtis

Relationships between leisure-time physical activity,obesity and disability in elderly menVincenzo Di Francesco1, Mauro Zamboni1, Elena Zoico1, Arianna Bortolani1, Stefania Maggi2, LuisaBissoli1, Alessandra Zivelonghi1, Silvia Guariento1, and Ottavio Bosello1

1Department of Biomedical and Surgical Sciences, Division of Geriatrics and Clinical Nutrition, University ofVerona, Verona, 2National Research Council Center on Aging, University of Padova, Padova, Italy

INTRODUCTIONAge-associated changes in body composition main-

ly consist of a decline in muscle mass and an increasein fat mass, with centripetal redistribution (1-3). Thesemodifications may contribute to functional impairment,leading to disability in the elderly (2-9). Higher per-centages of fat mass have been associated with greaterfunctional disability in older men and women (2-7).Loss of skeletal muscle mass has also been shown to becorrelated with disability in the elderly (5, 8, 9).

A sedentary life-style is related to impaired fitnessand to obesity (10) and may in itself be a major causalfactor of disability (11). Furthermore, resistance exercisetraining increases muscle mass and counteracts themuscle weakness and physical frailty typical of aging (8).

Few data are available on the effects of sponta-neous leisure-time physical activity (LTPA), such aswalking or gardening, on the risk of developing obesi-ty and disability in the elderly. There is no published ev-idence of a positive correlation between LTPA andfat-free mass. So far only intensive resistance physicalactivity has been shown to be related positively with fat-free mass. Interventional studies demonstrated thatonly the prescription of such a kind of resistance ex-ercise was able to prevent age-related fat-free massdecline (12). Cross-sectional studies show that LTPA isnot associated with either muscle size (13) or fat-freemass (14).

Current guidelines on exercise and health are most-ly set for younger adults. Attention should be paid to theeffect of exercise on older subjects, particularly thepossibility of muscle mass preservation at more ad-vanced ages. The aim of this study was to investigatethe relationships between LTPA, body composition,obesity, and disability in healthy community-dwelling el-derly men.

Aging Clinical and Experimental Research

METHODSSubjectsSubjects were randomly selected from the patient lists

of 11 general practitioners in the city of Verona, Italy. En-try criteria were the ability to walk at least 800 meterswithout difficulty; no cognitive impairment (defined as Mi-ni Mental Test score lower than 24); no neoplasms or se-vere chronic diseases such as heart failure (NYHA class 2or higher), chronic obstructive pulmonary disease (as de-fined by clinical records or spirometric tests), renal failure(serum creatinine greater than 1.2 mg/dL); and, in gen-eral, no condition that could affect life expectancy. A to-tal of 85 community-dwelling men (aged 68 to 79 years,BMI 19 to 38 kg/m2) was selected from their residencesin the center of the city. Table 1 lists the main samplecharacteristics.

All subjects gave their written consent to the study. Theprotocol was approved by the local Ethical Committee.

ProceduresAnthropometry. Body weight was measured to the

nearest 0.1 kg and height to the nearest 0.5 cm usinganalog-scale instruments (Salus scale and Salus Sta-diometer, Milan, Italy). Body mass index (BMI) was cal-culated as body weight adjusted by stature (kg/m2). Ac-cording to the WHO classification of obesity (15), subjectswith BMI between 25 and 29.9 kg/m2 were classified as

“overweight” and those with BMI equal to or greaterthan 30 kg/m2 as “obese” (16).

Body Composition. Body composition was deter-mined using Dual-energy X-ray Absorptiometry (DXA)(Hologic QDR 2000, Waltham, USA) array beam withsoftware version 7.2. The characteristics and physical con-cept of DXA measurements have been described else-where (17). All of objects containing metal (jewelry, zip fas-teners, snaps, belts) were removed. Measurements weretaken with the subject in the supine position on thescanning table. Radiation exposure was less than 8 Sv,and mean measurement time was 6 minutes. Daily qual-ity assurance tests were performed according to themanufacturer’s directions. All the scans were subse-quently analyzed by a single trained investigator. Totalbody fat was expressed as a percentage of body weight aswell as in kg, and lean body mass was expressed in kg.The coefficient of variation (CV) for double determinationin 11 male subjects aged 65-75 years with BMI 22 to 32kg/m2 was 1% for total body fat, 1.3% for lean mass, and2.3% for percent fat mass. Skeletal muscle compart-ments of arms and legs were examined using the sub-re-gion option of the software. Appendicular skeletal musclemass (ASM) was calculated as the sum of the fat-free massof arms and legs (8). The CV for double determination ofASM in 18 elderly subjects was 2.5%.

Reported disability. Reported disability was defined ac-cording to Langlois et al. (18), based on the ability to car-ry out four of the six items from the Activity of Daily Liv-ing scale (ADLs) (19) (bathing, getting out of bed, dress-ing, eating without the help of another person) and walk-ing across a small room, scored as easy, difficult, very dif-ficult or impossible, on three Rosow-Breslau physicalfunction items (walking 800 meters, climbing stairs, doingheavy housework), scored as easy, difficult, very difficultor impossible (20), and on selected items of the Instru-mental Activity of Daily Living scale (IADL) (shopping, us-ing the telephone, doing light housework, preparingmeals) (21). Two groups were identified:1) No Physical Function Limitations: subjects reported

“easy” for all ADLs, ”no difficulty” for the physical func-tion items, and “no difficulty” or “don’t do” for allIADLs.

2) With Physical Limitations: participants reported somelevel of physical disability on any of the three scales.In a larger Italian community-based study, this com-

bined scale showed a strong association with well-estab-lished predictors of physical performance (18).

The presence of chronic conditions, information abouteducational level and social status, and smoking habitswere determined by standardized questionnaires alreadyin use in the Italian Longitudinal Study on Aging (22). Inparticular, already known radiological evidence of kneearthritis was evaluated in all subjects.

Physical activity. Physical activity was assessed by a

V. Di Francesco, M. Zamboni, E. Zoico, et al.

202 Aging Clin Exp Res, Vol. 17, No. 3

Aging Clin Exp Res 17: 201-206, 2005©2005, Editrice Kurtis

Table 1 - Main characteristics of 85 men composing study sample.

Means±SD Range

Age (years) 72.7±2.2 68-79Height (m) 1.69±0.07 1.55-1.90Weight (kg) 79.1±12.4 51.3-111.5BMI (kg/m2) 27.5±3.9 19.5-37.9Fat mass* (Kg) 22.1±7.1 14.4-47.3Fat-free mass* (kg) 52.6±5.3 37.4-64.2ASM* (kg) 21.3±2.3 15.2-26.5

n (%)

Living with partner 71 (83.5)Educational level:

Primary 28 (32.9)Secondary 40 (47.1)University 17 (20)

Current smokers 14 (16.5)Former smokers 49 (57.6)Hypertension 50 (58.8) Diabetes 8 (9.4) Cardiovascular diseases 13 (15.3) Osteoarthritis of knees 8 (9.4)

BMI: body mass index; ASM: appendicular skeletal muscle mass. *evaluatedby Dual Energy X-ray Absorptiometry.

self-administered questionnaire, originally designed for re-tired men and already used for the Italian population(23). This questionnaire demonstrated a substantial 4-month test-retest correlation (R=0.93, p<0.001) andhas been validated by the doubly labeled water method(R=0.61, p<0.01) (24). The core questionnaire consistedof seven questions about the frequency and duration ofwalking and/or cycling during the previous week, the av-erage amount of time spent weekly on hobbies like gar-dening, farming and the average time spent monthly onodd jobs and sports. The items covered the large major-ity of daily activities in this sample of retired Italian men.

Estimated times were converted into minutes perweek for each type of activity and summed to obtain to-tal weekly LTPA. Hobbies and sports were includedonly when they demanded physical effort. The samplewas also divided into two groups according to the timespent walking, by using a cut-off value of 210 minutes ofwalking per week, corresponding on average to 30minutes/day.

Activities were also grouped by level of intensity usingthe intensity codes and categories proposed by Caspersen

et al. (13): light (e.g., walking the dog), moderate (e.g.,walking, slow cycling, fishing, shooting), and heavy (e.g.,brisk walking, cycling, gardening, sports, dancing).

Statistical analysis Data are showed as means ± standard deviation values.

Body composition and exercise data were used as con-tinuous variables for mean comparison by the Mann-Whitney U-test and Spearman’s correlation. Variableswere also recoded in tertiles for cross-tabulation andevaluated using both the chi-square test and analysis ofvariance, calculated by the Kruskall-Wallis test. The oddsratio (OR) (95% CI) predicting obesity and functionallimitation based on different physical exercise classeswere obtained from logistic regression models, after con-trolling for potential covariates when indicated. Logistic re-gression was performed using disability as the dependentvariable. Data were analysed by SPSS software for Win-dows, rel. 11 (SPSS Inc. Chicago Illinois, USA).

RESULTSTable 2 shows physical activity patterns as estimated on

the basis of the received questionnaires. Only 3 subjects(3.5%) declared complete inactivity. The most frequent ex-ercise was walking. Eighty-eight percent of subjectswalked regularly during the week, either at moderate orhigher speed.

By dividing subjects into tertiles of time spent walking,only 6.7% of the obese subjects (BMI ≥30 kg/m2) werefound to be in the highest tertile, compared with 30.5%in the second and 34.5% in the lowest tertile (chi-squaretest p<0.05).

Walking less than 210 min/week (30 min/day) was as-sociated with an increased prevalence of obesity (OR2.7, 95% CI 1.1-6.7).

Table 3 shows the partial correlation between intensityof exercise and the three most frequent types of exerciseperformed by our subjects, and body composition vari-ables, after adjusting for BMI and age. Total and high-in-tensity LTPA were inversely correlated with body fatand percent body fat, and directly correlated with ASM.

Physical activity, obesity, and disability in elderly men



Table 2 - Physical activity patterns study sample.

Type of activity Minutes of Percent of men activity/week reporting type

mean±SD (range) of exercise

Walking 298±288 (0-1680) 88% Gardening 239±393 (0-1860) 52% Cycling 75±131 (0-600) 46% Farming 28±114 (0-690) 11% Dancing 30±47 (0-161) 15% Sports 37±107 (0-480) 16% Odd jobs 73±135 (0-900) 51%

Low-intensity activity 5±31 (0-240) 8%Medium-intensity activity 291±318 (0-1680) 84%High-intensity activity 417±448 (0-2020) 82%Total activity 688±691 (0-2320) 96.5%

Table 3 - Partial correlation between exercise, expressed as minutes per week, and body composition evaluated by DXA. Data adjust-ed by age and BMI.

Body fat (kg) Percent body fat (%) Fat-free mass (kg) ASM (kg)

Total exercise -0.238* -0.276* 0.194 0.250*Moderate intensity -0.016 0.024 -0.01 -0.002High intensity -0.296** -0.340** 0.185 0.238*Walking -0.082 0.050 0.146 0.156Cycling 0.001 -0.040 0.095 0.142Gardening -0.324** -0.338** 0.066 0.296**

*p<0.05, **p<0.01. ASM: Appendicular mass skeletal muscle; DXA: Dual Energy X-ray Absorptiometry.

Moderate-intensity LTPA and total walking time (includ-ing both moderate and high-intensity walking) were not as-sociated with body composition variables.

By dividing subjects into tertiles of high-intensity LTPA,mean appendicular fat-free mass was higher in moreactive men: weighted means adjusted for BMI and age: 1st

tertile: 20.7, 2nd 21.3 and 3rd 22.1 kg (p=0.05; data notshown in Table).

Thirty-six subjects (42.3%) were classified as beingdisabled. Almost all the disabilities were mentioned amongthe Rosow-Breslau items: climbing stairs, doing heavyhousework, kneeling and bending. Only 1 subject re-ported difficulty in dressing (ADL scale) and 1 in writing(IADL scale).

Compared with elderly men without physical limita-tions, those with disability reported significantly less timespent in total exercise (795±532 vs 544±440 min/week,p<0.05) and, notably, fewer minutes of walking perweek (327±185 vs 258±190, p<0.05).

Figure 1 shows the prevalence of subjects with dis-ability, according to BMI and tertiles of time spent week-ly in physical exercise. The risk of disability was thehighest for overweight subjects at the lowest tertile ofleisure-time physical activity, even after adjusting for thepresence of knee arthritis (OR 2.31, 95% CI 1.38-4.01).

Backward logistic regression analysis was performed us-ing physical function limitations as the dependent variable,and age, cigarettes smoked per day, BMI, fat-free mass,fat mass, ASM, walking time, moderate and high-intensityminutes of LTPA (included as hours per week) as inde-pendent variables. BMI was selected as the positive pre-dictor of physical function limitation: Exp(B) 1.17 (95% CI1.01-1.35). High-intensity LTPA was the only negativepredictor of disability: Exp(B) 0.92 (95% CI 0.85-0.99).An increase of 1 unit of BMI was associated with a 17%greater probability of functional limitation, 1 hour of

high-intensity LTPA per week to a 8% reduction in theprobability of functional limitations.

DISCUSSIONOur data show that, in elderly men, walking is in-

versely associated with body fat, BMI and reported dis-ability, and that the highest rate of reported disability is ob-served in sedentary subjects with BMI higher than 25. Ourstudy also shows a significant association between LTPAand appendicular fat-free mass. The relation betweenbody fat, obesity and reported disability has been previ-ously shown in the elderly (2, 4, 6, 7). However, our find-ings indicate a link between LTPA, obesity and disability.In particular, in our study subjects walking less than 30min. daily showed the highest probability of being obese.The evidence of the beneficial effect of exercise comesfrom studies conducted on young adults: however, theamount of daily physical exercise recently suggested forpreventing obesity (25) is much higher than that ob-served in our subjects. Conversely, our results are in linewith WHO recommendations of moderate daily exer-cise as part of the lifestyle for healthy elderly people(26) and particularly with the “Healthy People 2010” pro-gram (27), indicating the goal of 30 minutes at least 5days a week to promote health even at more advancedages than those of our sample.

In our subjects, we observed a significant association be-tween LTPA and appendicular fat-free mass. To the bestof our knowledge, no other study has reported a positiverelation between leisure-time exercise and fat-free mass.

So far, longitudinal observations have demonstratedthat only resistance exercise can influence fat-free mass(9, 12). Cross-sectional studies have failed to observe anyassociation between leisure-time exercise and fat-freemass (13, 14).

Discrepancies in study sample, methods used to assessleisure-time physical activity and body composition mayexplain these differing results.

We tested appendicular fat-free mass, and not only fat-free mass, and this may have contributed to our positivefindings. It is likely that the amount of fat-free mass in thelegs (the greater part of appendicular fat-free mass) ismuch more responsive to LTPA, which consists primar-ily of walking, cycling and gardening.

We recently observed that, in old subjects, even a 2-yearfollow-up was associated with body composition changes(i.e., loss of fat-free mass and increase in fat mass) (3).

However, on the basis of our results, showing an op-posite association between LTPA, fat and appendicularfat-free mass, this type of exercise, not dangerous for mostolder subjects, may counteract the effects of aging on bodycomposition and, in particular, prevent sarcopenia.

In our subjects, leisure-time physical activity was neg-atively related with reported disability. Physical disabilityis a condition depending on flexibility, balance, aerobic ca-




50

% d

isab

ility

1st 2nd 3rd(0-420) (421-728) (729-2300)

Tertiles of physical exercise (min/week)

BMI <25 (n=22)BMI>=25 (n=63)

40

30

20

10

0

60 a

b

Fig. 1 - Prevalence of subjects with disability, according to BMI andto tertiles of time spent weekly in physical exercise in 85 menaged 68 to 79 years. Odds ratio for physical function limita-tions for (a) Vs (b) = 2.31 (95% CI 1.38-4.01) (adjusted for pres-ence of knee arthritis).

pacity and muscle strength (28) and may be improved byactivities such as gardening, walking, etc.

Actually we found that subjects in the lower tertile ofleisure-time physical activity and the higher tertile ofBMI showed a higher probability of being disabled, indi-cating that obese sedentary subjects are at high risk of dis-ability. However, it must be admitted that a cross-sectionalstudy can only show associations and not cause-effect re-lations. In other words, on the basis of our study, it is notpossible to exclude a different causative sequence, inwhich high BMI itself is responsible for greater disabilityand then leads to inactivity.

Knee osteo-arthritis is frequent in old age, particularlyin overweight and obese subjects (29), and may itself af-fect disability and leisure-time physical activity (30). Itwas therefore interesting to note that the observed rela-tion between low leisure-time physical activity and highBMI with reported disability was still significant, even af-ter adjusting for knee osteo-arthritis.

This study has some limitations which deserve com-ment. First, both disability and LTPA were evaluated by in-direct measures using questionnaires. Nevertheless, re-ported disability has been shown to be associated with di-rect performance evaluation and is considered a reliableequivalent of everyday autonomy in the elderly (19, 20).The leisure-time physical activity questionnaire whichwas applied, demonstrated a substantial 4-month test-retest correlation and was validated by the doubly la-beled water method (24).

Second, our study sample was relatively small and on-ly healthy subjects were selected at the high end of thefunctional spectrum. Thus, our findings may not be rep-resentative of the general Italian elderly population. Con-versely this selected group, with a LTPA level higherthan that of the normal age-matched population (31, 32)should be considered a good model for studying the effectsof volitional exercise on body composition and disability.

Even considering these limitations, our results indicatethat the promotion of LTPA already familiar in the elder-ly, such as walking, cycling or gardening, may be able toprevent age-dependent body composition changes, aswell as disability. To confirm this hypothesis, further lon-gitudinal studies are needed, also in a more frail dependentelderly population, but our cross-sectional data already in-dicate that LTPA should be encouraged in the elderly.

In conclusion, our study shows that, in elderly men,LTPA is inversely associated with body fat, BMI and re-ported disability, and positively associated with appen-dicular fat-free mass. The highest prevalence of re-ported disability was observed in sedentary subjectswith BMI higher than 25 kg/m2.

ACKNOWLEDGEMENTSThis study was supported by a grant from the MIUR (Ministero

Istruzione Università e Ricerca), Cofin 2003 N. 200369951-002.

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