Severe central obesity or diabetes can replace weight loss in the detection of frailty in obese younger elderly – a preliminary study

Figures & data

Table

New potential variables
1. Severe obesity as defined by waist circumference
Rationale: Abdominal obesity is associated with frailty and its outcomes (eg, functional impairment, higher mortality rate); is linked to insulin-resistance and higher inflammatory state, which are all mechanistically associated with frailty and sarcopenia.
Cutoff: The cutoff for the definition of severe obesity is the highest quartile (75th) for each gender (for males, 119.6 cm; for females, 132 cm). Since our study population was selectively chosen based on the presence of obesity, the usually applied higher cutoff for the general population was selected based on statistical reasoning. Females and males were analyzed separately.
2. Severe obesity as defined by % body fat
Rationale: The proportion of body fat increases with age in parallel to the decrease in lean mass, which is at the core of sarcopenia and frailty.
Cutoff: The selected cut-off is based on the highest quartile (75th) for each gender (for males, 35.5%; for females, 47.9%), to keep unity in cutoffs chosen for analysis. Females and males were analyzed separately.
3. Severe obesity as defined by BMI
Rationale: BMI is the most commonly used measure of obesity which is related to higher risk for frailty and its outcomes such as disability and mortality.
Cutoff: The cutoff chosen for BMI-based definition of severe obesity in this study is the highest quartile (75th) (for both genders: >38.5 kg/m^2) and is selected here to keep unity in cutoffs chosen for analysis. The cutoff is within the range of hazardous levels of obesity (BMI >35 kg/m^2).

Abbreviation: BMI, body mass index.

Table 1 (A) Participants’ health characteristics with stratification to frailty status by Fried phenotype model (exposure) and (B) participants’ frailty and disability characteristics with stratification to frailty status by Fried phenotype model (exposure)

	Total sample (n=50)			Not-prone for frailty (NFP) (n= 16)			Frailty prone (FP) (n=34; 7 of them frail)
	All	Females (n=30)	Males (n=20)	All	Females (n=10)	Males (n=6)	All	Females (n=20)	Males (n=14)
(A) Health characteristics
Age (years)	69±3	68.7±3	69.4±3.4	68.43±2.7	67.9±2.1	69.2±3.6	69.3±3.4	69.1±3.4	69.5±3.4
	(63–75)	(63–75)	(65–75)	(65–74.8)	(65–71)	(65.2–74.8)	(63–75)	(63–75)	(65–75)
BMI (kg/m^2)	35±6	36.6±6.3	31.9±3.6a	33.7±5.8	35.5±6.3	30.7±3.6	35.2±5.8	37.1±6.4	32.4±3.6a
	(25–51)	(26.8–51.4)	(25–39.4)	(24.5–49.1)	(26.8–49.1)	(24.6–34.1)	(26.8–51.4)	(27.5–51.4)	(26.8–39.4)
WC (cm)	118±14	119.9±16.3	114.8±10.7	110.6±10	111.6±11	109±8.7	121.3±15.1b	124.1±17.2b	117.3±10.8
	(87–147)	(87–146.5)	(99–145)	(93.5–137.5)	(93.5–137.5)	(99–118.7)	(87–146.5)	(87–146.5)	(104–145)
Fat (% of body weight)	39±8	44.6±4.5	31.2±4.5a	39±7.7	43.5±4.9	31.6±5.2	39.4±8.2a	45.2±4.3	31.1±4.4
	(23–54)	(37.7–54.3)	(23.3–37.4)	(24.3–54.3)	(37.7–54.3)	(24.3–37.3)	(23.3–51.7)	(38.2–51.7)	(23.3–37.4)
General obesity (%; mean BMI ± SD)c	78; 37±5	87; 38±6	65; 34±2	75; 36±5	80; 38±5	67; 33±1	79; 37±5	90; 38±6	64; 35±3
Abdominal obesity (%)c	96; 119±14	97; 121±15	95; 116±10	94; 111±10	100; 112±11	83; 111±8	97; 122±14	95; 126±15	100; 117±11
Prevalent morbidities (partial list)
% diabetes (n)	52 (26)	43 (13)	65 (13)	44 (7)	30 (3)	67 (4)	56 (19)	50 (10)	64 (9)
% hypertension (n)	70 (35)	70 (21)	70 (14)	56 (9)	70 (7)	33 (2)	76 (26)	70 (14)	86 (12)b
% osteoporosis (n)	24 (12)	27 (8)	20 (4)	31 (5)	40 (4)	17 (1)	21 (7)	20 (4)	21 (3)
% co-morbidity (≥4 conditions) (n)d	24 (12)	20 (6)	30 (6)	12 (2)	0	33 (2)	29 (10)	30 (6)	29 (4)
Metabolic syndrome (%, ≥3 components)	90	90	90	81	80	83	94	95	93
HbA1c (%; n=41)	6.7±1.2	6.6±1.3	6.7±1.1	6.56±1.3	6±0.8	7.6±1.3a	6.7±1.2	6.9±1.4	6.4±0.9
	(5–11)	(5–11)	(5–10)	(5–10)	(5–8)	(6–10)	(5–11)	(6–11)	(5–8)
(B) Frailty status
Fried model
Physical activity energy expenditure (Kcals per week)	518±757	504.9±755	538.4±777	1,300±658	1,296±689	1,307±668	150.2±465	109±390e	209±566e
	(0–2,755)	(0–2,755)	(0–2,297)	(400–2,775)	(400–2,755)	(500–2,298)	(0–1,966)	(0–1,704)	(0–1,966)
Frail by physical activity (%)	60 (30)	60 (18)	60 (12)	0	0	0	88 (30)	90 (18)	86 (12)
Hand grip (average of both hands; kg)	31±8	25.3±5.6	38.2±5.2f	32.1±6.2	28.4±3.4	38.2±4.8	29.8±9.2	23.8±6e	38.2±5.6f
	(13–46)	(12.8–36.3)	(29.6–46.1)	(23.6–44)	(23.6–36.3)	(32.05–44.05)	(12.8–46.1)	(12.8–34.6)	(29.6–46.1)
Frail by grip strength (%)	22 (11)	27 (8)	15 (3)	0	0	0	32 (11)	40 (8)	21 (3)
4 m walk (seconds)	3.4±0.8	3.6±0.9	3.2±0.5	3±0.4	3±0.3	2.9±0.5	3.6±0.8e	3.9±0.9e	3.3±0.5f
	(2.1–5.7)	(2.4–5.7)	(2.1–4.1)	(2.1–3.6)	(2.6–3.6)	(2.1–3.5)	(2.3–5.7)	(2.3–5.7)	(2.5–4.1)
Frail by walk time (%)	18 (9)	27 (8)	5 (1)	0	0	0	26 (9)	40 (8)	7 (1)
% unintentional weight loss	6 (3)	10 (3)	0	0	0	0	9 (3)	15 (3)	0
% exhaustion	16 (8)	17 (5)	15 (3)	0	0	0	24 (8)	25 (5)	21 (3)
% frail-prone (pre-frail + frail) by the 5 questions screening tool (% frail)	50	60	35	12	20	0	68	80	50
	(16% frail)	(20% frail)	(10% frail)	(0 frail)	(0 frail)		(24% frail)e	(30% frail)e	(14% frail)e
Functional assessment
Physical function tests
Sit to stand 30 seconds (STS 30) (repetitions)	11±3	10.4±3.4	11.8±3.3	12.4±1.7	11.6±1.5	12.8±1.8	10.5±3.8	9.8±3.8	11.43±3.7
	(0–16)	(0–16)	(0–16)	(9–16)	(9–13)	(11–16)	(0–16)	(0–16)	(0–16)
2 minute walk test (meters)	164.6±40.8	152.4±38.5	182.2±38.5	184.2±24.1	176.8±19.2	196.5±28.0	155.1±44.1e	139.5±40.1e	176.1±41.5f
	(58–251)	(58–202)	(107–251)	(142–234)	(142–202)	(167–234)	(57.9–251.1)	(57.9–198.1)	(107.5–251.1)
Leg extension (average of both legs; kg)	27±9	22.7±7.5	33.3±7.3f	29.5±8	26.6±6.5	34.2±8.4	25.7±9.3	20.7±7.3	32.9±7f
	(7.5–49.5)	(7.5–38)	(20.5–49.5)	(18–44.5)	(18–35.5)	(20.5–44.5)	(7.5–49.5)	(7.5–38)	(23.5–49.5)
Functional level (reported by patient)
Functional score (0–36)g	13±5	13.9±5	12.05±4	10.3±1.3	10.7±1.5	9.7±0.8	14.5±5.1e	15.5±5.4e	13.1±4.4e
	(9–27)	(9–27)	(9–21)	(9–14)	(9–14)	(9–11)	(9–27)	(9–27)	(9–21)

Notes: Data are shown as mean ± SD for continuous variables (range) or % for nominal/categorical variables.

a Males vs females in the same group (all population, not prone and frailty-prone groups) significantly different (P<0.05).

b Males vs males, females vs females, and all vs all between groups (not prone and frailty-prone groups) significantly different (P<0.05).

c General obesity was defined using BMI levels ≥30 kg/m² and abdominal obesity was defined as waist circumference ≥102 cm for men and ≥88 cm for women.

d The presence of four or more of the following conditions: coronary heart disease/congestive heart failure/stroke/chronic kidney disease/asthma/diabetes/hypertension/osteoporosis/glaucoma and/or cataract/unbalanced dyslipidemia.

e Males vs males, females vs females, and all vs all between groups (not prone and frailty-prone groups) significantly different (P<0.05).

f Males vs females in the same group (all population, not prone and frailty-prone groups) significantly different (P<0.05).

g CFAQ to assess physical function state by questions on activities of daily living (nine questions in total). Each had an answer score of 0–4. A score of “0” indicates that the activity was not performed unrelated to health problems. Increasing score from 1 to 4 reflects greater difficulty associated with the specific activity. Answers in each of the nine questions in the functional questionnaire were summed to a total score ranging from 0 (no impairment at all) up to 36 (the highest functional impairment). χ² test for categorical variables and t-test (or Mann–Whitney) for continuous variables.

Abbreviations: BMI, body mass index; WC, waist circumference; CFAQ, Comprehensive Functional Assessment Questionnaire.

Table 2 Spearman correlations coefficients of anthropometric and metabolic variables and functional tests

Frailty and functional variables	% body fat (n=50)	BMI (kg/m^2) (n=50)	Waist circumference (cm) (n=50)	% HbA1C (n=41)
Fried phenotype model
4m walk (average; sec)	0.212	0.275	0.291*	0.096
Hand grip (average of both hands; kg)	−0.659**	−0.348*	−0.23	0.003 (F: −0.505*)
PA energy expenditure (Kcals per week)	−0.066	−0.084	−0.337*	−0.147 (F: −0.523*)
Frailty total scores by Fried (0–5)	0.174	0.212	0.464** (F: 0.453*)	0.127 (M: −0.546*; F: 0.533**)
Other functional tests
Leg extension (average of both legs; Kg)	−0.438**	−0.23	−0.099	0.203
Sit to stand 30 secs (STS 30; repetitions)	−0.247 (n=46)	−0.172 (n=46)	−0.348* (n=46) (F: −0.464*)	−0.334* (n=37) (F: −0.673**)
2 min walk test (meters)	−0.439** (F: −0.505**)	−0.544** (F: −0.505**)	−0.570** (F: −0.729**)	−0.23 (F: −0.528*)
Functional Assessment Questionnaire
Functional score (0–36)1	0.251	0.263	0.296*	0.231

Notes: Correlations between anthropometric and metabolic characteristics, and functional outcomes (Spearman’s rho). Correlations for gender added only when significant. Bold numbers indicate significant results in the level of the whole sample.

* Correlation is significant at the 0.05 level (two-tailed).

** Correlation is significant at the 0.01 level (two-tailed).

1 As indicated within Table 1B.

Abbreviations: BMI, body mass index; F, females; M, males; PA, physical activity.

Figure 1 Sensitivity rates (%) of the different models per each cutoff to differentiate the frailty states.

Notes: Sensitivity rates stratified by the different model per each cutoff to differentiate the frailty state levels. Models were validated against functional impairment (as represented by the functional activities of daily living questionnaire used in our study with any score >16).
Abbreviations: BMI, body mass index; FRAIL, fatigue, resistance, ambulation, illnesses, and loss of weight; WC, waist circumference.

Table 3 Participants’ general and frailty characteristics with stratification to functional status by the comprehensive functional assessment questionnaire (outcome)

	No functional impairment (score ≤16) (n=42)	Functional impairment (score >16) (n=8)	P-value between groups
Age (years)	69.0±3.0	69.1±4.2	0.929
Gender (% females) (n)	59.5 (25)	62.5 (5)	0.875
Marital status (% not married)a (n)	38 (16)	50 (4)	0.476
Economic status (% report of average or not so good)b (n)	26 (11)	50 (4)	0.178
Highest educational level (% with lower than academic level)c (n)	26 (11)	12.5 (1)	0.498
Smoking (% current smokers)d (n)	7 (3)	12.5 (1)	0.609
% comorbidity (≥4 conditions)e (n)	16.6 (7)	62.5 (5)	0.005
% frail-prone by Fried (% frail)	62 (4.7)	100 (62.5)	0.034
Frailty by Fried (scores)	0.9±0.88	2.88±1.64	0.011
% frail-prone by Fried + WC (% frail)	64 (12)	100 (62.5)	0.043
Frailty by Fried + WC (scores)	1.10±1.08	3±1.31	0.004
% frail-prone by Fried + diabetes (% frail)	78.5 (9.5)	100 (62.5)	0.148
Frailty by Fried + diabetes (scores)	1.36±1.03	3.38±1.3	0.003

Notes:

a “Married” vs merged groups of “not-married” (single/divorced/widowed =1).

b Based on the following question: “How do you define your economic status” (1 – not so good; 2 – average; 3 – good; 4 – excellent). “Good or excellent” vs merged groups of “not” (average/not so good =1).

c Based on the following question: “What is your highest educational level” (1 – elementary; 2 – high school; 3 – academic). “Academic” vs merged groups of “not-academic” (elementary/high school =1).

d “Non- or past smokers” (merged) vs current smokers (=1).

e The presence of four or more of the following conditions: coronary heart disease/congestive heart failure/stroke/chronic kidney disease/asthma/diabetes/hypertension/osteoporosis/glaucoma and/or cataract/unbalanced dyslipidemia. Data are shown as mean ± SD for continuous variables or % for nominal/categorical variables. χ² test for categorical variables and t-test (or Mann–Whitney) for continuous variables.

Abbreviation: WC, waist circumference.

Figure 2 The adjusted correlation between frailty scores (by the three detective models) to function scores using linear regression.

Notes: Stepwise multiple linear regression testing the correlations of different variables (explanatory variables) with functional impairment (outcome). The independent role of frailty (as presented by the three most valid models) was assessed. (A) Includes all variables and Fried frailty model; (B) Includes all variables and frailty model including severe abdominal obesity instead of weight loss; (C) Includes all variables and frailty model including diabetes instead of weight loss. Bars represent the adjusted coefficients and lines represent the confidence intervals. *Correlation is significant at the 0.05 level (two-tailed).
Abbreviation: WC, waist circumference.

Figure 3 Optional screening and/or diagnosing flow for obese younger elderly subjects.

Notes: Suggested scheme to diagnose or screen for frailty in young (65–75 years) obese elderly – step by step: 1. The five-item fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) scale by Morley et al¹²; 2. The Fried phenotype model for frailty⁹; and 3. High levels of WC (severe abdominal obesity) chosen for this study were based on the 75th percentile: for males, 119.6 cm and for females, 132 cm.
Abbreviations: WC, waist circumference; BMI, body mass index.

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