Research Reports

The Association Between Body Adiposity Measures, Postural Balance, Fear of Falling, and Fall Risk in Older Community-Dwelling Women

Neri, Silvia Gonçalves Ricci PT, MSc¹; Gadelha, André Bonadias MSc¹; de David, Ana Cristina PhD¹; Ferreira, Aparecido Pimentel PhD²; Safons, Marisete Peralta PhD¹; Tiedemann, Anne PhD³; Lima, Ricardo M. PhD¹

Author Information

¹College of Physical Education, University of Brasília, Brasília/DF, Brazil.

²Catholic University of Brasilia, Brasília/DF, Brazil.

³Musculoskeletal Division, The George Institute for Global Health, The University of Sydney, Sydney, New South Wales, Australia.

Address correspondence to: Silvia Gonçalves Ricci Neri, PT, MSc, College of Physical Education, University of Brasília, Asa Norte, Zip code: 70910-900, Brasília/DF, Brazil ([email protected]).

The authors declare no conflicts of interest.Bill Andrews was the Decision Editor.

Journal of Geriatric Physical Therapy 42(3):p E94-E100, July/September 2019. | DOI: 10.1519/JPT.0000000000000165

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Abstract

Background and Purpose:

Recent investigations demonstrate an association between obesity and the propensity of older adults to fall. The aim of this study was to investigate the association between body adiposity measures, postural balance, fear of falling, and risk of falls in older women.

Methods:

One hundred forty-seven volunteers took part in this cross-sectional study. Participants underwent body composition assessment using dual-energy x-ray absorptiometry and had body mass index, waist circumference (WC), and body adiposity index measured. Postural balance was assessed using a force platform, while fear of falling and risk of falls were, respectively, evaluated by the Falls Efficacy Scale—International and the QuickScreen Clinical Falls Risk Assessment.

Results and Discussion:

All adiposity measures were correlated to at least 1 postural stability parameter and to fear of falling (ρ= 0.163, P < .05 to r = 0.337, P < .001); however, WC was the index most strongly correlated to risk of falls (ρ= 0.325; P < .001). When obesity was classified using WC, it was observed that compared with nonobese individuals (n = 51), obese individuals (n = 96) exhibited greater center of pressure displacement in the anteroposterior and mediolateral axes, especially during conditions with feet apart (P < .05). The obese group also exhibited an increased fear of falling (28.04 vs 24.59; P = .002) and had a higher proportion of individuals with increased fall risk (72% vs 35%; P < .001).

Conclusion:

In summary, adiposity measures are associated with risk of falls in older women, which might be mediated by reduced postural balance and increased fear of falling. Among these indices, WC, an easy and low-cost assessment, demonstrated the strongest association with falls-related outcomes.

INTRODUCTION

An important change that occurs with advancing age is fat mass accumulation; currently, more than 35% of Americans older than 60 years are classified as obese.¹ This number and related complications are expected to increase as the world's population ages. Gadelha and others documented that obesity is associated with a variety of metabolic disorders,² and that obesity can also contribute to a reduction in the ability to perform activities of daily living.³ Moreover, recent investigations have demonstrated an association between obesity and the propensity of older adults to fall.⁴^,⁵ Obesity is also associated with longer periods of hospitalization⁶ and a higher risk of disability after a fall.⁴

Falls represent the leading cause of accidental deaths among people aged 60 years and older⁷ and can also contribute to long-term physical, psychological, and economic costs.⁸ There are a variety of risk factors for falls that contribute to reduced postural stability.⁹ An essential biomechanical pathway to maintaining postural stability involves controlling the body center of pressure (CoP) with respect to its base of support.¹⁰ Laboratory-based assessments using measures of CoP recorded with force platforms have identified an association between increased CoP sway and a higher risk of falls.¹¹ Postural instability may be linked to obesity and falls in older people. Indeed, previous research demonstrates a negative association between obesity and postural control, with obese older adults demonstrating increased CoP sway during quiet standing when compared with their leaner counterparts.^12–15 These studies¹²^,¹³^,¹⁵ used body mass index (BMI) to classify obesity, while the influence of different body adiposity measures on postural stability has yet to be explored. Another important factor that might be involved in the relationship between body fat excess and falls is fear of falling,¹⁶ which is more common among obese older adults.¹⁷

Although BMI is the most widely used measurement to classify obesity, it does not consider body fat distribution.¹⁸ In this regard, dual-energy x-ray absorptiometry (DXA) has been considered the gold standard for assessing body composition, providing data of fat mass and fat-free mass for whole body as well for specific regions, such as android and gynoid areas.¹⁹ In addition, android distribution, which reflects abdominal fat,²⁰ rather than gynoid pattern, which is characterized by body fat deposition predominantly in the lower limbs,²¹ may exert a greater impact on postural stability due to a greater proportion of body mass further away from the ankle axis of rotation.²² The use of DXA, however, is not widely available.²³ Therefore, the use of more accessible measurements of adiposity for the prediction of falls merits attention and would provide important practical applications. In an effort to improve upon commonly used methods to estimate percent body fat, Bergman et al²⁴ recently proposed the body adiposity index, which was strongly associated with DXA-derived body fat percentage. Another simple adiposity index, that is frequently used by health professionals, is waist circumference (WC), which is positively associated with abdominal fat mass and has been shown to be the best adiposity index in the prediction of functional disability in older women.³

To our knowledge, no previous studies have examined the association between different body adiposity measures and risk of falls among older adults. Information on body adiposity measures more strongly associated to falls-related outcomes would help in the identification of older individuals at increased risk of falling and in the implementation of preventive interventions. Also, such an investigation is likely to more clearly identify the strength of the association between obesity and falls in older age. Hence, the aim of this study was to investigate the association between body adiposity measures, postural balance, fear of falling, and risk of falls in older women.

METHODS

Design and Participants

This cross-sectional study was conducted from July 2015 to June 2016 and included women aged between 60 and 80 years. Two hundred forty-seven volunteers were recruited through flyers and visits to local community social groups by the research team. All potential participants completed a questionnaire to verify their eligibility prior to enrolment; exclusion criteria included musculoskeletal and neurological disorders, vestibulopathy, diabetes, cancer, and 6-month postoperative condition. In addition, the Mini-Mental State Examination and the Katz index were used to verify that none of the volunteers had cognitive impairment²⁵ or functional dependency,²⁶ respectively. Physical activity level was evaluated using the short version of the International Physical Activity Questionnaire.²⁷ After exclusion criteria were applied, a total of 147 women (mean age= 68.6 years, SD= 6.1) were included in the present analyses. All participants gave their written informed consent to participate in this study, and the experimental protocol was approved by the University Ethics Committee (protocol 1.223.636).

Study Measures

Body adiposity

Standard procedures were used to measure weight with 0.1 kg precision on a physician's digital balance beam scale (model E150-INAN Filizola, São Paulo, São Paulo, Brazil), and height was measured at the nearest 0.1 cm using a wall stadiometer (WCS/CARDIOMED, Curitiba, Paraná, Brazil). Waist circumference was assessed at the level of umbilicus and hip circumference was determined at the level of the maximum extension of the buttocks posteriorly in a horizontal plane. An anthropometric tape (Sanny, São Paulo, São Paulo, Brazil) was used to measure both waist and hip circumferences. Body mass index was derived as body weight divided by height squared (kg/m²) and body adiposity index was calculated as hip circumference ÷ height^1.5−18. Body composition was measured using DXA (General Electric-GE model 8548 BX1L, 2005, DPX lunar type, Encore 2010 software, Rommelsdorf, North Rhine-Westphalia, Germany), according to procedures described elsewhere.² Briefly, participants laid supine on the DXA table with body centered. The software provided measures of fat mass and fat-free mass for whole body as well for specific regions. Coefficients of variation observed for the DXA in our laboratory were 2.1% and 1.9% for fat mass and fat-free mass, respectively. For this study, the variables analyzed were whole body, android, and gynoid fat percentage. All measurements were carried out by the same trained technician and the equipment was calibrated daily according to the manufacturers' specifications.

Postural stability

Postural stability was evaluated using a force platform (AccuSway Plus, AMTI, Watertown, Massachusetts), which measures displacements of CoP. The force platform signals were sampled at 100 Hz and data were filtered using 10 Hz low-pass cutoff frequency. The software AMTI Balance Clinic was used for signal recording.²⁸ The reliability coefficient was described elsewhere (r≥ 0.75).²⁹

Postural stability was measured under 4 experimental conditions: feet 10-cm apart/eyes open, feet 10-cm apart/eyes closed, feet together/eyes open, and feet together/eyes closed. To standardize participant stance position, the force platform was marked with tape to indicate the desired positioning of the feet. Participants were asked to keep their sight fixed at a mark on the wall, positioned 2 m away from the platform and 1.5 m above floor level, and to breathe normally. Participants were barefoot and were instructed to stand for 30 seconds on the force platform, with arms relaxed and with minimal body sway. They performed 3 trials for each condition, which were randomly presented to minimize fatigue and learning effects, and they were able to rest midway through the trials. Environmental conditions were kept constant, with no visual or auditory disturbances. An assessor helped throughout the session to ensure that procedures were adequately followed.

To quantify postural stability, CoP mean speed and the range of CoP displacement along anteroposterior (AP) and mediolateral (ML) axes were measured. The mean speed of the CoP corresponds to the cumulative distance over the sampling period. The range of the CoP displacement represents the difference between the maximum and minimum values of the CoP along the AP and ML axes. Center of pressure mean speed is considered to be a sensitive and valid measure of postural stability with a faster speed indicating a less stable individual.³⁰ In addition, ML range is a strong single predictor of falling risk,¹¹ and AP range is associated with risk of serious injury following fall events.³¹

Fear of falling

Fear of falling was evaluated using the Falls Efficacy Scale—International.³² This scale assesses the level of concern about the possibility of falling during the performance of 16 activities of daily living, such as taking a bath, cleaning the house, and preparing simple meals. Each activity is scored from 1 to 4 points, providing a total score ranging from 16 (absence of concern) to 64 (extreme concern). The assessment was carried out by a trained examiner.

Risk of falls

To evaluate risk of falls, the QuickScreen Clinical Falls Risk Assessment (QuickScreen) was applied.³³ This instrument assesses 8 factors related to falls, as follows: falls in the last 12 months, regular use of 4 or more medications, any psychotropic medication use, low contrast visual acuity, peripheral sensation, balance, reaction time, and lower-limb muscle strength. The result indicates the probability of falling in the next 12 months, providing classification in 1 of 4 possible levels of risk (7%, 13%, 27%, or 49%). The assessment procedures were conducted in accordance with specifications described elsewhere³³ and carried out by a trained examiner.

Statistical Analysis

Data were expressed as means and standard deviations, medians and interquartile range, or as relative frequencies as appropriate. To investigate the data distribution, the Kolmogorov-Smirnov test was performed. Correlations between body adiposity measures and dependent variables were assessed using Pearson's or Spearman's correlation test (when the variables did not meet all the assumptions for parametric statistics). The adiposity measure most highly correlated with falls risk was used to classify participants as obese or nonobese, using cutoff values recommended by the World Health Organization.³⁴ Between-group comparisons for the continuous measures were conducted using independent samples t test or Mann-Whitney U test. For categorical variables, the χ² test was used to identify between-group differences. Statistical significance was set at P < .05. All statistical analyses were conducted with Statistical Package for Social Sciences software version 20.0 (SPSS Inc, Chicago, Illinois).

RESULTS

Participant characteristics are presented in Table 1. Correlations between body adiposity measures, postural stability, fear of falling, and fall risk are shown in Table 2. All adiposity measures were positively significantly correlated with at least 1 postural stability parameter. Of note, highly significant correlations were observed between BMI and range of CoP displacement along the AP axis during the feet apart experimental condition. Similarly, WC was highly significantly correlated with AP range in feet apart/eyes closed and feet together/eyes closed conditions. Also, all the adiposity measures were positively and significantly correlated with fear of falling. Importantly, WC was the measure that more strongly correlated to risk of falls and thus was used to classify obesity in subsequent analyses.

Table 1. - Characteristics of Sample^a

Variables	Total (n =147)	Nonobese (n = 51)	Obese (n = 96)
Age, y	68.6 (6.2)	68.8 (6.6)	68.5 (5.9)
Time since menopause, y	20.8 (9.4)	19.9 (9.5)	21.2 (9.5)
Weight, kg	66.9 (11.4)	56.9 (6.7)	72.2 (9.8)^b
Height, m	1.6 (0.1)	1.6 (0.1)	1.6 (0.1)
Body mass index, kg/m²	27.3 (4.4)	23.4 (2.3)	29.4 (3.8)^b
Waist circumference, cm	92.8 (10.7)	81.7 (4.6)	98.7 (7.9)^b
Body adiposity index, %	35 (5.3)	31.3 (3.5)	36.9 (5.0)^b
Body fat, %	44.2 (5.9)	39.4 (5.3)	46.7 (4.4)^b
Android fat, %	48.6 (7.0)	43.3 (6.9)	51.4 (5.1)^b
Gynoid fat, %	50.4 (5.7)	47 (6.3)	52.1 (4.5)^b
Hormone replacement therapy	11 (7.5)	7 (13.7)	4 (4.2)
Alcohol consumption	53 (36.1)	17 (33.3)	36 (37.5)
Current smoker	4 (2.7)	2 (3.9)	2 (2.1)
Physical activity level^c
Sedentary	18 (12.3)	1 (2.0)	17 (17.7)^d
Irregularly active	82 (55.8)	27 (52.9)	55 (57.3)
Active	44 (29.9)	21 (41.2)	23 (24.0)
Very active	3 (2.0)	2 (3.9)	1 (1.0)

^aData are presented as mean and standard deviation or absolute and relative frequencies.

^bP < .001.

^cPhysical activity level was evaluated using the International Physical Activity Questionnaire.

^dP < .05.

Table 2. - Correlations Between Body Adiposity Indices, Postural Stability, Fear of Falling, and Risk of Falls in Older Women (n = 147)

Falls-Related Variables	BMI, kg/m²	WC, cm	BAI, %	Body Fat, %^a	Android Fat, %^a	Gynoid Fat, %^a
Postural stability
Feet apart, eyes open
CoP speed, cm/s	−0.025	0.010	−0.039	−0.026	0.004	−0.034
AP range, cm	0.319^b	0.240^c	0.257^c	0.233^c	0.212^c	0.220
ML range, cm	0.219^c	0.222^c	0.195^c	0.238^c	0.187^c	0.149
Feet apart, eyes closed
CoP speed, cm/s	−0.024	−0.001	−0.050	0.015	0.001	0.033
AP range, cm	0.319^b	0.337^b	0.246^c	0.256^c	0.191^c	0.240^c
ML range, cm	0.189^c	0.266^c	0.136	0.140	0.043	0.081
Feet together, eyes open
CoP speed, cm/s	−0.070	−0.007	−0.121	−0.040	0.001	−0.083
AP range, cm	0.127	0.127	0.059	0.079	0.144	0.110
ML range, cm	0.028	0.087	−0.075	0.033	0.002	−0.047
Feet together, eyes closed
CoP speed, cm/s	−0.066	−0.016	−0.138	−0.028	−0.021	−0.054
AP range, cm	0.163^c	0.221^b	0.043	0.164^c	0.077	0.081
ML range, cm	0.075	0.152	−0.007	0.082	0.023	0.021
Fear of falling
FES-I	0.240^c	0.237^c	0.265^c	0.281^c	0.225^c	0.223^c
Risk of falls
QuickScreen	0.220^c	0.325^b	0.182^c	0.193^c	0.115	0.130

Abbreviations: AP, anteroposterior; BAI, body adiposity index; BMI, body mass index; CoP, center of pressure; FES-I, Falls Efficacy Scale—International; ML, mediolateral; QuickScreen, QuickScreen Clinical Falls Risk Assessment; WC, waist circumference.

^aDual-energy x-ray absorptiometry derived data.

^bP < .001.

^cP < .05.

Ninety-six participants (65%) were identified as obese (WC ≥88 cm) and 51 (35%) as nonobese (WC <88 cm). There were no between-group differences for age, time since menopause, height, hormone replacement therapy, alcohol consumption, and smoking status. As expected, obese participants had higher weight, BMI, WC, body adiposity index, body fat, android fat, and gynoid fat percentage than their leaner counterparts. Obese individuals were less physically active. Of note, 75% of obese participants were classified as sedentary or irregularly active, while this proportion was 55% among nonobese group (Table 1).

Postural stability parameters according to obesity classification are summarized in Table 3. The obese group exhibited significantly higher mean CoP displacement along the AP and ML axes during the experimental conditions with feet apart. Moreover, the mean AP CoP displacement was also significantly higher in the feet together/eyes closed condition for obese participants compared with nonobese participants.

Table 3. - Postural Stability in Older Women Stratified According to Obesity Group (n = 147)^a

Postural Stability Measure	Nonobese (n= 51)	Obese (n= 96)
Feet apart, eyes open
CoP speed, cm/s	1.23 (0.4)	1.23 (0.4)
AP range, cm	1.99 (0.5)	2.31 (0.5)^b
ML range, cm	1.25 (0.4)	1.50 (0.5)^b
Feet apart, eyes closed
CoP speed, cm/s	1.57 (0.6)	1.51 (0.4)
AP range, cm	2.31 (0.6)	2.82 (0.7)^c
ML range, cm	1.32 (0.5)	1.58 (0.5)^b
Feet together, eyes open
CoP speed, cm/s	1.99 (0.7)	1.83 (0.5)
AP range, cm	2.53 (0.7)	2.69 (0.6)
ML range, cm	2.73 (0.7)	2.86 (0.7)
Feet together, eyes closed
CoP speed, cm/s	2.67 (0.9)	2.50 (0.7)
AP range, cm	3.04 (0.7)	3.35 (0.8)^b
ML range, cm	3.44 (0.9)	3.64 (1.0)

Abbreviations: AP, anteroposterior; CoP, center of pressure; ML, mediolateral.

^aData are presented as mean and standard deviation.

^bP < .05.

^cP < .001.

Figure 1 illustrates between-group differences for fear of falling. The obese group exhibited a significantly higher fear of falling (median = 27, interquartile range = 12) than the nonobese group (median = 22, interquartile range = 6, P = .002 for between-group comparison).

Figure 1.:
Fear of falling in older women stratified by obesity group (n = 147). Data are presented as minimum value, first quartile, median, third quartile, and maximum value. Asterisk denotes significant between-group difference (P = .002).

Figure 2 shows the estimated probability of participants falling in the next 12 months as evaluated using the QuickScreen. The proportion of older participants with increased risk of falls was significantly higher in the obese group. Seventy-two percent of the obese group had a fall risk of 13 or 27%, while 35% of the nonobese group presented the same fall risk scores (P < .001). Noteworthy, none of the participants were classified at the highest probability of falls level (49%). Regarding the aspects evaluated by the QuickScreen, the obese group exhibited a greater proportion of women with reduced balance (50% vs 29%, P = .022), reaction time (45% vs 16%, P < .001), and lower-limb muscle strength (38% vs 10%, P < .001) compared with the nonobese group. There were no between-group differences for other items (all P > .05).

Figure 2.:
Risk of falls in older women stratified by obesity group (n = 147). Data are presented as relative frequency. Asterisk denotes significant between-group difference (P < .001).

DISCUSSION

Recent reports have identified an association between obesity and increased risk of falls.⁴^,⁵ However, the mechanisms responsible for and the selection of the adiposity measure to evaluate this association are not clear. The present study was designed to examine the relationship between body adiposity measures and risk of falls and to investigate the associations between obesity and postural balance and fear of falling in older women. The salient findings indicated that all the adiposity measures were positively associated with an increased risk of falls, with the strongest correlation observed for WC. Moreover, obese participants (WC ≥88 cm) exhibited reduced postural balance control and increased both risk and fear of falling. In conjunction, these observations provide support for the concept that obesity is linked to an increased risk of falls among older people and suggest that WC should be the preferred measure to assess obesity in the context of identifying older women at risk of falling.

To our knowledge, no previous studies have examined the association between different body adiposity measures and the risk of falls among older adults. Although DXA has been considered a gold standard assessment for body composition,¹⁹ we observed that WC, an anthropometric measure that reflects abdominal fat mass, was the best predictor of falls risk. In agreement with this finding, WC has previously been identified as the best predictor for other health outcomes, such as metabolic syndrome² and functional disability.³ Based on these results, we suggest that WC should be used in preference to other high-cost adiposity measures since it is widely available, easy to use, and demonstrated to be associated with risk of falls and other negative outcomes in older people.

Our results provide some information about potential underlying mechanisms for the association between obesity and falls, since obese participants had reduced objectively measured postural balance compared with their nonobese peers. This may be attributed to a greater proportion of body mass further away from the ankle axis of rotation, requiring a larger ankle torque to counter the greater gravitational torque,²² which in turn may affect balance control, gait patterns, and the ability to easily perform activities of daily living.³ The reduced reaction time and lower-limb muscle strength may also affect postural adjustment strategies and predispose the individual to fall.³⁵ Furthermore, it is known that central obesity is a pivotal risk factor for metabolic disorders,² which can contribute, even indirectly, to increased fall risk.¹²

Fear of falling was also positively associated with obesity, resulting from the recognition of being at risk of falling and of the adverse outcomes caused from falls.¹⁶ Several studies have shown activity restriction secondary to fear of falling, which could in turn lead to deconditioning and increased risk of falling.¹⁶ In this regard, we observed that obese older adults tended to be less physically active than their leaner counterparts, which may contribute to the link between obesity and falls. From a practical standpoint, it was previously demonstrated that older people who have reported fear of falling were 75% more likely to fall in the subsequent 20 months than those who did not express this condition.¹⁶ Our findings corroborate a previous report from Jeon et al,¹⁷ who showed an association between BMI and fear of falling in a sample of 351 Korean older people living in rural areas; however, exploration of the risk of falls was not in the scope of the study. Conversely, Mitchell et al⁵ found a higher risk of falls among obese seniors, while fear of falling did not differ across BMI groups; however, fear of falling was assessed as a dichotomous response to a single question. This approach to determine fear of falling has been shown to be less sensitive than more specific instruments to evaluate the outcome such as the Falls Efficacy Scale—International.³² Therefore, the association may have been apparent if a more detailed scale had been used.

The current study has several strengths and limitations. Objective measurement of the outcomes and novelty of the results are strengths. The fact that the study sample was composed of healthy and functionally independent community-dwelling women may reduce the applicability of the results to men and to more frail sections of the older population. Moreover, the cross-sectional nature of the study does not allow cause-and-effect relationships to be established. Therefore, the results should be considered preliminary and further research with a prospective follow-up is recommended to confirm whether WC is the best body adiposity measure in the prediction of postural instability, fear of falling, and risk of falls among older people.

CONCLUSION

The results indicate that several body adiposity measures are associated with postural instability, fear of falling, and fall risk among older women. Despite the inclusion of the gold standard (ie, DXA) method for measuring body composition in this study, a stronger association with risk of falls was observed for WC, an easy and low-cost assessment. The results provide support for the concept that obesity is associated with reduced balance control, higher fear of falling, and increased risk of falls. In practical terms, given that WC is a simple low-cost measurement, it may be a useful addition to assessments of fall risk among older women.

ACKNOWLEDGMENTS

The authors thank the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES). Author Tiedemann is supported by an Australian National Health and Medical Research Council Fellowship.

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Keywords:

aging; falls; obesity; postural balance

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The Association Between Body Adiposity Measures, Postural Balance, Fear of Falling, and Fall Risk in Older Community-Dwelling Women