Geriatric Nursing 34 (2013) 465e468

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Geriatric Nursing
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Feature Article

Relationship between BMI and physical performance among older adults

Raiana Souza Ferreira a, Raildo da Silva Coqueiro, MS a, *, Aline Rodrigues Barbosa, PhD a, b,
Paloma Andrade Pinheiro a, c, Marcos Henrique Fernandes, PhD a, c
a
Núcleo de Estudos em Epidemiologia do Envelhecimento (NEPE), Departamento de Saúde, Universidade Estadual do Sudoeste da Bahia, Av. José Moreira Sobrinho, S/N, Jequiezinho,
Jequié, BA 45206-190, Brazil
b
Departamento de Educação Física, Centro de Desportos, Universidade Federal de Santa Catarina, Florianópolis, Brazil
c
Programa de Pós-Graduação em Enfermagem e Saúde (PPGES), Departamento de Saúde, Universidade Estadual do Sudoeste da Bahia, Jequié, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Our objective was to examine the relationship between body mass index (BMI) and physical performance
Received 16 May 2013 in community-dwelling older adults. This was a descriptive and association study, based on secondary
Received in revised form data derived from a population-based epidemiological research involving 316 older adults. The BMI was
23 July 2013
thus classified: <22.0 kg/m2, underweight; 22.0
BMI
27.0 kg/m2, adequate; >27.0 kg/m2, overweight.
Accepted 25 July 2013
Available online 28 August 2013
Physical performance was assessed based on “chair stand”, “pick up a pen” and walking tests. Associa-
tions between BMI and performance at each test were tested by Cox regression for survival analysis with
multiple modeling adjusted by gender and age, adopting a significance level of 5% (a ¼ 0.05). Individuals
Keywords:
Body mass index
with underweight (badjusted ¼ 0.64; p ¼ 0.004), performed poorly in the “chair stand” test when
Nutritional status compared to individuals with adequate weight. The BMI was a predictor of good physical function, with
Physical fitness underweight being more of a limiting factor than overweight.
Time and motion studies Ó 2013 Mosby, Inc. All rights reserved.
Health of the elderly

Epidemiological studies that used body mass index (BMI),
a classic indicator of nutritional status, demonstrate that both
underweight and overweight coexist in high proportions among
populations of older adults.1e3 Considering them as two extremes
of the BMI, underweight and overweight pose health risks to older
adults.1,3,4 The former is related to multiple consequences, such as
changes to muscle and body mass, immune dysfunction, anemia,
cognitive impairment, wound healing difficulties, slower post-
operative recovery and greater risk of institutionalization, hospi-
talization and mortality.4e6 Overweight is an independent risk
factor for cardiovascular and pulmonary disease, diabetes, dyslipi-
demia, many types of cancer, osteopathy and cognitive and
Author bio-line: Raiana Souza Ferreira, Bachelor in physiotherapy, member from
Núcleo de Estudos em Epidemiologia do Envelhecimento (NEPE), Universidade
Estadual do Sudoeste da Bahia (UESB), Brazil. Raildo da Silva Coqueiro, MS,
Professor Assistente in the Departamento de Saúde, Researcher from NEPE, UESB,
Brazil. Aline Rodrigues Barbosa, PhD, Researcher collaborator from NEPE, Professor
Adjunto in the Centro de Desportos, Universidade Federal de Santa Catarina, Brazil.
Paloma Andrade Pinheiro, Master’s degree Student in Enfermagem e Saúde,
Member from NEPE, UESB, Brazil. Marcos Henrique Fernandes, PhD, Professor
Adjunto in the Departamento de Saúde, Researcher from NEPE, UESB, Brazil.
* Corresponding author. Tel.: þ55 73 3528 9726.
E-mail addresses: rscoqueiro@uesb.edu.br, raiconquista@yahoo.com.br (R. da
Silva Coqueiro).
psychological problems.7 Both conditions of nutritional inadequacy
affect physical fitness, leading the individual to a condition of
fragility and subsequent functional dependency and low quality of
life.5
The ability to carry out daily activities in a safe, independent
manner without incurring in excessive fatigue is directly related
with good functioning of the musculoskeletal system.8 Therefore,
assessing physical performance through tasks that demand
muscular strength and endurance, flexibility, mobility and balance
provides a diagnosis of the functional health of older adults.8e10 A
few studies using BMI sought to analyze the association between
underweight and/or overweight and motor test performance in
community-dwelling older adults.10e13 The results from these
studies showed that this association was dependent on gender, age
group and type of test carried out.11,12 In a recent study involving
individuals aged 55 or more, performance in a battery of motor
system tests was independent from BMI.10 It is not yet possible to
determine, based on existing research, whether an inadequate BMI
is a predictor of weak physical performance in older adults and
which disorder, underweight or overweight, impairs the physical
function the most.
The purpose of this study was to examine the relationship
between BMI and physical performance in community-dwelling
older adults. Specifically we hypothesized that those who were
underweight would have poorer physical performance in tests of

0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2013.07.013
466 R.S. Ferreira et al. / Geriatric Nursing 34 (2013) 465e468

muscle strength/endurance and those who were overweight would was measured according to the technique by Frisancho,17 using
show poorer performance on tests of mobility/flexibility. a portable compact stadiometer (Wiso, China) placed at a suitable
location according to the manufacturer’s rules. Height measure-
Methods ments were taken three times and mean values were used to
calculate body mass index [BMI ¼ body mass (kg)/height2 (m)].
Setting and study population The BMI was thus classified according to the cut-off points of
the American Academy of Family Physicians et al18 adopted by
This was a descriptive and association study, based on se- the Brazilian System of Surveillance for Food and Nutrition
condary data derived from a cross-sectional, population-based (Portuguese acronym, SISVAN)19: BMI < 22.0 kg/m2, underweight;
household survey called “Nutritional status, risk behaviors and 22.0
BMI
27.0 kg/m2, adequate; BMI > 27.0 kg/m2, overweight.
health conditions of older adults residents of Lafaiete Coutinho,
Bahia”. Details about the setting and study population as well as
Statistical analyses
data collection have already been published.14 In short, a complete
census was conducted in Lafaiete Coutinho (January 2011) for the
The associations between BMI (explanatory variable) and
identification of older adults (60 years). The location of the resi-
performance at each physical performance test (dependent vari-
dences was conducted using information from The Family Health
ables) were tested with Cox’s regression technique for survival
Strategy, a program of primary health care that covers all county. All
analysis with multiple modeling adjusted by gender and age. The
residents (n ¼ 355) in the urban zone were contacted. Of the 355
level of significance adopted for all analyses was 5% (a ¼ 0.05). The
older adults that made up the study population, 316 (89.0%) took
data were tabulated and analyzed with statistical program SPSSÒ
part in the research: 17 refusals (4.8%) were registered and 22
version 16.0.
(6.2%) individuals were not located after three household visits on
alternate days, and were regarded as losses. The study was carried
out in accordance with the World Medical Association’s Declaration Results
of Helsinki and was approved by the Ethics Committee on Human
Research. Study participants amounted to 173 women (54.7%) and 143
In the present study, older adults who met any of the exclusion men (45.3%). Age varied between 60 and 105 years, the mean being
criteria as described below were not enrolled: individuals who 74.2  9.8 years. The average age of the women was 74.9  10 years
were unable to understand the test instructions due to cognitive (60e103), whereas for men it was 73.4  9.4 years. The other
problems; those who couldn’t walk or needed help to remain characteristics of the studied population are shown in Table 1. Most
standing up, who had paralysis of a limb, who used a leg prosthesis individuals reported living in common law partnership, not
or who could not keep their balance were not included in the lower knowing how to read or write and having financial difficulties.
limbs test and; those who underwent eye surgery in the past Body mass and height measurements were taken from 301
6 weeks did not take the “pick up a pen” test. individuals. The distribution of the older adults according to BMI
was: underweight 28.9% (n ¼ 87), adequate weight 42.5% (n ¼ 128)
Measurements and overweight 28.6% (n ¼ 86). Of the 316 individuals interviewed,
25 (7.9%) were unable to carry out any flexibility or mobility tests
Physical performance tests due to physical limitations. The number of refusals was specific to
A detailed description of the procedures for implementing each each test: strength/endurance of lower limbs, 21 older adults;
physical performance test was previously published.8 The following mobility/flexibility, 16 older adults; and walking, four older adults.
is a brief description. The “chair stand” test assessed the strength/ The mean time spent by the participant carrying out the physical
endurance of the lower limbs.15 The participants were invited to performance tests is shown in Fig. 1.
cross their arms at chest height and then stand up and sit down on Table 2 shows the survival analysis results with adjusted
the chair five times, as quickly as possible, while being timed in modeling according to Cox. The data shows the association
seconds (s). Individuals were considered apt to carry out the test between BMI and performance in lower limb strength/endurance
when concluding it 60 s or less. test. The underweight individuals took longer to complete the test
The “pick up a pen” test checked mobility/flexibility.16 For this in relation to older people with normal weight. The time spent by
task, a pen was placed approximately 30 cm from the participant’s overweight individuals to carry out the lower limb strength/
foot, and on the command “go,” the participant had to pick up the endurance test did not differ significantly from adequate weight
penny from the floor and stand up. Timed from the command “go”
until the individual was standing erect with pen in hand. Partici- Table 1
Characteristics of the study population. Lafaiete Coutinho, Brazil, 2011.
pants were considered capable of carrying out the test when they
concluded it without support in 30 s or less. Variables % Response N %
The walking test checked the ability to move of older adults.15 In Age group 99.7
order to test their walking speed the participants were instructed to 60e69 years 115 36.5
walk from one end to the other of a 2.44 m course in their habitual 70e79 years 106 33.7
P80 years 94 29.8
speed, as if walking on a sidewalk. Participants could use mobility
Marital status 100.0
support devices, if necessary, and the course was covered twice and Living with partner 179 56.6
timed in seconds. The shortest time was considered for the anal- Single 38 12.0
yses. The individual was considered apt to carry through the test if Widower 81 25.6
Divorced 18 5.7
capable of concluding it in 60 s or less.
Literacy 100.0
Yes 105 33.2
BMI (explanatory variable) No 211 66.8
Body mass was measured with a portable digital balance Financial difficulty 97.8
(Zhongshan Camry Eletronic, G-Tech Glass 6, China); the individual Yes 220 71.2
No 89 28.8
was weighed barefoot and wearing a minimum of clothes. Height
 R.S. Ferreira et al. / Geriatric Nursing 34 (2013) 465e468 467

Fig. 1. Mean time  standard deviation in carrying out physical performance tests.
Lafaiete Coutinho, Brazil, 2011.

participants (Fig. 2). No associations were observed between BMI

and performance in mobility/flexibility tests or walking.

Discussion

The results in the present study show that BMI was not associ-
ated with performance in walking and mobility/flexibility tests. Fig. 2. Accumulated proportion of older adults, according to time taken to complete
However, underweight individuals had the worst performance, the “chair stand” test, according to nutritional status. Lafaiete Coutinho, Brazil, 2011.
independent of gender and age, in the lower limb strength/endur-
ance test, when compared with individuals of adequate weight.
The relationship between underweight and lower limb with this nutritional disorder. The fact that BMI is highly correlated
strength/endurance verified in the present study diverges from with fat-free mass in older adults, including oldest old21 suggests
observations in other studies.10,11 In the study by Goins et al10 that lower BMI values can be associated with progressive loss of
involving American Indians (55 years of age), the higher BMI muscle mass, strength and quality, a condition known as sarcope-
values were associated with the worst performance in the “chair nia.22 It is important to know that due to reduction of height with
stand” test. Data from the SABE/São Paulo Research11 carried out advancing age, BMI may have different meaning in young adults
with 2143 older adults did not show any association between this and older adults.21 The best BMI cut-off points to identify under-
test and nutritional status. However, it is worth stressing that the weight and/or overweight in older adults is still controversial.1,2,4 In
studies adopted different BMI cut-off points to classify underweight the present study we used the BMI cut-off point adopted by the
and/or overweight, and the study by Goins et al10 involved younger Brazilian system of surveillance for food and nutrition (Portuguese
individuals (55 years of age and older). acronym, SISVAN),19 recommended by respected health organiza-
These findings suggest that the association between BMI and tions recognized worldwide.18
physical performance can vary in different population groups and It is a known fact that adequate nutrition is essential to keep
possibly be mediated by exogenous characteristics. It is well- healthy and that changes to BMI have been associated with sarco-
documented in epidemiologic studies that socioeconomic inequal- penia in old age.23 Literature has demonstrated that musculoskeletal
ities and/or socioeconomic development and income inequality dysfunctions are predictive of functional limitations and physical
have a negative result on health condition, including physical incapacity in older adults.24 Therefore, keeping a good nutritional
performance and nutritional status/BMI.1,3,9 We believe that the status is critical to preserve muscular strength and functional
differences observed among the studies can be explained by the capacity, and therefore, the quality of life of these individuals.
characteristics of the populations studied. The present study was It is important to stress the limitations and strong points of the
carried out in a city in northeast Brazil, a less developed region in study. The exclusion of individuals who were unable to complete
the country with high levels of poverty (47.8%) and low levels of the tests or who refused to perform them can be understood as
social inequality (Gini coefficient ¼ 0.35).20 a bias in the analysis; but as the distribution of BMI did not differ
Impairment of strength/endurance in underweight individuals among these individuals (data not shown), we believe that this
can be explained by a lower volume of muscle mass in individuals limitation did not affect the conclusions of study. Although the
cross-sectional design does not allow a causal link to be established,
Table 2 the results observed find support in literature. The physical
Cox multiple regression model coefficients between physical performance and performance tests used in this study are easy to apply, safe and
nutritional status. Lafaiete Coutinho, Brazil, 2011. valid, and are widely published, especially in relation to pop-
Dependent variables Nutritional status badjusteda 95% IC p-value ulations of older adults.9,10 In the same way, the use of BMI to assess
Lower limb strength/ Underweight 0.64 0.47e0.87 0.004 the nutritional status of individuals is justified by how easy it is to
endurance Adequate 1 obtain weight and height data, low cost, little variation between
Overweight 0.76 0.56e1.02 0.068 evaluators and widespread use in epidemiological studies.10e12
Mobility/flexibility Underweight 0.95 0.70e1.29 0.751
The results from this study may contribute to the knowledge by
Adequate 1
Overweight 0.94 0.69e1.27 0.682 health professionals of how different nutritional status can inter-
Walking Underweight 0.98 0.73e1.31 0.905 fere with a status of fragility, as well as contribute to steer targets,
Adequate 1 objectives and conducts aiming at preventing incapacity. With the
Overweight 1.09 0.81e1.45 0.580 results found, we can conclude that the negative impact of nutri-
a
Controlled for gender and age. tional inadequacy over physical performance was specific to the
468 R.S. Ferreira et al. / Geriatric Nursing 34 (2013) 465e468
test carried out. Underweight has proved to be a more limiting
factor of good physical function than overweight.
Acknowledgments
The research was partly funded by the UESB (UESB 117/2009 and
011/2010). The authors thank the Municipal Secretariat of Health of
Lafaiete Coutinho-BA and the elderly who participated in the study.
References
1. Coqueiro RS, Barbosa AR, Borgatto AF. Nutritional status, health conditions and
socio-demographic factors in the elderly of Havana, Cuba: data from SABE
survey. J Nutr Health Aging. 2010;14(10):803e808.
2. Nascimento CM, Ribeiro AQ, Cotta RMM, et al. Estado nutricional e fatores
associados em idosos do Município de Viçosa, Minas Gerais, Brasil. Cad Saúde
Pública. 2011;27(12):2409e2418.
3. Fares D, Barbosa AR, Borgatto AF, Coqueiro RS, Fernandes MH. Factors associ-
ated with nutritional status of the elderly in two regions of Brazil. Rev Assoc
Med Bras. 2012;58(4):434e441.
4. Ferreira LS, Amaral TF, Marucci MFN, Nascimento LF, Lebrão ML, Duarte YA.
Undernutrition as a major risk factor for death among older Brazilian adults in
the community-dwelling setting: SABE survey. Nutrition. 2011;27(10):1017e
1022.
5. Ji L, Meng H, Dong B. Factors associated with poor nutritional status among the
oldest-old. Clin Nutr. 2012;31(6):922e926.
6. Schilp J, Wijnhoven HA, Deeg DJ, Visser M. Early determinants for the devel-
opment of undernutrition in an older general population: Longitudinal Aging
Study Amsterdam. Br J Nutr. 2011;106(5):708e717.
7. Zenón TG, Silva JAV. Malnutrición en el anciano. Parte II: obesidad, la nueva
pandemia. Med Int Mex. 2012;28(2):154e161.
8. Pinheiro PA, Passos TDO, Coqueiro RS, Fernandes MH, Barbosa AR. Motor
performance of the elderly in northeast Brazil: differences with age and sex.
Rev Esc Enferm USP. 2013;47(1):128e136.
9. Barbosa AR, Miranda LM, Guimarães AV, Xavier-Corseuil H, Weber-Corseuil M.
Age and gender differences regarding physical performance in the elderly from
Barbados and Cuba. Rev Salud Publica. 2011;13(1):54e66.
10. Goins RT, Innes K, Dong L. Lower body functioning prevalence and correlates in
older American Indians in a southeastern tribe: the Native Elder Care Study.
J Am Geriatr Soc. 2012;60:577e582.
11. Barbosa AR, Souza JMP, Lebrão ML, et al. Estado nutricional e desempenho
motor de idosos de São Paulo. Rev Assoc Med Bras. 2007;53(1):75e79.
12. Sergi G, Perissinotto E, Toffanello ED, et al. Lower extremity motor performance
and body mass index in elderly people: the Italian Longitudinal Study on Aging.
J Am Geriatr Soc. 2007;55:2023e2029.
13. Lang IA, Llewellyn DJ, Alexander K, Melzer D. Obesity, physical function, and
mortality in older adults. J Am Geriatr Soc. 2008;56:1474e1478.
14. Santos KT, Fernandes MH, Reis LA, Coqueiro RS, Rocha SV. Depressive symp-
toms and motor performance in the elderly: a population based study. Rev Bras
Fisioter. 2012;16(4):295e300.
15. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance
battery assessing lower extremity function: association with self-reported
disability and prediction of mortality and nursing home admission. J Gerontol.
1994;49(2):M85eM94.
16. Reuben DB, Siu AL. An objective measure of physical function of elderly
outpatients. The physical performance test. J Am Geriatr Soc. 1990;38(10):
1105e1112.
17. Frisancho AR. New standards of weight and body composition by frame size
and height for assessment of nutritional status of adults and the elderly. Am J
Clin Nutr. 1984;40(4):808e819.
18. American Academy of Family Physicians, American Dietetic Association, National
Council on the Aging. Nutrition Screening e intervention Resources for Health Care
Professionals Working with Older Adults. Nutrition Screening Initiative. Wash-
ington: American Dietetic Association. Available from: http://www.eatright.org/
cps/rde/xchg/ada/hs.xsl/nutrition_nsi_ENU_HTML.htm; 2002. Retrieved March
21, 2012.
19. Brasil Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de
Atenção Básica. Protocolos do Sistema de Vigilância Alimentar e Nutricional e SISVAN
na assistência à saúde/Ministério da Saúde, Secretaria de Atenção à Saúde. Departa-
mento de Atenção Básica, Brasília: Ministério da Saúde. Avaliable from: http://
www.fag.edu.br/professores/fabiana/Est%E1gio%20ESCOLA/protocolo_sisvan.pdf;
2008. Retrieved June 27, 2013.
20. IBGE. IBGE Cidades@. Avaliable from: http://www.ibge.gov.br/cidadesat/topwindow.
htm?1; Retrieved October 10, 2012.
21. Meeuwsen S, Horgan GW, Elia M. The relationship between BMI and percent
body fat, measured by bioelectrical impedance, in a large adult sample is
curvilinear and influenced by age and sex. Clin Nutr. 2010;29:560e566.
22. Muscaritoli M, Anker SD, Argilés J, et al. Consensus definition of sarcopenia,
cachexia and pre-cachexia: joint document elaborated by Special Interest
Groups (SIG) ‘‘cachexia-anorexia in chronic wasting diseases’’ and ‘‘nutrition in
geriatrics’’. Clin Nutr. 2010;29(2):154e159.
23. Alley DE, Koster A, Mackey D, et al. Hospitalization and change in body
composition and strength in a population-based cohort of older persons. J Am
Geriatr Soc. 2010;58(11):2085e2091.
24. Onder G, Penninx BWJH, Ferrucci L, Fried LP, Guralnik JM, Pahor M. Measures of
physical performance and risk for progressive and catastrophic disability:
results from the Women’s Health and Aging Study. J Gerontol A Biol Sci Med Sci.
2005;60:74e79.