Implementation frameworks guiding digital self-management intervention in chronic pain: A scoping review.

BACKGROUND AND OBJECTIVE: The development, evaluation and implementation of digital self-management interventions for chronic pain have increased exponentially. While intervention outcomes appear promising to improve well-being and functioning in target populations, it is unclear how the development and evaluation processes were structured and how implementation was planned and executed. The aim of this systematic review is to provide a comprehensive overview of implementation frameworks used to guide and evaluate scientific innovation in chronic pain. DATABASES AND DATA TREATMENT: Four bibliography databases (Medline, Web of Science, PsycInfo, CINAHL) and two registries (PubMed Central, MedaRxiv) were systematically searched. Hits (n = 6830) and full texts (n = 351) were screened and read by two independent reviewers. Peer-reviewed articles that met the inclusion criteria were included in the narrative synthesis. RESULTS: In total, 10 studies were identified that report on seven distinct interventions. Five implementation frameworks were utilized across these studies: Behavioural Interventions using Technology (BIT); Consolidated Framework for Implementation Research (CFIR); mHealth Agile and User-Centered Research and Development Lifecycle; Medical Research Council (MRC); Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM). Frameworks were operationalized using qualitative and quantitative methods, evaluating the innovation on various levels (e.g., individual vs. organizational) and applying a variety of study designs (e.g., single-arm or large trials). CONCLUSIONS: By utilizing implementation frameworks, access to evidence-based chronic pain care may be increased. Although the evidence on the utility of implementation frameworks to guide and evaluate digital self-management interventions is still limited, the body of literature is increasing. Future studies are urged to operationalize, communicate and discuss the innovation process, to promote transparency and replicability. SIGNIFICANCE: The use of implementation frameworks to guide and evaluate digital self-management interventions for chronic pain is a recent development in the field. Several promising examples exist and are presented in this review. Currently, the evidence is still limited, and prospective studies need to transparently operationalize, communicate and discuss their efforts. By utilizing an implementation framework, promising interventions can be made available to end-users, closing the research-to-clinical practice gap and increasing access to evidence-based care to people with chronic pain.

The house is a machine for everything: the role of the built environment in group homes during the COVID-19 pandemic.

OBJECTIVES: Individuals living in group homes during the COVID-19 pandemic faced unique challenges and health risks related to living in shared spaces. This study aimed to assess the experiences of living and working in a group home during the pandemic and to explore the role of the built environment. STUDY DESIGN AND METHODS: We conducted longitudinal working groups with group home residents with intellectual and developmental disabilities and serious mental illness, group home staff, and families/caregivers of residents from December 2020 through December 2022. Common themes highlighting ways in which group home residents, staff, and caregivers perceived the built environment to impact living in a group home during the COVID-19 pandemic were identified. RESULTS: Resonant themes centered around increased risk of COVID-19 infection, ad hoc spatial adaptations for infection control, space-related challenges due to isolation and quarantine requirements, and limited access to public spaces. CONCLUSION: Group home residents and staff experienced multiple health and wellness challenges during the COVID-19 pandemic related to their surrounding built environment. Mechanisms to engage group home residents in modifications of their built environment may improve the effectiveness of infection control policies while acknowledging individual autonomy.

Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: During ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC), rectal dissection can be performed via close rectal dissection (CRD) or in a total mesorectal excision plane (TME). Although CRD should protect autonomic nerve function, this technique may be more challenging than TME. The aim of this study was to compare long-term outcomes of patients undergoing CRD and TME. METHODS: This single-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC between January 2002 and October 2017. Primary outcomes were chronic pouch failure (PF) among patients who underwent CRD and TME and the association between CRD and developing chronic PF. Chronic PF was defined as a pouch-related complication occurring ≥ 3 months after primary IPAA surgery requiring redo pouch surgery, pouch excision or permanent defunctioning ileostomy. Secondary outcomes were risk factors and causes for chronic PF. Pouch function and quality of life were assessed via the Pouch dysfunction score and Cleveland global quality of life score. RESULTS: Out of 289 patients (155 males, median age 37 years [interquartile range 26.5-45.5 years]), 128 underwent CRD. There was a shorter median postoperative follow-up for CRD patients than for TME patients (3.7 vs 10.9 years, p < 0.01). Chronic PF occurred in 6 (4.7%) CRD patients and 20 (12.4%) TME patients. The failure-free pouch survival rate 3 years after IPAA surgery was comparable among CRD and TME patients (96.1% vs. 93.5%, p = 0.5). CRD was a no predictor for developing chronic PF on univariate analyses (HR 0.7 CI-95 0.3-2.0, p = 0.54). A lower proportion of CRD patients developed chronic PF due to a septic cause (1% vs 6%, p = 0.03). CONCLUSIONS: Although differences in chronic PF among CRD and TME patients were not observed, a trend toward TME patients developing chronic pelvic sepsis was detected. Surgeons may consider performing CRD during IPAA surgery for UC.

Perspectives on the Implementation of Screening and Treatment for Depression and Alcohol Use Disorder in Primary Care in Colombia.

Depression and alcohol use disorder (AUD) greatly contribute to the burden of disease worldwide, and have large impact on Colombia's population. In this study, a qualitative analysis evaluates the implementation of a technology-supported model for screening, decision support, and digital therapy for depression and AUD in Colombian primary care clinics. Patient, provider, and administrator interviews were conducted, exploring attitudes towards depression and AUD, attitudes towards technology, and implementation successes and challenges. Researchers used qualitative methods to analyze interview themes. Despite stigma around depression and AUD, the model improved provider capacity to diagnose and manage patients, helped patients feel supported, and provided useful prevalence data for administrators. Challenges included limited provider time and questions about sustainability. The implementation facilitated the identification, diagnosis, and care of patients with depression and AUD. There is ongoing need to decrease stigma, create stronger networks of mental health professionals, and transition intervention ownership to the healthcare center.

[Bone marrow fibrosis in primary myelofibrosis in relation to myelodysplasia- and age-related mutations of hematopoietic cells]. / Knochenmarkfibrose bei primärer Myelofibrose in Abhängigkeit von myelodysplasie- und altersassoziierten Mutationen der Hämatopoese.

Besides histopathological findings, there are no indicators of increased risk for fibrotic progression in myeloproliferative neoplasms (MPNs). Age-related clonal hematopoiesis (ARCH) or clonal hematopoiesis of indetermined potential (CHIP) are frequent findings in the elderly and combinations with MPN driver mutations (JAK2, MPL, and CALR) have been described. To determine the impact of ARCH/CHIP-related mutations for the development of fibrosis in primary myelofibrosis (PMF), the mutational status of cases with fibrotic progression from grade 0 to grade 2/3 (n = 77) as evidenced by follow-up bone marrow biopsies (median 6.2 years) was compared to prefibrotic PMF samples without the development of fibrosis (n = 27; median follow-up 7.3 years). Frequent ARCH/CHIP-associated mutations (TET2, ASXL1, DNMT3A) demonstrable at presentation were not connected with fibrotic progression. However, mutations that are rarely found in ARCH/CHIP (SRSF2, U2AF1, SF3B1, IDH1/2, and EZH2) were present in 24.7% of cases with later development of fibrosis and not detectable in cases staying free from fibrosis (P = 0.0028). Determination of tumor mutational burden (TMB) in a subgroup of cases (n = 32) did not show significant differences (7.68 mutations/MB vs. 6.85 mutations/MB). We conclude that mutations rarely found in ARCH/CHIP provide an independent risk factor for rapid fibrotic progression (median 2.0 years) when already manifest at first presentation.

Digital assessment of working memory and processing speed in everyday life: Feasibility, validation, and lessons-learned.

OBJECTIVES: Cognitive functioning is often impaired in mental and neurological conditions and might fluctuate throughout the day. An existing experience-sampling tool was upgraded to assess individual's cognition in everyday life. The objectives were to test the feasibility and validity of two momentary cognition tasks. METHODS: The momentary Visuospatial Working Memory Task (mVSWMT) and momentary Digit Symbol Substitution Task (mDSST) were add-ons to an experience sampling method (ESM) smartphone app. Healthy adults (n = 49) between 19 and 73 years of age performed the tasks within an ESM questionnaire 8 times a day, over 6 consecutive days. Feasibility was determined through completion rate and participant experience. Validity was assessed through contextualization of cognitive performance within intrapersonal and situational factors in everyday life. FINDINGS: Participants experienced the tasks as pleasant, felt motivated, and the completion rate was high (71%). Social context, age, and distraction influenced cognitive performance in everyday life. The mVSWMT was too difficult as only 37% of recalls were correct and thus requires adjustments (i.e. fixed time between encoding and recall; more trials per moment). The mDSST speed outcome seems the most sensitive outcome measure to capture between- and within-person variance. CONCLUSIONS: Short momentary cognition tasks for repeated assessment are feasible and hold promise, but more research is needed to improve validity and applicability in different samples. Recommendations for teams engaging in the field include matching task design with traditional neuropsychological tests and involving a multidisciplinary team as well as users. Special attention for individual needs can improve motivation and prevent frustration. Finally, tests should be attractive and competitive to stimulate engagement, but still reflect actual cognitive functioning.

Do you observe what I perceive? The relationship between two perspectives on the ability of people with cognitive impairments to use everyday technology.

Objectives: Everyday technologies (ETs) can be challenging to use, particularly for older adults with cognitive impairments. This study evaluated the relationship between the self-perceived ability to use ET and observable performance of self-chosen and familiar, but challenging ETs in people with mild cognitive impairment (MCI) or dementia.Method: A self-perceived report, the Everyday Technology Use Questionnaire (S-ETUQ), and a structured observational tool, the Management of Everyday Technology Assessment (META), assessing the perceived and observed ability to use ET, were used in 41 people with MCI and 38 people with dementia. Correlations were investigated with non-parametric statistical tests.Results: In the dementia group, self-perceived report and observational scores correlated on a significant medium level (Rs=0.44, p = 0.006). In the MCI group, no significant correlation was found.Conclusion: The findings of this study suggest the ability of older adults with cognitive impairments to use ETs can be depicted with self-perceived reports as well as with observations. However, the combination of both approaches is recommended to get a comprehensive picture. While the S-ETUQ provides a broad picture of the use, presence and relevance of technologies in an individual's life, the META describes a specific human-technology interaction in detail. Furthermore, the results suggest people with early dementia retain the ability and insight to accurately reflect on their own ability to use ET, emphasizing the need to include their experiences in research and clinical work.

[Liquid biopsy in tumor diagnostics : Applications, perspectives, and limitations of the "cancer liquidome"]. / Liquid Biopsy in der Tumordiagnostik : Anwendungen, Perspektiven und Limitationen des Cancer Liquidome.

The detection of tumor-specific genetic alterations in body fluids as an addition to or even replacement for established tissue-based tumor diagnostics is currently a hot topic in academic research and industry. Progress in methods for nucleic acid analyses together with promising results from clinical studies have raised great expectations for cancer screening, diagnosis, prognosis, and therapy monitoring by means of a minimally invasive blood draw. Individual focused assays have already been introduced into routine diagnostics and represent a valuable option in cases where no tissue samples are available. However, before the use of liquid biopsy outside of clinical studies is enforced and more complex markers (like tumor mutational burden) are analyzed, several practical challenges and principal problems have to be addressed. This review focusses on the detection of free-circulating nucleic acids in blood plasma and critically discusses established and future applications as well as challenges and limitations of this new method.

Association of Obesity and Frailty in Older Adults: NHANES 1999-2004.

OBJECTIVES: Body composition changes with aging can increase rates of obesity, frailty and impact function. Measuring adiposity using body fat (%BF) or central adiposity using waist circumference (WC) have greater diagnostic accuracy than traditional measures such as body mass index (BMI). DESIGN: This is an observational study. SETTING: This study focused on older community-dwelling participants. PARTICIPANTS: We identified individuals age ≥ 60 years old using the 1999-2004 cross-sectional National Health and Nutrition Survey (NHANES). INTERVENTION: The primary analysis evaluated the association between frailty and %BF or WC. Frailty was the primary predictor (robust=referent) and %BF and WC were considered continuous outcomes. Multiple imputation analyses accounted for missing characteristics. MEASUREMENT: Dual energy x-ray absorptiometry was used to assess %BF and WC was objectively measured. Frailty was defined using an adapted version of Fried's criteria that was self-reported: (low BMI<18.5kg/m2; slow walking speed [<0.8m/s]; weakness [unable to lift 10lbs]; exhaustion [difficulty walking between rooms on same floor] and low physical activity [compared to others]). Robust, pre-frail and frail persons met zero, 1 or 2, and ≥3 criteria, respectively. RESULTS: Of the 4,984 participants, the mean age was 71.1±0.2 (SE) years and 56.5% were females. We classified 2,246 (50.4%), 2,195 (40.3%), and 541 (9.2%) individuals as robust, pre-frail and frail, respectively. Percent BF was 35.9±0.13, 38.3±0.20 and 40.0±0.46 in the robust, pre-frail and frail individuals, respectively. WC was 99.5±0.32 in the robust, 100.1±0.43 in pre-frail, 104.7±1.17 in frail individuals. Compared to robust individuals, only frail individuals had greater %BF on average (ß=0.97±0.43,p=0.03); however, pre-frail and frail individuals had 2.18 and 4.80 greater WC, respectively (ß=2.18±0.64,p=0.002, and ß=4.80±1.1,p<0.001). CONCLUSION: Our results demonstrate that in older adults, frailty and pre-frailty are associated with a greater likelihood of high WC (as dichotomized) and a greater average WC (continuous).

Depression and Handgrip Strength Among U.S. Adults Aged 60 Years and Older from NHANES 2011-2014.

OBJECTIVES: Sarcopenia is a gradual loss of muscle mass and strength that occurs with aging. This muscle deterioration is linked to increased morbidity, disability, and other adverse outcomes. Although reduced handgrip strength can be considered a marker of sarcopenia and other aging-related decline in the elderly, there is limited research on this physical health problem in at-risk groups with common biopsychosocial conditions such as depression. Our primary objective was to ascertain level of combined handgrip strength and its relationship with depression among adults aged 60 years and older. DESIGN: Unadjusted and adjusted linear regression models were conducted with a cross-sectional survey dataset. SETTING: Secondary dataset from the 2011-2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: Community-dwelling, non-institutionalized adults ≥60 years old (n=3,421). MEASUREMENTS: The predictor variables included a positive screen for clinically relevant depression (referent=PHQ-9 score <10). The criterion variable of combined handgrip strength (kg) was determined using a dynamometer. RESULTS: Mean age and BMI were 69.9 years (51.5% female) and 28.8 kg/m2, respectively. Mean combined handgrip strength in the overall cohort was 73.5 and 46.6 kg in males and females, respectively. Three hundred thirty-six (9.8%) reported symptoms of depression. In unadjusted and fully adjusted models, depression was significantly associated with reduced handgrip strength (B = -0.26±0.79 and B = -0.19±0.08, respectively; p<0.001). CONCLUSION: Our findings demonstrate handgrip strength has a significant inverse association with depression. Future longitudinal studies should investigate the causal processes and potential moderators and mediators of the relationships between depression and reduced handgrip strength. This information may further encourage the use of depression and handgrip strength assessments and aid in the monitoring and implementation of health care services that address both physical and mental health limitations among older adult populations.

Association of adiposity, telomere length and mortality: data from the NHANES 1999-2002.

BACKGROUND/OBJECTIVES: Telomere shortening is associated with age and risk of medical comorbidity. We assessed the relationship between measures of adiposity, leukocyte telomere length, and mortality and whether it is modified by age. SUBJECTS/METHODS: Subjects with dual-energy X-ray absorptiometry measures were identified using the National Health and Nutrition Examination Survey 1999-2002. Obesity was categorized using two body fat definitions (BF1%: men ⩾25%; females ⩾35%; BF2% ⩾28% and ⩾38%, respectively), body mass index (BMI) and waist circumference (WC; men ⩾102 cm; females ⩾88 cm). Telomere length relative to standard reference DNA (T/S ratio) was assessed using quantitative PCR. Weighted multivariable regression models evaluated the association of telomere length with adiposity, both continuously and categorically (low/normal BF%, low/high WC and standard BMI categories). Differences in telomere length by age and adiposity were ascertained and subsequent models were stratified by age. Proportional hazard models assessed the risk of mortality by adiposity status. A telomere by adiposity interaction was tested in the entire cohort and by age category (<60 vs ⩾60 years; <70 vs ⩾70 years). RESULTS: We identified 7827 subjects. Mean age was 46.1 years. Overall telomere length was 1.05±0.01 (s.e.) that differed by BF1% (low/high: 1.12±0.02 vs 1.03±0.02; P<0.001), BF2% (1.02±0.02 vs 1.11±0.02; P<0.001), BMI (underweight 1.08±0.03; normal 1.09±0.02; overweight 1.04±0.02; and obese 1.03±0.02;P<0.001) and WC (low/high 1.09±0.02 vs 1.02±0.02; P<0.001). Adjusted ß-coefficients evaluating the relationship between telomere length and adiposity (measured continuously) were as follows: BF1% (ß=-0.0033±0.0008; P<0.001), BF2% (-0.041±0.008; P<0.001), BMI (ß=-0.025±0.0008; P=0.005) and WC (ß=-0.0011±0.0004; P=0.007). High BF% (BF1%: ß=-0.035±0.011; P=0.002; BF2%: ß=-0.041±0.008; P<0.001) and WC (ß=-0.035±0.011; P=0.008) were inversely related to telomere length (TL). Stratifying by age, high BF1% (-0.061±0.013), BF2% (-0.065±0.01), BMI-obesity (-0.07±0.015) and high WC (-0.048±0.013) were significant (all P<0.001). This association diminished with increasing age. In older participants, TL was inversely related to mortality (hazard ratio 0.36 (0.27, 0.49)), as were those classified by BF1% (0.68 (0.56, 0.81)), BF2% (0.75 (0.65, 0.80)), BMI (0.50 (0.42, 0.60)) and WC (0.72 (0.63, 0.83)). No interaction was observed between adiposity status, telomere length and mortality. CONCLUSIONS: Obesity is associated with shorter telomere length in young participants, a relationship that diminishes with increasing age. It does not moderate the relationship with mortality.

External validation of a prognostic model of preoperative risk factors for failure of restorative proctocolectomy.

AIM: The Cleveland Clinic has proposed a prognostic model of preoperative risk factors for failure of restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis. The model incorporates four predictive variables: completion proctectomy, handsewn anastomosis, diabetes mellitus and Crohn's disease. The aim of the present study was to perform an external validation of this model in a new cohort of patients who had RPC. METHOD: Validation was performed in a multicentre cohort of 747 consecutive patients who had an RPC between 1990 and 2015 in three tertiary-care facilities, using a Kaplan-Meier survival analysis and Cox regression analysis. The performance of the model was expressed using the Harrell concordance error rate. The primary outcome measure was pouch survival with maintenance of anal function. RESULTS: During the study period, 45 (6.0%) patients experienced failure at a median interval of 31 months (interquartile range 9-82 months) from the original RPC. Multivariable analysis showed handsewn anastomosis to be the only significant independent predictor. The Harrell concordance error rate was 0.42, indicating poor performance. Anastomotic leakage and Crohn's disease of the pouch were strong postoperative predictors for pouch failure and showed a significant difference in pouch survival after 10 years (P < 0.001). CONCLUSION: The poor performance of the Cleveland Clinic prognostic model makes it unsuitable for daily clinical practice. Handsewn anastomosis was associated with pouch failure in our cohort with relatively few events. A prediction model for anastomotic leakage or Crohn's disease of the pouch may be a better solution since these variables are strongly associated with pouch failure.

Prevalence of weakness and its relationship with limitations based on the Foundations for the National Institutes for Health project: data from the Health and Retirement Study.

BACKGROUND/OBJECTIVES: The objectives of this study were to determine the prevalence of muscle weakness using the two 2014 Foundation for the National Institutes of Health (FNIH) Sarcopenia Project criteria and its relationship with physical limitations, basic activities of daily living (ADL) and instrumental ADL. SUBJECTS/METHODS: We performed a cross-sectional analysis of community-dwelling adults from the Health and Retirement Study 2006-2008 and identified a subsample of 5092 adults aged ⩾60 years with grip strength (GS) data. Self-reported physical limitations, basic ADL and instrumental ADL were assessed. Criteria for GS (men<26 kg; women <16 kg) and GS adjusted for body mass index (GS/BMI; men <1.0; women <0.56) were applied to the sample. We determined the prevalence of muscle weakness in each sex. Multivariable logistic regression was used to calculate the association of physical limitations, basic ADL and instrument ADL with weakness definitions in each sex. RESULTS: Mean age was 72.1 years (54.9% female). Mean GS was 38.3 and 22.9 kg and mean BMI was 29 kg/m2, respectively, in men and women. Weakness prevalence using GS and GS:BMI definitions were 7.8 and 15.2 (P<0.001), respectively, in men and 11.4 and 13.3% (P=0.04) in women. Overall prevalence of physical limitations, basic ADL limitations and instrumental ADL limitations was 52.9, 28.1 and 35.9%, respectively. In those with weakness, prevalence of physical limitations, basic ADL and instrumental ADL was 78.5, 42.3 and 65.3%, respectively, using the GS definition, and 79.7, 40.7 and 58.8%, respectively, using the GS/BMI definition. GS and the GS/BMI definitions of weakness were strongly associated with physical limitations (odds ratio (OR) 2.19 (95% confidence interval (CI): (1.67-2.87)) and 2.52 (2.01-3.17)), basic ADL (OR 1.59 (1.22-2.07) and 1.66 (1.32-2.07)) and instrumental ADLs (OR 1.98 (1.28-2.54) and 1.78 (1.44-2.20)). CONCLUSIONS: The new FNIH guidelines for weakness are associated with higher prevalence of physical limitations, basic ADL impairments and instrumental ADL impairments as compared with individuals without weakness.

The future of mental health care: peer-to-peer support and social media.

AIMS: People with serious mental illness are increasingly turning to popular social media, including Facebook, Twitter or YouTube, to share their illness experiences or seek advice from others with similar health conditions. This emerging form of unsolicited communication among self-forming online communities of patients and individuals with diverse health concerns is referred to as peer-to-peer support. We offer a perspective on how online peer-to-peer connections among people with serious mental illness could advance efforts to promote mental and physical wellbeing in this group. METHODS: In this commentary, we take the perspective that when an individual with serious mental illness decides to connect with similar others online it represents a critical point in their illness experience. We propose a conceptual model to illustrate how online peer-to-peer connections may afford opportunities for individuals with serious mental illness to challenge stigma, increase consumer activation and access online interventions for mental and physical wellbeing. RESULTS: People with serious mental illness report benefits from interacting with peers online from greater social connectedness, feelings of group belonging and by sharing personal stories and strategies for coping with day-to-day challenges of living with a mental illness. Within online communities, individuals with serious mental illness could challenge stigma through personal empowerment and providing hope. By learning from peers online, these individuals may gain insight about important health care decisions, which could promote mental health care seeking behaviours. These individuals could also access interventions for mental and physical wellbeing delivered through social media that could incorporate mutual support between peers, help promote treatment engagement and reach a wider demographic. Unforeseen risks may include exposure to misleading information, facing hostile or derogatory comments from others, or feeling more uncertain about one's health condition. However, given the evidence to date, the benefits of online peer-to-peer support appear to outweigh the potential risks. CONCLUSION: Future research must explore these opportunities to support and empower people with serious mental illness through online peer networks while carefully considering potential risks that may arise from online peer-to-peer interactions. Efforts will also need to address methodological challenges in the form of evaluating interventions delivered through social media and collecting objective mental and physical health outcome measures online. A key challenge will be to determine whether skills learned from peers in online networks translate into tangible and meaningful improvements in recovery, employment, or mental and physical wellbeing in the offline world.

Diagnostic accuracy of body mass index to identify obesity in older adults: NHANES 1999-2004.

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.

Impact of obesity on disability, function, and physical activity: data from the Osteoarthritis Initiative.

OBJECTIVES: Older adults with obesity are at risk for osteoarthritis (OA) and are predisposed to functional decline and disability. We examined the association between obesity and disability, physical activity, and quality of life at 6 years. METHOD: Using data from the longitudinal Osteoarthritis Initiative (OAI), we analysed older adults (age ≥ 60 years) with a body mass index (BMI) at baseline ≥ 18.5 kg/m(2) (n = 2378) using standard BMI categories. Outcomes were assessed at the 6-year follow-up and included: the Late-Life Function and Disability Index (LLDI), the 12-item Short Form Health Survey (SF-12), and the Physical Activity Scale for the Elderly (PASE). Linear regression predicted outcomes based on BMI category, adjusting for age, sex, race, education, smoking, cohort status, radiographic knee OA, co-morbidity scores, and baseline scores when available. RESULTS: Follow-up data were available for 1727 (71.9%) participants (mean age 67.9 ± 5.3 years; 61.6% female). At baseline, obese subjects compared to overweight and normal were on a greater number of medications (4.28 vs. 3.63 vs. 3.32), had lower gait speeds (1.22 vs. 1.32 vs. 1.36 m/s), higher Charlson scores (0.59 vs. 0.37 vs. 0.30), and higher Western Ontario and McMaster University OA Index (WOMAC) scores (right: 14.8 vs. 10.3 vs. 7.5; left: 14.4 vs. 9.9 vs. 7.5). SF-12 scores at 6 years were lower in obese patients than in overweight or normal [99.5 (95% CI 98.7-100.4) vs. 101.1 (95% CI 100.4-101.8) vs. 102.8 (95% CI 101.8-103.8)], as were PASE scores [115.1 (95% CI 110.3-119.8) vs. 126.2 (95% CI 122.2-130.2) vs. 131.4 (95% CI 125.8-137.0)]. The LLDI limitation component demonstrated differences in obese compared to overweight or normal [78.6 (95% CI 77.4-79.9) vs. 81.2 (95% CI 80.2-82.3) vs. 82.5 (95% CI 81.1-84.0)]. CONCLUSIONS: Obesity was associated with worse physical activity scores, lower quality of life, and higher risk of 6-year disability.