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JAMDA
journal homepage: www.jamda.com
Original Study
Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, N.T., Hong Kong
The Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, School of Public Health, Prince of Wales Hospital, N.T.,
Hong Kong
c
The Key Laboratory of Geriatrics, Beijing Hospital, Beijing Institute of Geriatrics, Ministry of Health, Beijing, China
b
a b s t r a c t
Keywords:
Frailty
successful aging
walking speed
physical activity
quality of life
appendicular fat
Objectives: Operational denitions of successful aging place a strong emphasis on functional capacity, and
strategies for successful aging include many factors common to frailty research. We explore the hypothesis that frailty and successful aging are two sides of the same coin and that walking speed may be
an objective indicator of successful aging.
Design: Observational study of two Chinese cohorts using one to dene fast walkers and applying this
criteria to another cohort to examine associated factors.
Setting: Community survey in cities in China.
Participants: A total of 1929 men and women aged 25 to 89 years of age in four cities in China and 4000
men and women 65 years old in Hong Kong SAR China.
Measurements: The top 25th percentile of walking speed for the whole cohort of 1929 men was determined, and the cutoff value was used to dene fast walkers. This value was applied to the Hong Kong
Chinese population to examine factors associated with fast walking speed. These factors include age,
gender, socioeconomic and lifestyle factors, medical history, quality of life, cognitive function, depressive
symptoms, body mass index, body composition, and telomere length.
Results: Fast walkers had better self-rated health, lower prevalence of stroke, hypertension, cataracts,
osteoporosis, and impaired cognitive function. They were more likely to be current alcohol users, more
physically active, consumed more vegetables, had better physical component of health-related quality of
life, and received more education. They also had lower body mass index, percentage whole body fat as
well as appendicular fat, and higher appendicular muscle mass index. In multivariate analysis, the signicant contributing variables were age, gender, current alcohol use, physical activity level, vegetable
intake, quality of life, and appendicular fat. The area under the curve value on receiver-operating characteristic analysis was 0.77 for these seven variables.
Conclusions: Frailty and successful aging may be considered two sides of the same entity, and fast walking
speed may be used as an objective indicator of successful aging.
2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
were able to walk or take public transport to the study site. They were
recruited using a stratied sampling method so that approximately
33% would be in each of these age groups: 65 to 69, 70 to 74, and 75.
This study was conducted in accordance with the Declaration of
Helsinki and was approved by the Clinical Research Ethics Committee
of the Chinese University of Hong Kong. Written informed consent
was obtained from all subjects.
Questionnaire
A standardized, structured interview was performed to collect
information on age, education level, smoking habits, and alcohol use.
Information on the duration and level of past and current use of cigarettes, cigars, and pipes was obtained. Smoking history was classied
in terms of former smoking (at least 100 cigarettes smoked in a lifetime), current smoking, or never smoking. Subjects were also asked
about their alcohol use, and drinking status was dened as never,
former, or current. The presence of known chronic disease was also
recorded, and participants were also asked to rate their health status
into ve categories from poor to excellent. Cognitive function was
assessed by the Mini-Mental Status Examination30 according to the
original osteoporosis study protocol.31 Health-related quality of life
was evaluated by the 12-Item Short Form Health Survey (SF-12). It
derives summary scores from specic items from the eight domains of
the SF-36, with physical component summary score (summary of
physical functioning, physical role, bodily pain, and general health)
and the mental component summary score summary of vitality, social
functioning, emotional role, and mental health,32 being highly correlated with that of the SF-36 (0.951 and 0.969, respectively). Depressive
symptoms were assessed using the Geriatric Depression Scale33 with a
score 8 representing depressive symptoms, validated in elderly
Chinese subjects.34
Self-rated SES was assessed by asking participants to place a mark
on a picture of an upright ladder with ten rungs, with the top rung
representing people who have the most money, the most education,
and the most respected jobs and the bottom rung representing people
at the other extreme (SES ladder). This is a subjective measure of social
status developed by the John D. and Catherine T. MacArthur Research
Network on Socioeconomic Status and Health. It has been associated
with key health outcomes in various population surveys of different
cultural and ethnic groups35 and had been applied in the Hong Kong
population to examine gender differences in socioeconomic status.36
Dietary intake was assessed at baseline using a validated semiquantitative food frequency questionnaire.37 A trained interviewer
asked each participant to report the frequency and the usual amount
of consumption of each food item over the past year. Portion size was
explained to participants using a catalogue of pictures of individual
food portions. The daily amount of consumption of major food groups
including cereal, egg and egg products, sh and shellsh, fruits and
dried fruits, legumes/nuts/seeds, meat and poultry, milk and milk
products, and vegetables was calculated. Mean daily nutrient intake
was calculated using food tables derived from McCance and Widdowson38 and the Chinese Medical Sciences Institute.39
Measurements and Methods
Body weight was measured with subjects wearing a light gown,
using the Physician Balance Beam Scale (Health o meter, McCook, IL).
Height was measured using the Holtain Harpenden stadiometer
(Holtain Ltd, Crosswell, Crymych, Pembs, Wales). Body mass index
(BMI) was calculated as (body weight in kg/[height in m2]). BMI
was divided into different categories to represent underweight
(<18.5 kg/m2), normal weight (18.5 to < 23 kg/m2), overweight (23 to
24.9 kg/m2), obesity I (25 to 29.9 kg/m2), and obesity II (30 kg/m2),
using Asian criteria.40 Blood pressure was measured after a 5-minute
rest in the sitting position using a standard mercury sphygmomanometer (W.A. Baum Co. Inc., Copiague, NY) by trained staff. The rst
and fth Korotkoff phases were recorded as systolic and diastolic
blood pressure. The average of two readings was taken. Body
composition was measured by dual-energy X-ray absorptiometry
(Hologic QDR-4500W, software version 11.2: Hologice, Inc., Waltham,
MA). Total appendicular skeletal muscle mass was calculated by the
sum of lean mass measured in the four limbs, with the operator
adjusting the cut lines of the limbs according to specic anatomical
landmarks as described by Heymseld et al.41
Assessment of Telomere Length by a Real-Time Quantitative PCR
Method
Measurement of telomere length of DNA samples follows the
method published by Cawthon,42 with modication.43 The principle of
this technique is to measure the factor of the ratio between the telomere repeat copy number, and a single copy gene copy number is our
sample with respect to a reference DNA sample (known as T/S ratio).
Real-time quantitative polymerase chain reaction was performed on
Roche LightCycler 480 (Roche, Mannheim, Germany).
Statistical Analysis
Statistical analyses were performed using SAS software, version
9.2 (SAS Institute). Percentages of fast walkers (walking speed of
1.39 m/s) were compared between men and women by chi-square
tests. Associated factors of fast walkers were analyzed by t-tests for
continuous variables and chi-square tests for categorical variables.
Logistic regression was performed for signicant risk factors, using the
stepwise selection method. Receiver-operating characteristic (ROC)
curves were constructed using predicted probabilities to evaluate the
discriminative quality of the model. The area under the ROC curve
(AUC) was used to measure the concordance of predictive values with
actual outcomes. All statistical tests were two sided. P values less than
.05 were considered signicant.
Results
The frequency of people who had a walking speed of 1.39 m/s
(fast walkers) is shown by gender and three different age groups at
baseline and during different periods of follow-up (Table 1). For the
Table 1
Walking Speed 1.39 m/s (Fast Walkers) by Age Groups
Male
N
Walking speed 1.39 m/s
Age 65-74
Baseline
1372
2 y FU
1237
4 y FU
1154
Age 75-84
Baseline
585
2 y FU
478
4 y FU
386
Age 85
Baseline
43
2 y FU
28
4 y FU
20
All ages
Baseline
2000
2 y FU
1743
4 y FU
1560
Female
Freq
Freq
146
102
61
10.64%
8.25%
5.29%
1334
1159
1116
36
22
10
2.7%*
1.9%*
0.9%*
21
10
2
3.59%
2.09%
0.52%
608
487
432
6
3
3
0.99%*
0.62%*
0.69%
58
33
29
0
0
0
0%
0%
0%
2000
1679
1577
42
25
13
0
0
0
167
112
63
FU, follow-up.
*P value < .05 for chi-square test.
0%
0%
0%
8.35%
6.43%
4.04%
2.1%*
1.49%*
0.82%*
Table 2
Baseline Characteristics
Walking Speed Using Best Time
1.39 m/s, Freq (%)/Mean (SD)
No (n 3791)
Age
Female
Self-rated health
Excellent
Good
Fair
Poor
Very poor
Diabetes
High/low thyroid
Stroke
Parkinson disease
Hypertension
Heart attack/coronary/
myocardial infarction
Angina
Congestive heart failure/
enlarged heart
COPD
Glaucoma
Cataracts
Gastrectomy
Arthritis
Osteoporosis
MMSE
Depression (GDS > 8)
SBP >160 and/or DBP > 90
Current smoking
Current alcohol use
PASE score
Fruits and dried fruits
intake (g/day)
Vegetables intake (g/day)
Protein intake (g/day)
SF-12dphysical
SF-12dmental
Education
Primary or below
Secondary/matriculation
University or above
SES ladderdHong Kong (> 5)
SES ladderdcommunity (> 5)
BMI (kg/m2)
Whole body % fat
Whole body fat (kg)
Appendicular fat (kg)
ASM/height squared (kg/m2)
Telomere length (kb)
72.63 (5.21)
1958 (51.7%)
342
1408
1751
260
30
554
157
174
16
1642
376
(9.0%)
(37.1%)
(46.2%)
(6.9%)
(0.8%)
(14.6%)
(4.1%)
(4.6%)
(0.4%)
(43.3%)
(9.9%)
333 (8.8%)
146 (3.9%)
P Value*
Yes (n 209)
69.77 (3.70)
42 (20.1%)
40
99
64
6
0
25
3
1
0
65
17
(19.1%)
(47.4%)
(30.6%)
(2.9%)
(0.0%)
(12.0%)
(1.4%)
(0.5%)
(0.0%)
(31.1%)
(8.1%)
19 (9.1%)
5 (2.4%)
<.0001
<.0001
<.0001
.2888
.052
.0047
.8856
.0005
.3989
.8788
.2813
321
161
1528
305
888
1139
25.53
356
650
258
463
90.34
259.50
(8.5%)
(4.3%)
(40.3%)
(8.1%)
(23.4%)
(30.0%)
(3.70)
(9.4%)
(17.2%)
(6.8%)
(12.2%)
(42.19)
(192.41)
12
6
68
19
34
34
27.22
16
35
17
59
109.11
286.36
(5.7%)
(2.9%)
(32.5%)
(9.1%)
(16.3%)
(16.3%)
(2.81)
(7.7%)
(16.8%)
(8.1%)
(28.2%)
(52.81)
(275.25)
.1649
.3329
.0255
.5897
.0168
<.0001
<.0001
.3992
.8787
.46
<.0001
<.0001
.1652
240.95
75.70
48.36
55.40
(157.86)
(33.25)
(8.48)
(7.32)
276.40
90.13
52.30
56.19
(202.55)
(35.21)
(6.35)
(6.66)
.0135
<.0001
<.0001
.1274
<.0001
2769
681
341
2044
3263
23.72
29.72
17.31
7.10
6.60
9.09
(73.0%)
(18.0%)
(9.0%)
(57.5%)
(89.9%)
(3.32)
(7.18)
(5.31)
(2.58)
(0.96)
(2.01)
94
66
49
129
190
23.12
24.98
15.17
5.89
7.06
9.05
(45.0%)
(31.6%)
(23.4%)
(62.9%)
(91.8%)
(2.91)
(6.36)
(4.70)
(2.03)
(0.91)
(1.77)
0.1258
0.3878
0.0048
<.0001
<.0001
<.0001
<.0001
0.8482
ASM, appendicular skeletal mass; BMI, body mass index; COPD, chronic obstructive
pulmonary disease; DBP, diastolic blood pressure; GDS, Geriatric Depressive Scale;
MMSE, Mini-Mental State Exam; SBP, systolic blood pressure; SES, social-economic
status; SF-12, 12-Item Short Form Health Survey.
Items in bold indicate P value < .05.
*P value of t-test for continuous or chi-square for categorical variables.
Table 3
Logistic Regression of Walking Speed
Walking Speed 1.39 m/s Freq (%)/Mean (SD)
Age
Female
Current alcohol use
PASE score
Vegetables intake (g/day)
SF-12dphysical
Appendicular fat (kg)
No (n 3791)
Yes (n 209)
72.63
1958
463
90.34
240.95
48.36
7.10
69.77
42
59
109.11
276.40
52.30
5.89
(5.21)
(51.7%)
(12.2%)
(42.19)
(157.86)
(8.48)
(2.58)
(3.70)
(20.1%)
(28.2%)
(52.81)
(202.55)
(6.35)
(2.03)
Unit*
1.99
0.42
1.45
1.14
1.14
1.49
1.35
(1.64, 2.41)
(0.28, 0.64)
(1.03, 2.03)
(1.02, 1.29)
(1.01, 1.28)
(1.23, 1.81)
(1.1, 1.65)
Fig. 1. Receiver-operator characteristic curve of the fast walker; area under the
curve 0.772 (95% condence interval, 0.741e0.803).
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