A Case Control Study on Physical

Health Components and

Cardiometabolic Risk Markers among

Elderly

Muhammad Kamil Che Hasan 9/21/2014 1

Outline

• Problem Statement

• Significant of Study

• General Objective

• Specific Objective

• Literature Review

• Study Flowchart

• Methodology

• Inclusion & Exclusion Criteria

• Data Analysis

• Discussion

• Conclusion

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Problem Statement

• Rising in trend of non-communicable diseases (e.g. diabetes mellitus, obesity, cardiovascular diseases) has become significant over the years

• Cardiometabolic diseases remain the leading cause of death and disabilities in the Malaysian population

• Abnormalities in physical (musculoskeletal) health were found associated with various health conditions.

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Significant of Study

• Relevance between physical health components and physiological profile among elderly is still lacking.

• The relationship between physical health status and cardiometabolic profile is not explored much.

• This study will add new knowledge in the relationship of alterations in physical health and changes in cardiometabolic risk markers.

• It may help identifying physical health disturbance and cardiometabolic disease target group for prevention and rehabilitation.

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General Objective

• To explore the relationship between physical health components and cardiometabolic risk markers among elderly with cardiometabolic disease.

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To measure physical health components in elderly with cardiometabolic diseases as follows: a.Cardiorespiratory endurance (6-Minutes Walk Test) b.Muscular strength (Arm Curl Test & Chair Stand Test) c.Agility (Timed-up-and Go Test) d.Flexibility (Back Scratch Test & Sit and Reach Test)

To compare physical health components and cardiometabolic risk markers between control and cardiometabolic group.

To investigate the relationship between physical health components and cardiometabolic risk markers among elderly with cardiometabolic diseases.

To determine cardiometabolic risk markers which are waist circumference, BMI, high-sensitivity C-reactive protein (hsCRP), serum adiponectin, fasting blood lipids (e.g. cholesterol, triglycerides, HDL, LDL), fasting glucose, fasting insulin and fasting insulin sensitivity (HOMAIR) in elderly with cardiometabolic diseases.

1

2

3

4

Specific Objective

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• Cardiometabolic disease is a condition with the presence of at least 3 of the 5 following metabolic abnormalities including central obesity, hypertension, insulin resistance, elevated level of triglycerides and low concentration of high-density lipoprotein

(Kelly 2012; Salvi et al. 2012; Gluba et al. 2012; Chang et al. 2009)

• Cardiometabolic risk factors are closely related to diabetes and cardiovascular disease which are fasting hyperglycemia, overweight/obesity, elevated systolic and diastolic blood pressure, and dyslipidemia.

(Vanuzzo et al. 2008)

• In geriatric populations, the speeds of walking and gait pattern are widely investigated in order to predict various health conditions such as dementia, muscle strength and stroke

(Newman et al. 2011; Ben et al. 2008; Inzitari 2007)

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Literature Review

• Normal gait profiles also can be applied as the reference for disability assessment, intervention and treatment planning

(Chiu & Wang 2007)

• Physical activity declines with increasing age (Purath et al. 2007)

• The increase of aging population may increase the number of individuals who are at risk of chronic disease.

(Christensen et al. 2009)

• Increased risk for sedentary lifestyle, declines in physical activities.

(Centers for Disease Control 2006)

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Literature Review

Study Flowchart

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Selection of subjects from UKM Medical Centre

Consent form and Sociodemographic Information Collection

Having at least 3 or more cardiometabolic diseases such as diabetes, obesity, hypertension, dyslipidemia, and cardiovascular diseases

CARDIOMETABOLIC GROUP CONTROL GROUP

Physical health components data will be obtained*: i. Cardiorepiratory fitness (6-minutes walk test)

ii. Body composition (Waist Circumference, Body-Mass Index)

iii. Muscular strength (Arm Curl Test, Chair Stand Test)

vi. Agility (Timed-up-and Go)

v. Flexibility (Back Scratch Test, Sit and Reach Test)

(*if the patient feel tired, the test will be done in two different times) &

International Physical Health Questionnaire

YES NO

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Blood Pressure Measurement &

Blood Sampling (10ml) for cardiometabolic markers:

i. Human Sensitivity C-Reactive Protein (hsCRP)

ii. Serum Adiponectin

iii. Fasting Glucose and Insulin

iv. Fasting Lipid Profile

Analysis & Results

Methodology • Medical ward & Physiotherapy Unit UKMMC Population &

Setting

• Case control Study Study design

• Purposive sampling Sampling

• Power and Sample Size Calculations version 3.0.43

• Sample size : 34 each group Sample size

• 1) Six minutes walk test, 2) Waist circumference, 3) BMI, 4) Arm Curl Test, Chair Stand Test and 5) Timed-up-and-go 6) Back Scratch Test, Sit and Reach Test

Instrument

• Clinical test

• Laboratory Test Data

collection

• Statistical Package for Social Science (SPSS) Version 20 Analysis

• Research Ethical Committee of UKMMC Ethical approval

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• Aged between 60-75 years

• Physically independent

• Having at least three

cardiometabolic disease such as

diabetes, obesity, hypertension,

dyslipidemia, and cardiovascular

diseases (for cardiometabolic

group).

• Healthy or having not more than

two cardiometabolic disease (for

control group)

• Registered blindness

• Severe hearing impairment

• Uncontrolled epilepsy

• Progressive neurological disease

• Chronic disabling arthritis

• Use of walking aids

• Any neurological, skeletal muscle,

or joint disturbance that precluded

participation in testing.

• Have been advised by their

physician to refrain from exercise

for health reasons.

Inclusion Criteria

Exclusion Criteria

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Data Analysis

• Sociodemographic data – descriptive statistics

• Physical health components –independent t-test

• Cardiometabolic risk markers (Glucose, insulin, HOMA-IR, HDL, TG, LDL, Adiponectin, hsCRP) – Mann-Whitney U test.

• Cardiometabolic risk markers (Cholesterol, WC, BMI, SBP, DBP) – independent t-test

• Correlation between physical health components and cardiometabolic risk markers - Spearman rho correlation test.

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Sociodemographic Data

Control (n=34) Cardiometabolic (n=34)

Age (Mean ± SD) 65.79 ± 4.88 64.71 ± 4.01

Frequency Percentage (%) Frequency Percentage (%)

Gender

Male

Female

20

14

58.8

41.2

24

10

70.6

29.4

Race

Malay

Chinese

Indian

Others

22

9

3

0

64.7

26.5

8.8

0

23

5

3

3

67.7

14.7

8.8

8.8

Educational Level

Primary Level

Secondary Level

Tertiary Level

10

17

7

29.4

50.0

20.6

11

19

4

32.4

55.9

11.8

Smoking Status

Yes

No

6

28

17.6

82.4

0

34

0

100

Marital Status

Single

Married

0

34

0

100

1

33

2.9

97.1

Occupation

Own Business

Retired

11

23

32.4

67.6

7

27

20.6

79.4 9/21/2014 14

Physical Health Components

Physical Health Components Mean ± SD

Independent t-test

Control

(n=34)

Cardiometabolic

(n=34)

t-value

p-value

Chair Stand Test

(frequency in 30s) 11± 3 10 ± 3

1.022

0.311

Arm Curl Test

(frequency in 30s) 15 ± 3 14 ± 4

0.679

0.500

Chair Sit and Reach Test(cm) 0.89 ± 3.21 -0.49 ± 4.75

1.405

0.165

Time Up and Go (s) 6.94 ± 1.41 8.02 ± 3.38

-1.732

0.090

Six Minutes Walk Test (m) 409.52 ± 85.14 404.50 ± 87.20

0.241

0.811

Back Scratch Test (cm) -13.97 ± 2.99 -12.24 ± 2.12

-0.542

0.590

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Cardiometabolic Risk Markers

Cardiometabolic risk markers

Mean ± SD

t-value/

z-value

p-value

Control (n=34)

Cardiometabolic (n= 34)

Glucose (mmol/L) 5.10 ± 0.12 6.62 ± 0.42

-3.202b

0.001*

Insulin (mU/L) 3.37 ± 0.75 10.29 ± 2.68

-2.600 b

0.009*

HOMA-IR 0.79 ± 0.183 3.49 ± 1.09

-2.846 b

0.004*

Cholesterol (mmol/L) 4.24 ± 0.14 3.85 ± 0.15

1.873 a

0.065

High Density Lipoprotein (mmol/L) 1.04 ± 0.05 0.94 ± 0.05

-2.600 b

0.009

Triglycerides (mmol/L) 1.12 ± 0.11 1.49 ± 0.13

-2.846 b

0.004*

Low Density Lipoprotein (mmol/L) 2.97 ± 0.12 2.62 ± 0.13

-1.908 b

0.056*

Adiponectine (ug/ml) 3.87 ± 0.15 3.42 ± 0.19

-2.668 b

0.008

High Sensitivity C-Reactive Protein (mg/L) 0.31 ± 0.04 0.36 ± 0.05

-2.085 b

0.037

Waist Circumference (cm) 91.02 ± 1.92 97.18 ± 1.78

-1.717 a

0.086*

Body Mass Index (kg/m2) 26.19 ± 0.79 28.97 ± 0.92

-0.760 a

0.447*

Systolic (mmHg) 138.74 ± 17.95 144.03 ± 19.69

-1.159 a

0.251

Diastolic (mmHg) 84.15 ± 11.54 84.24 ± 7.90

-0.037a

0.971 9/21/2014 16

Correlation

• physical health components and cardiometabolic risk markers in plasma

Cardiometabolic Risks Markers in Plasma

Glucose Insulin HOMA-IR Cholesterol HDL TG LDL Adiponectin hsCRP

CST 0.265*

(0.029)

0.146

(0.235)

0.163

(0.185)

-0.050

(0.684)

-0.121

(0.326)

0.159

(0.195)

-0.040

(0.745)

0.062

(0.615)

-0.054

(0.664)

ACT 0.161

(0.191)

0.110

(0.371)

0.125

(0.308)

-0.114

(0.354)

-0.110

(0.372)

0.074

(0.549)

-0.094

(0.447)

-0.074

(0.546)

-0.058

(0.638)

CSRT -0.137

(0.264)

-0.276*

(0.023)

-0.291*

(0.016)

0.022

(0.860)

0.137

(0.265)

0.024

(0.846)

-0.070

(0.568)

0.205

(0.094)

-0.236

(0.052)

TUG 0.011

(0.927)

-0.087

(0.479)

-0.078

(0.526)

-0.109

(0.378)

0.011

(0.929)

-0.141

(0.253)

-0.139

(0.260)

0.060

(0.626)

0.128

(0.297)

SMWT 0.104

(0.398)

0.073

(0.555)

0.064

(0.603)

-0.020

(0.874)

-0.142

(0.274)

0.197

(0.107)

0.016

(0.897)

0.029

(0.815)

-0.159

(0.196)

BST -0.090

(0.467)

0.027

(0.830)

0.000

(0.998)

-0.189

(0.898)

0.066

(0.595)

-0.136

(0.269)

-0.203

(0.097)

0.036

(0.772)

-0.115

(0.351)

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Correlation • physical health component and other cardiometabolic risk

markers Cardiometabolic Risks Markers in Health Status

WC BMI Systolic Diastolic

CST -0.041

(0.738)

0.022

(0.857)

0.182

(0.138)

0.318**

(0.008)

ACT 0.027

(0.825)

0.020

(0.870)

0.036

(0.774)

0.172

(0.161)

CSRT -0.147

(0.233)

-0.119

(0.332)

0.043

(0.727)

-0.067

(0.588)

TUG -0.158

(0.199)

-0.100

(0.415)

-0.078

(0.529)

-0.116

(0.345)

SMWT -0.118

(0.338)

-0.022

(0.860)

-0.032

(0.794)

0.103

(0.402)

BST -0.276*

(0.022)

-0.289*

(0.017)

-0.022

(0.856)

-0.073

(0.553)

*Correlation is significant at the 0.05 level

**Correlation is significant at the 0.01 level

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Correlation

• waist circumference (WC) and BMI with other cardiometabolic risk markers

Blood Profile

Glucose Insulin HOMA-IR HDL TRIGL LDL Adipo. hsCRP

WC 0.139

(0.258)

0.399**

(0.001)

0.379**

(0.001)

-0.207

(0.090)

0.280**

(0.021)

0.097

(0.433)

-0.202

(0.099)

0.427**

(<0.001)

BMI 0.247*

(0.042)

0.485**

(<0.001)

0.488**

(<0.001)

-0.297*

(0.014)

0.272**

(0.025)

-0.016

(0.897)

-0.341**

(0.004)

0.550**

(<0.001)

**Correlation is significant at the 0.01 level

*Correlation is significant at the 0.05 level

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Discussion

• Cardiorespiratory endurance among two groups or elderly is comparable to each other.

(Mador et al. 2012)

• Lower and upper muscular strength has similar finding between the two groups.

(Forte et al. 2013; Goble et al. 2009)

• Flexibility and agility among control and cardiometabolic groups was found to have similar effect on elderly

(Hunter et al. 2013; Hong et al. 1999)

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Discussion - 2

• cardiometabolic group have combination of higher level in glucose, insulin and HOMA-IR as compared to the control group

(Tobisch et al. 2011; Hsieh et al. 2008; Doehner et al. 2005; Shepherd & Khan 1999)

• high density lipoprotein, triglycerides and high sensitivity

CRP has higher level in cardiometabolic group (Wang et al. 2013; Tofan et al. 2012; Hadaegh et al. 2006; Hsiao et al. 2013)

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Discussion - 3

• waist circumference has relationship with insulin, HOMA-IR, triglycerides, hsCRP.

• BMI was found significant having positive relationship with glucose, insulin, HOMA-IR , TG, and hsCRP.

• BMI was observed negative relationship with HDL and adiponectin.

(Cnop et al. 2003; Gavrila et al. 2003; Yang et al. 2002)

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Strength & Limitation

Strength

• test protocol and the use of instruments were practical for elderly

• latest cardiometabolic risk markers were used – hsCRP and adiponectin

Limitation

• could not represent a whole population because sample was recruited among volunteers in UKMMC

• there was a gap between day 1 and day 2, therefore large number of participants who could not attend day 2

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Nursing

• Orthopedic nurses particularly should highly emphasis the community to promote physical well-being in order to prevent further complications

• Platform for future nurse practitioner to include physical health test as part of their initial assessment

• Involvement in multi-disiplinary collaboration to strengthen the finding

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Conclusion

• Physical health components are not associated with cardiometabolic risk markers among elderly

• Waist circumference and body mass index has association in cardiometabolic risk markers. It is suggested that the higher BMI in a person, the higher risk to get cardiometabolic disease

• Elderly with good muscular strength and flexibility components in physical health leads the potential of preventing the cardiometabolic diseases by reducing the cardiometabolic risk markers

• Therefore, effective muscular strength and flexibility promotion strategies for physical health are urgently needed in preventing cardiometabolic diseases

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Acknowledgements

• Associate Prof. Ho Siew Eng

• Dr. Nor Farah Mohamad Fauzi

• Mr. Leonard H. Joseph

• Dr. Muhammad Lokman Md Isa

• Ms. Quzaimah Zulkifle

• Ms. Farrah Ilyani Che Jamaludin

• Dr. Hanita Othman

• Pathology Laboratory staff

• Participants

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Sample Size

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HOMA-IR

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