Archives of Gerontology and Geriatrics 94 (2021) 104379

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Archives of Gerontology and Geriatrics

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Can anthropometric measures be used as proxies for body composition and

physical function in geriatric outpatients?
Carolina H.Y. Ling a, c, Carel G.M. Meskers b, Andrea B. Maier c, d, *
a
Internal Medicine Department, The Prince Charles Hospital, Queensland, Australia
b
Amsterdam UMC, Department of Rehabilitation medicine, VU University, Amsterdam Movement Sciences, @AgeAmsterdam, Amsterdam, The Netherlands
c
Department of Human Movement Sciences, @AgeAmsterdam, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, The Netherlands
d
Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: The study aimed to evaluate the associations between anthropometric measures with body compo­
Body constitution sition, in particular skeletal muscle mass, and with physical function in a cohort of geriatric outpatients.
Muscle atrophy Methods: We included 572 outpatients who attended geriatric clinics at Amsterdam UMC, location VUmc,
Physical functional performance
Netherlands from January 2014 to December 2015. Anthropometric measures (height, weight, body circum­
Aged
ferences, body mass index (BMI), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR)), and physical
function measures (handgrip strength (HGS), Short Physical Performance Battery (SPPB) and Timed Up and Go
test (TUG)) were obtained. Body composition was analysed using bioimpedance analysis (BIA) in a subgroup of
78 patients. Gender-stratified regression analyses were performed to test associations between anthropometric
measures with body composition and physical function, adjusted for age.
Results: In females, BMI, WHtR and all measured body circumferences were positively associated with body fat
mass (BFM) (all β≥0.64, all p≤0.001). BMI and mid-upper arm circumference were also associated with fat-free
mass (FFM) (β=0.49, p=0.001; β=0.53, p=0.01), skeletal muscle mass (SMM) (β=0.39, p=0.01; β=0.44,
p=0.02) and skeletal muscle index (SMI) (β=0.44, p=0.003; β=0.44, p=0.02). In males, BMI, WHR, WHtR and
waist circumference were positively associated with BFM (all β≥0.54, all p≤0.02). Calf circumference was
associated with FFM (β=0.46, p=0.01), SMM (β=0.47, p=0.01) and SMI (β=0.50, p=0.01). BMI and central fat
anthropometric measures were inversely associated with physical function.
Conclusions: Mid-upper arm circumference and calf circumference could serve as practical proxy measures for
skeletal muscle mass in geriatric outpatient setting, but their associations with physical function were weak.

1. Introduction computed tomography (CT) and magnetic resonance imaging (MRI).

Age-related low muscle mass, strength and function are measures of
sarcopenia (Cruz-Jentoft et al., 2010). Sarcopenia is highly prevalent as
a comorbid disease in the older people (Pacifico et al., 2020), affecting
up to 50% of those aged 80 years and older (von Haehling et al., 2010)
and is associated with functional impairment (Tanimoto et al., 2013),
falls (Yeung et al., 2019), fractures (Yeung et al., 2019), cognitive
impairment (Chang et al., 2016), reduced quality of life (Tsekoura et al.,
2017) and all-cause mortality (Liu et al., 2017). Body composition and
thereby muscle mass can be assessed using various techniques such as
bioimpedance analysis (BIA), dual energy X-ray absorptiometry (DXA),
Although these modalities show good accuracies, their clinical appli­
cability is often limited by costs, lack of equipment accessibility and
expertise (Reijnierse et al., 2017, Yeung et al., 2020). Simple anthro­
pometry is a commonly used tool in clinical settings for estimation of
body composition, especially as indicator of body fat to define over­
weight and obesity (Physical status: the use and interpretation of
anthropometry 1995). It is also routinely used for nutritional assessment
(Madden and Smith, 2016) and as screening tool for cardiometabolic
risk (Chen et al., 2007) and mortality in older adults (Tsutsumi et al.,
2012).
Anthropometric measures such as calf circumference (Tsekoura

* Corresponding author: Department of Human Movement Sciences, @AgeAmsterdam, Vrije Universiteit Amsterdam, Faculteit der Gedrags- en Bewegingswe­
tenschappen – afdeling Bewegingswetenschappen, Amsterdam Movement Sciences, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands
E-mail address: a.b.maier@vu.nl (A.B. Maier).

https://doi.org/10.1016/j.archger.2021.104379
Received 30 September 2020; Received in revised form 2 February 2021; Accepted 10 February 2021
Available online 12 February 2021
0167-4943/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
C.H.Y. Ling et al.
et al., 2017, Kawakami et al., 2015) and mid-upper arm circumference
(Schaap et al., 2018) could potentially be used as indicators of lean body
and skeletal muscle mass. Moreover, the European Working Group on
Sarcopenia in Older People (EWGSOP2) has recommended the use of
calf circumference as a proxy measure for skeletal muscle mass when
other quantification techniques are not available (Cruz-Jentoft et al.,
2019).
There is limited study on the associations between anthropometry
with body composition, especially skeletal muscle mass, and physical
function measures in older adults (Woo et al., 2007), used in a clinical
setting. The present study examined the relationships between anthro­
pometric measures and body composition, and between anthropometric
measures and physical function in a cohort of geriatric outpatients.
2. Materials and Methods
2.1. Study population and design
The study cohort included 572 consecutive patients referred to
geriatric subspecialty outpatient clinics of the Center of Geriatrics
Amsterdam (COGA) at the Amsterdam UMC, location VUmc, Amster­
dam, Netherlands from January 2014 to December 2015 for specialist
assessment and management. There were no inclusion or exclusion
criteria for participation in the study. Every patient who provided con­
sent was recruited. All patients underwent comprehensive geriatric
assessment during their initial medical appointment, including assess­
ment of their comorbidities, nutritional status, cognition, psychological
state and functional status. This study was performed in accordance with
the Declaration of Helsinki (1964) and approved by the Medical Ethics
Committee of Vrije University Medical Center, approval number:
2017.582.
2.2. Procedures
2.2.1. Data collection
Demographic information (age and gender), comorbidities (i.e. hy­
pertension, myocardial infarction, diabetes mellitus, chronic obstructive
pulmonary disease, malignancy, Parkinson’s disease and arthritis), and
the presence of polypharmacy (defined as five or more medications)
were recorded.
Nutritional status was assessed using the Mini Nutritional Assess­
ment tool (MNA) (Guigoz, 2006). MNA is a validated rapid nutrition
assessment tool in the older people, which comprises of 18 items
grouped in 4 rubrics: anthropometric assessment, general assessment,
short dietary assessment and subjective assessment (score range 0-30
points, higher score indicates better nutrition).
The Mini Mental State Examination (MMSE) was used to assess
cognitive function (Tombaugh and McIntyre, 1992). MMSE is a 30-point
questionnaire that assesses the cognitive domains of orientation, work­
ing memory, attention, memory recall, language and visuospatial
function (score range 0-30 points, higher score indicates better
cognition).
The Geriatric depression scale (GDS) was used to detect depressive
symptoms (Montorio and Izal, 1996). GDS is a 15-item self-report
screening tool of depression in older adults (score range 0-15 points,
higher score indicates more depressive symptoms).
The Katz Activities of Daily Living (Katz ADL) scale (Katz et al.,
1963) was used to measure performance in basic ADL including bathing,
dressing, toileting, continence, transferring and feeding (score range 0-6
points, higher score indicates better functioning).
Frailty status was measured using the Fried frailty score (based on
the presence of five indicators: unintentional weight loss, exhaustion,
weakness (i.e. low handgrip strength), slowness (i.e. low gait speed) and
inactivity, score range 0-5 points) (Fried et al., 2001).
2
Archives of Gerontology and Geriatrics 94 (2021) 104379
2.2.2. Anthropometric measures
Height, weight and body circumferences including mid-upper arm
circumference (MUAC), waist circumference (WC), hip circumference
(HC) and calf circumferences (CC) were obtained using appropriate
calibrated measuring equipment (i.e. stadiometer, weighing scale and
flexible tape measure), following a standardized protocol. Body mass
index (BMI) was calculated as body weight (kg) / [height (m)]2. Waist-
to-hip ratio (WHR) and waist-to-height ratio (WHtR) were used to infer
central distribution of body fat (Cornier et al., 2011) and were calculated
as waist circumference divided by hip circumference, and waist
circumference divided by height respectively.
2.2.3. Body composition measurements
A random sample of 78 participants underwent body composition
measurements using direct segmental multi-frequency bioelectrical
impedance analysis (DSM-BIA; In-Body 720; Biospace Co., Ltd, Seoul,
Korea). Participants wore normal indoor clothing and stood barefoot on
the BIA machine platform with their arms abducted and hands gripping
onto the handles.
The DSM-BIA is a simple and non-invasive device for the assessment
of body composition. It has been shown to have high concordance with
standard method, dual energy X-ray absorptiometry (DXA) (Ling et al.,
2011). It gives immediate and extensive results including quantitative
values of total body fat-free mass (FFM) and body fat mass (BFM).
Relative FFM (%) and relative BFM (%) were calculated as total FFM
(kg) / body weight (kg) x 100% and total BFM (kg) / body weight (kg) x
100% respectively. Measurement of skeletal muscle mass (SMM), a
component of FFM, was obtained using estimation equation for Cauca­
sian subjects derived from BIA (Sergi et al., 2017). Skeletal muscle index
(SMI) was calculated as SMM (kg) / height2 (m2) (Baumgartner et al.,
1998).
2.2.4. Physical function
2.2.4.1. Muscle strength. Handgrip strength (HGS) was obtained three
times in both hands using a handheld hydraulic dynamometer with
participants in a standing position and arms parallel to the body. The
maximal HGS measurement was used for analysis (Reijnierse et al.,
2017).
2.2.4.2. Physical performance. Participants performed the Short Phys­
ical Performance Battery (SPPB, score range 0-12 with a score ≤8 in­
dicates poor physical performance) (Beaudart et al., 2016), chair stand
test time and gait speed (both subscales of SPPB), and the Timed Up and
Go test (TUG) (Podsiadlo and Richardson, 1991).
2.3. Statistical analysis
Continuous variables with Gaussian and non-Gaussian distributions
are presented as mean (standard deviation, SD) and median (inter­
quartile range, IQR) respectively. Independent Samples t-test and Mann-
Whitney U test were used to compare two independent samples of
Gaussian and non-Gaussian distributions respectively. Gender-stratified
regression analysis was used to assess the relationships between
anthropometry and body composition parameters (FFM, BFM, SMM and
SMI), and between anthropometry and physical function (handgrip
strength, SPPB total score, chair stand test time, gait speed and TUG
time), adjusted for age. A 2-tailed p-value of < 0.05 was considered
significant. All statistical analyses were performed using SPSS for Win­
dows (SPSS Inc, Chicago), version 25.
3. Results
Participants characteristics are summarised in Table 1. The mean age
was 80.8 years (SD 7.0), and 59.6% of participants were female. The
C.H.Y. Ling et al. Archives of Gerontology and Geriatrics 94 (2021) 104379

Table 1 and 0.41 respectively. BMI and MUAC were also associated with FFM (β
Characteristics of participants according to gender. = 0.49, p = 0.001, R2 = 0.29; and β = 0.53, p = 0.01, R2 = 0.35
Total (n=572) Female Male (n=231) respectively), SMM (β = 0.39, p = 0.01, R2 = 0.23; and β = 0.44, p =
(n=341) 0.02, R2 = 0.30) and SMI (β = 0.44, p = 0.003, R2 = 0.27; and β = 0.44,
Age, years 80.8 (7.0) 81.1 (7.6) 80.3 (6.1) p = 0.02, R2 = 0.30). In males, BMI, WHR, WHtR and WC were posi­
Comorbidity, % tively associated with BFM (all β≥0.54, all p≤0.02). R2 values for BMI,
Hypertension 51.6 54.6 47.3 WHR, WHtR and WC were 0.75, 0.27, 0.49 and 0.54 respectively. CC
Myocardial infarct 14.3 9.5 21.4 was positively associated with FFM (β = 0.46, p = 0.01, R2 = 0.29), SMM
Diabetes mellitus 20.7 19.8 21.9
COPD 7.1 5.5 9.4
(β = 0.47, p = 0.01, R2 = 0.32) and SMI (β = 0.50, p = 0.01, R2 = 0.28).
Malignancy 22.5 18.0 29.0 The associations between anthropometric measures and handgrip
Parkinson’s disease 2.5 2.1 3.1 strength, adjusted for age are presented in Table 4. CC was positively
Arthritis 18.1 22.6 11.6 associated with HGS in females (β = 0.20, p = 0.002) and HC was
Polypharmacy, % 61.7 64.2 58.0
associated with HGS in males (β = 0.23, p = 0.005). None of the other
MNA score 24.5 (21.5 – 24.0 (20.0 – 25.5 (23.0 –
26.5) 25.5) 27.0) anthropometric measures were associated with HGS. The associations
MMSE score 26 (22-28) 26 (21-28) 26 (22-28) between anthropometric measures and physical performance are shown
GDS-15 score 3 (1-6) 3 (1-6) 3 (1-6) in Table 5. In females, higher BMI and WC were associated with lower
Katz ADL score 6 (5-6) 5 (4.25-6) 6 (5-6) SPPB total score (β = -0.20, p = 0.001 and β = -0.24, p < 0.001
Fried Frailty score 2 (1-3) 2 (1-3) 2 (1-2)
Anthropometry
respectively), slower gait speed (β = -0.23, p < 0.001 and β = -0.29, p <
Height, cm 166.2 (9.7) 160.8 (6.9) 173.7 (7.9) 0.001) and greater TUG time (β = 0.22, p = 0.003 and β = 0.17, p =
Weight, kg 70.0 (12.9) 65.8 (12.2) 75.7 (12.6) 0.033). Higher WHR and WHtR were also associated with lower SPPB
BMI, kg/m2 25.3 (4.2) 25.5 (4.5) 25.0 (3.7) total score (β = -0.19, p = 0.004 and β = -0.23, p = 0.001) and slower
MUAC, cm 29.0 (6.7) 28.1 (4.4) 30.0 (8.5)
gait speed (β = -0.17, p = 0.01 and β = -0.29, p < 0.001). In males,
WC, cm 96.1 (11.5) 94.5 (11.9) 98.6 (10.5)
HC, cm 101.8 (9.1) 102.1 (9.5) 101.3 (8.4) higher BMI was associated with lower SPPB total score (β = -0.19, p =
CC, cm 34.6 (6.3) 34.0 (3.5) 35.5 (8.8) 0.01) and longer chair stand test time (β = 0.18, p = 0.03). Higher WHtR
Physical performance was associated with lower SPPB total score (β = -0.24, p = 0.004), longer
HGS, kg 22.1 (9.7) 17.3 (6.7) 28.9 (8.8) chair stand test time (β = 0.27, p = 0.003) and slower gait speed (β =
SPPB total score 8 (6-10) 8 (5-10) 9 (6-11)
-0.17, p = 0.04). Higher WC was associated with longer chair stand test
Chair stand test time, s 13.7 (11.4- 14.0(11.8-19.6) 13.2(11.0-17.8)
18.5) time (β = 0.19, p = 0.03). Higher MUAC and CC were associated with
Gait speed, m/s 0.8 (0.3) 0.8 (0.3) 0.9 (0.4) greater TUG time (β = 0.65, p < 0.001 and β = 0.18, p = 0.04
Timed Up and Go 14.9 (11.5- 16.0 (12.0- 13.7 (11.1- respectively).
time, s 19.0) 21.0) 17.1)

Values are presented as mean (SD) or median (IQR), unless otherwise indicated. 4. Discussion
COPD, Chronic obstructive pulmonary disease; MNA, Mini Nutritional Assess­
ment (score range 0-30); MMSE, Mini-Mental State Examination (score range 0- The present study found gender differences in the associations be­
30); GDS-15, Geriatric Depression Scale-15 (score range 0-15); Katz ADL, ac­ tween anthropometric measures and body composition in a cohort of
tivities of daily living scale (score range 0-6); BMI, body mass index; MUAC, mid
geriatric outpatients. Body mass index (BMI) and mid-upper arm
upper arm circumference; WC, waist circumference; HC, hip circumference; CC,
circumference in females, and calf circumference in males, were asso­
calf circumference; HGS, handgrip strength; SPPB, Short Physical Performance
Battery.
ciated with fat-free mass, skeletal muscle mass and skeletal muscle
index. In contrast, majority of the anthropometric measures were asso­
ciated with body fat mass in females. BMI and central fat anthropometric
most prevalent comorbidity was hypertension. The median MMSE score
measures were associated with body fat mass in males. When evaluating
was 26 (IQR 22-28), Katz ADL score was 6 (IQR 5-6) and Fried Frailty
the relationships between anthropometric measures and physical func­
score was 2 (IQR 1-3). Mean BMI was 25.5 kg/m2 (SD 4.5) for females
tion, higher BMI and central fat anthropometric measures were associ­
and 25.0 kg/m2 (SD 3.7) for males. Mean HGS was 17.3 kg (SD 6.7) in
ated with overall poorer physical performance in both genders.
females and 28.9 kg (SD 8.8) in males.
Associations between mid-upper arm circumference and calf circum­
Body composition measurements obtained by DSM-BIA in a subset of
ference with physical function were weak and inconsistent.
78 participants are presented in Table 2. The mean total body FFM was
BMI demonstrated association with total body fat mass in both
43.9 kg (SD 7.1) in females with relative FFM of 64.3% vs. 54.4 kg (SD
genders, but also with fat-free mass in females, highlighting its inability
8.3) in males with relative FFM of 73.9%. The associations between
to differentiate between the two body components mass (Cornier et al.,
anthropometric measures and body composition, adjusted for age are
2011). Furthermore, BMI does not take into account centralised fat
shown in Table 3. In females, BMI, WHtR and all body circumferences
distribution that occurs with aging (Cornier et al., 2011), which is
were positively associated with BFM (all β≥0.64, all p≤0.001). R2 values
strongly linked to adverse health outcomes such as cardiometabolic
for BMI, WHtR, MUAC, WC, HC and CC were 0.81, 0.46, 0.42, 0.50, 0.65
diseases (Goodpaster et al., 2005) and mortality (Karastergiou et al.,
2012). Waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and
Table 2 waist circumference (WC) are commonly used anthropometric measures
Body composition parameters measured by DSM-BIA. of central fat (Cornier et al., 2011). All three measures were associated
with total body fat mass in males, while the WHtR and WC were asso­
Female (n=41) Male (n=37)
ciated with body fat mass in females. Interestingly, all body circumfer­
BFM, kg 25.5 (11.3) 19.4 (6.8) ences measurements including mid-upper arm circumference (MUAC),
Relative BFM, % 35.7 (9.5) 26.1 (7.8)
FFM, kg 43.9 (7.1) 54.4 (8.3)
waist circumference (WC), hip circumference (HC) and calf circumfer­
Relative FFM, % 64.3 (9.5) 73.9 (7.8) ence (CC) were associated with body fat mass in females, compared to
SMM, kg 23.8 (5.4) 29.5 (4.9) only WC in males. These findings could be explained by gender-related
SMI, kg/m2 9.2 (2.0) 9.9 (1.2) differences in body fat distribution, and reflect the preferential central
DSM-BIA, direct segmental multi-frequency bioelectrical impedance analysis; fat accumulation in males and peripheral fat deposition in females
BFM, body fat mass; FFM, fat free mass; SMM, skeletal muscle mass; SMI, (Sharma et al., 2016).
skeletal muscle index. The observed association between BMI and fat-free mass in females

3
C.H.Y. Ling et al. Archives of Gerontology and Geriatrics 94 (2021) 104379

Table 3
Associations between anthropometric and body composition measures, adjusted for age.
Anthro-pometry BFM (kg) FFM (kg) SMM (kg) SMI (kg/m2)
B (SE) β p B (SE) β p B (SE) β p B (SE) β p

Female, n = 41
BMI, kg/m2 1.90 (0.15) 0.90 <0.001 0.65 (0.18) 0.49 0.001 0.40 (0.15) 0.39 0.01 0.16 (0.05) 0.44 0.003
WHR 27.5 (29.9) 0.19 0.37 11.2 (16.5) 0.14 0.50 7.07 (9.74) 0.15 0.47 3.34 (3.09) 0.22 0.29
WHtR 92.2 (20.1) 0.68 <0.001 8.88 (14.8) 0.12 0.55 6.05 (8.73) 0.14 0.49 4.57 (2.68) 0.32 0.10
MUAC, cm 1.82 (0.46) 0.64 0.001 1.08 (0.35) 0.53 0.01 0.73 (0.29) 0.44 0.02 0.27 (0.11) 0.44 0.02
WC, cm 0.63 (0.12) 0.71 <0.001 0.15 (0.09) 0.30 0.13 0.09 (0.05) 0.31 0.11 0.04 (0.02) 0.38 0.05
HC, cm 0.84 (0.12) 0.81 <0.001 0.16 (0.11) 0.28 0.15 0.10 (0.06) 0.29 0.13 0.04 (0.02) 0.34 0.08
CC, cm 1.84 (0.43) 0.69 <0.001 0.65 (0.39) 0.32 0.11 0.31 (0.31) 0.20 0.33 0.10 (0.11) 0.18 0.36
Male, n = 37
BMI, kg/m2 2.18 (0.22) 0.87 <0.001 0.60 (0.53) 0.19 0.26 0.36 (0.31) 0.20 0.25 0.07 (0.08) 0.16 0.36
WHR 58.8 (22.1) 0.54 0.02 1.68 (27.2) 0.02 0.95 0.99 (15.9) 0.02 0.95 -0.33 (4.12) -0.02 0.94
WHtR 115.4 (27.2) 0.70 <0.001 -38.4 (39.1) -0.22 0.34 -21.7 (22.9) -0.21 0.35 -1.19 (6.05) -0.05 0.85
MUAC, cm 0.71 (0.44) 0.33 0.13 0.58 (0.52) 0.23 0.27 0.39 (0.30) 0.26 0.20 0.12 (0.07) 0.34 0.11
WC, cm 0.79 (0.17) 0.76 <0.001 0.12 (0.25) 0.11 0.63 0.07 (0.15) 0.11 0.63 0.02 (0.04) 0.13 0.58
HC, cm 0.52 (0.31) 0.35 0.11 0.24 (0.35) 0.15 0.49 0.14 (0.20) 0.16 0.49 0.05 (0.05) 0.22 0.33
CC, cm 0.26 (0.22) 0.23 0.25 0.58 (0.22) 0.46 0.01 0.35 (0.13) 0.47 0.01 0.09 (0.03) 0.50 0.01

BFM, total body fat mass; FFM, fat-free mass; SMM, skeletal muscle mass; SMI, skeletal muscle index; BMI, body mass index; WHR, waist-to-hip ratio; WHtR, waist-to-
height ratio; MUAC, mid-upper arm circumference; WC, waist circumference; HC, hip circumference; CC, calf circumference.

but not males, is contradictory to earlier report of stronger correlation

Table 4
between BMI and fat-free mass in men (Romero-Corral et al., 2008). This
Associations between anthropometric measures and HGS, adjusted for age.
may, in part, be explained by the involvement of older participants in
Anthropometry HGS (kg) our study and the fact that these participants were seeking medical care
Female (n=280) Male (n=203)
at geriatric outpatient clinics. Older men were shown to experience
B (SE) β p B (SE) β p
more muscle mass loss compared to women with aging (Mitchell et al.,
BMI, kg/m2 -0.11 -0.07 0.24 0.18 (0.17) 0.08 0.28
2012), therefore reducing the strength of association between BMI and
(0.10)
WHR -0.86 -0.01 0.86 -21.26 -0.16 0.054 fat-free mass. It is also possible that fat-free mass may have been over­
(4.78) (10.94) estimated by BMI in older females. A previous study has shown an
WHtR -6.22 -0.07 0.30 -5.53 (12.4) -0.04 0.66 overestimation of muscle mass or underestimation of true extent of
(5.93) muscle mass loss when there is excess body fat such as in sarcopenic
MUAC, cm 0.21 0.13 0.27 -0.01 (0.12) -0.01 0.95
obesity (Johnson Stoklossa et al., 2017), a geriatric syndrome defined by
(0.19)
WC, cm 0.01 0.01 0.90 0.06 (0.07) 0.08 0.36 the coexistence of both sarcopenia and obesity. In females, MUAC was
(0.04) associated with fat-free mass, skeletal muscle mass and skeletal muscle
HC, cm -0.00 -0.00 0.95 0.24 (0.09) 0.23 0.005 index. However, similar to BMI, it was also positively associated with
(0.05)
body fat mass. This result is not surprising as MUAC is a composite
CC, cm 0.40 0.20 0.002 0.07 (0.08) 0.07 0.41
(0.13) measure of bone, muscle and fat and does not distinguish fat mass from
fat-free mass. Our findings of positive associations between CC with
HGS, handgrip strength; BMI, body mass index; WHR, waist-to-hip ratio; WHtR,
fat-free mass, skeletal muscle mass and skeletal muscle index in males
waist-to-height ratio; MUAC, mid-upper arm circumference; WC, waist
corroborate with prior evidence of stronger correlation between CC and
circumference; HC, hip circumference; CC, calf circumference.
muscle mass in men compared to women (Kawakami et al., 2015).
In our cohort of older adults with weight mostly in the healthy to
overweight range as defined by BMI, we found inverse associations be­
tween BMI and central fat anthropometric measures with physical

Table 5
Associations between anthropometric measures and SPPB total score, chair stand test time, gait speed and time up and go, adjusted for age.
Anthropometry SPPB total score (points) Chair stand test time (s) Gait speed (m/s) Timed Up and Go time (s)
B (SE) β p B (SE) β p B (SE) β p B (SE) β p

Female n = 271 n = 225 n = 274 n = 187

BMI, kg/m2 -0.14 (0.04) -0.20 0.001 0.07 (0.15) 0.03 0.64 -0.01 (0.00) -0.23 <0.001 0.46 (0.15) 0.22 0.003
WHR -6.13 (2.13) -0.19 0.004 1.50 (7.98) 0.02 0.85 -0.50 (0.19) -0.17 0.01 -0.46 (6.86) -0.01 0.95
WHtR -8.78 (2.57) -0.23 0.001 -1.92 (9.46) -0.02 0.84 -1.03 (0.22) -0.29 <0.001 17.04 (9.02) 0.15 0.06
MUAC, cm -0.11 (0.08) -0.15 0.18 0.12 (0.21) 0.08 0.56 -0.01 (0.01) -0.19 0.09 0.25 (0.16) 0.24 0.12
WC, cm -0.06 (0.02) -0.24 <0.001 -0.02 (0.06) -0.02 0.80 -0.01 (0.00) -0.29 <0.001 0.13 (0.06) 0.17 0.033
HC, cm -0.04 (0.02) -0.12 0.08 -0.05 (0.08) -0.05 0.53 -0.01 (0.00) -0.20 0.001 0.20 (0.07) 0.23 0.004
CC, cm -0.02 (0.06) -0.02 0.80 0.00 (0.22) 0.00 0.99 0.00 (0.01) 0.01 0.89 0.29 (0.20) 0.12 0.15
Male n = 201 n = 174 n = 205 n = 149
BMI, kg/m2 -0.15 (0.06) -0.19 0.01 0.37 (0.17) 0.18 0.03 -0.01 (0.01) -0.14 0.06 0.19 (0.15) 0.10 0.21
WHR -5.12 (3.45) -0.13 0.14 16.73 (10.28) 0.15 0.11 -0.49 (0.47) -0.09 0.30 -2.89 (8.69) -0.03 0.74
WHtR -11.71 (4.01) -0.24 0.004 36.39 (11.91) 0.27 0.003 -1.08 (0.53) -0.17 0.04 17.53 (10.31) 0.15 0.09
MUAC, cm -0.05 (0.05) -0.13 0.30 0.07 (0.07) 0.13 0.37 -0.01 (0.00) -0.22 0.08 0.36 (0.06) 0.65 <0.001
WC, cm -0.04 (0.02) -0.13 0.11 0.15 (0.07) 0.19 0.03 -0.00 (0.00) -0.11 0.21 0.03 (0.06) 0.04 0.67
HC, cm -0.02 (0.03) -0.05 0.53 0.11 (0.09) 0.11 0.23 -0.00 (0.00) -0.06 0.49 0.04 (0.08) 0.05 0.57
CC, cm 0.00 (0.03) 0.00 0.97 0.00 (0.07) 0.00 0.97 -0.00 (0.00) -0.06 0.45 0.12 (0.06) 0.18 0.04

SPPB, Short Physical Performance Battery; CST, Chair Standing Test; GS, Gait Speed; TUG, Time Up and Go test; BMI, body mass index; WHR, waist-to-hip ratio; WHtR,
waist-to-height ratio; MUAC, mid-upper arm circumference; WC, waist circumference; HC, hip circumference; CC, calf circumference.

4
C.H.Y. Ling et al.
function. Previous work examining associations between BMI and
physical performance in older people has yielded inconsistent results
(Woo et al., 2007, Puzianowska-Kuznicka et al., 2019), although there is
stronger evidence for an association between obese-range BMI and
physical impairment (Davison et al., 2002).
Despite their positive associations with skeletal muscle mass, MUAC
and CC demonstrated weak and inconsistent associations with physical
function. Contrary to expectations, CC was associated with handgrip
strength in females, but not in males. Furthermore, no association was
found between MUAC and handgrip strength. These findings indicate
that there are other important determinants of handgrip strength besides
muscle mass, such as physical constructs and upper extremities func­
tional status (Wichelhaus et al., 2018). Significance of the association
between hip circumference and handgrip strength in males is unknown
and could be a chance finding. Moreover, larger MUAC and CC were
associated with poorer performance of the Timed Up and Go (TUG) test
in males. This discordance may be partially explained by the
multi-domain capabilities assessed by the TUG test beyond the muscu­
loskeletal system, including various aspects of the cognitive functioning
(Coelho-Junior et al., 2018, Chen and Tang, 2016).
4.1. Strengths and limitations
The strengths of this study include the use of clinically relevant
sample of ambulatory geriatrics patients and the comprehensive
assessment of anthropometric measures, body composition and physical
performance tests using validated tools. The main limitation of this
study is that body composition data was only available in a subset of the
study participants. Therefore, our results may not reflect the true effect
of the associations between anthropometry and body composition, and
larger confirmatory study is required. Furthermore, the results may not
be generalisable to other ethnic subgroups due to the inherent racial/
ethnic differences in anthropometric measurements. Moreover, BIA
machine uses prediction equations which are formulated on population-
specific data, and therefore, this may affect the accuracy of body
composition measurements when used in different populations.
5. Conclusions
The present study provides support for the use of simple anthro­
pometry as a proxy for body composition in geriatric outpatient setting.
Notably, mid-upper arm and calf circumferences were identified as
proxy measures for skeletal muscle mass, but their associations with
physical function were weak. Further studies are necessary to determine
the accuracy of these measures for estimation of skeletal muscle mass,
and to establish clinically meaningful reference values for use in the
older population.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Carolina H.Y. Ling: Conceptualization, Methodology, Formal
analysis, Resources, Writing – original draft. Carel G.M. Meskers:
Conceptualization, Methodology, Formal analysis, Investigation, Re­
sources, Writing – review & editing, Supervision. Andrea B. Maier:
Conceptualization, Methodology, Formal analysis, Investigation, Re­
sources, Writing – review & editing, Supervision.
Declaration of Competing Interest
None.
5
Archives of Gerontology and Geriatrics 94 (2021) 104379
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