Probable sarcopenia and obesity in women with urinary incontinence in the climacteric period

Introduction: Sarcopenia and obesity are associated with several health conditions. Few studies, however, have analyzed the presence of these conditions in climacteric women with incontinence, and the association between these conditions and the severity of urinary incontinence (UI) is not clear. Objective: To analyze probable sarcopenia, sarcopenia, and obesity in climacteric women with different UI severities, and the association between sarcopenia and UI severity. Methods: This was a cross-sectional study in a public maternity hospital in Northeast Brazil, with women aged ≥ 40 years. Sociodemographic issues, urogynecological history, UI severity (Incontinence Severity Index - ISI), grip strength, and anthropometric measures (waist circumference and body mass index - BMI) were evaluated. Means, standard deviations, absolute and relative frequencies, T test, and Fisher exact test were used (significance at 5%). Results: The sample comprised 177 women, with a mean age of 56.3 (± 9.7) years. Regarding UI, 69 (39.0%) women presented mixed UI, and 53.1% presented moderate UI severity. Only 18.1% women had normal BMIs, and 46.8% had general obesity and 80.3% had abdominal obesity. Probable sarcopenia (low strength) was observed in 35 (20%) women, and sarcopenia, in 3.4%. Women with severe/very severe UI presented lower grip strengths (p = 0.02) and higher BMIs (p = 0.04). Sarcopenia was associated with greater UI severity (p = 0.005). Conclusion: Probable sarcopenia and higher BMI were observed in women with greater UI severities, and sarcopenia was associated with greater UI severity. Preventive measures are needed in such conditions to avoid future complications.


Introduction
The physiological aging process is accompanied by several changes, including changes in body composition. 1 In the female aging process, the climacteric period corresponds to the physiological transition process from the reproductive phase to the non-reproductive phase of a woman's life. 2 In this period, the deficiency in estrogen levels due to menopause, can accelerate the effect of aging on tissues, including muscle, which can have consequences on the function of the pelvic floor muscles. 3 Loss of muscle strength, when associated with loss of muscle mass, results in a condition called sarcopenia. 4 The European Working Group on Sarcopenia in Older People (EWGSOP) recognizes this condition as a progressive and generalized muscle disease, which can present in a severe form when also associated with a loss of physical performance. 5 Currently, muscle strength predicts adverse outcomes more accurately and is considered the most reliable measure of muscle function. Thus, the EWGSOP, in its new definition, considers probable sarcopenia when low muscle strength is detected, using this measurement as the main parameter of sarcopenia. 5 Sarcopenia can cause serious health effects, including changes in mobility and risk of falls and fractures, which can lead to activity limitations, functional disability, impairment in the quality of life, and mortality. 5,6 Despite being associated with aging, sarcopenia can develop from the fourth decade of life. 5 The loss of muscle mass is 20% greater in women than that in men, and in the female population, this loss is significantly greater from the fifth decade of life as compared to that in the fourth decade. 7 In addition, during the menopausal transition period, women have a greater tendency to gain weight, which is associated with increases in the body mass index (BMI) and waist circumference. 8 The abnormal or excessive accumulation of fat is defined by the World Health Organization (WHO) as obesity, which is considered a global health problem due to the increase in its prevalence in recent decades and its association with multiple comorbidities. 9 Obesity accelerates the aging process, which can lead to changes in muscle phenotype, quantity, and quality. 10

Subjects and sample selection
This study employed a non-probabilistic sample, for convenience. Participants were recruited consecutively when they arrived for physical therapy evaluation at the MEAC urogynecology outpatient clinic. Women evaluated from July 2017 to July 2019 who met the inclusion criteria were considered for this study.

Inclusion and exclusion criteria
To participate in the study, the women needed to have

Data collection and instruments used
Prior to data collection, the interviewers were trained and their performance of the procedures were supervised.
The research project was submitted to the MEAC Research Ethics Committee (CAAE: 69965617.0.0000.5050), and data collection was initiated after approval was received.
Women were included consecutively as they entered the urogynecological physiotherapy service at the maternity hospital.
In the first contact, protocols and research objectives were clarified, after which they were asked to sign the Free and Informed Consent Term (FICT).
After consent, information was collected through a structured questionnaire, assessment of anthropometric measurements, grip strength test, and UI severity questionnaire. All the variables are described hereafter.

Socioeconomic and demographic variables
As for marital status, women were categorized as "with partnership" and "without partnership." In relation to ethnicity/race, they were classified as white, brown, and black. Regarding education, they were classified as illiterate, completed elementary school, completed high school, and higher education or more. Women were categorized into two groups on the basis of whether they were engaged performing income-generating activities.

Urogynecological and obstetric history
Variables including type of UI and number of pregnancies and deliveries were considered. Regarding For the measurement of waist circumference, a tape measure "Fiberglass" was used with divisions of 1 mm and the measurement followed the procedures suggested by the document Waist circumference and waist-hip ratio: report of a WHO expert consultation. 21 The participant was positioned with feet together and arms over the trunk and was instructed to relax. The In this position, after demonstration by the evaluator, maximum contractions were requested to be sustained for five seconds, with an interval of one minute between measurements. The dominant limb was considered for the evaluation. The arithmetic mean of the three consecutive measurements was considered for the analysis. 23 Women were classified as having low grip severe. This variable was recategorized into two groups for association analysis (mild to moderate and severe to very severe). These values and the other types of urinary incontinence are described in Table 2.
The mean grip strength among the women evaluated was 18.08 (± 5.61) kgf. Table 3 shows the MME and IMME

Discussion
The main objective of this study was to verify Preventive measures such as adequate nutrition and regular exercise seem to delay or reverse sarcopenia. 5 Further, sarcopenia was found in 3.4% of the sample.   A future longitudinal study is suggested, in which the cause-and-effect relationship between sarcopenia and UI severity can be analyzed, which cannot be observed in cross-sectional studies. Studies considering women with and without UI should also be conducted to analyze sarcopenia and the limitations that this condition can bring related to activities and social participation.
Finally, considering that the average age of the women was less than 60 years, there was a considerable number of women with probable sarcopenia (low muscle strength) and a higher frequency of sarcopenia compared to previous studies in the literature. In addition, there were also high percentages of women with general and abdominal obesity in this population.
Thus, understanding the repercussions that sarcopenia and obesity can cause, the importance of implementing preventive strategies aiming at reducing complications related to these conditions is emphasized. It is also noteworthy that sarcopenia was associated with a greater severity of UI, reinforcing the importance of preventing and recovering from this condition, with the aim of contributing to reducing the severity of UI.

Conclusion
In this study, the presence of probable sarcopenia (low muscle strength) and sarcopenia was observed in climacteric women with UI, along with high frequencies of general and abdominal obesity. In addition, sarcopenia was associated with greater severity of UI.
Thus, knowing the limitations that these conditions can cause, preventive measures that promote an increase in muscle mass and strength and reductions in body weight and waist circumference, in addition to the practice of physical exercise and adequate nutrition are required, as sarcopenia and obesity are reversible conditions.
Thus, such measures can also contribute to reducing the severity of UI, thereby preventing future complications.