Physical activity, sedentary behavior and dynapenia: A cross-sectional studyAbstract
Introduction: Population aging is a global phenomenon that brings with it significant challenges for public health, among which dynapenia, defined as the reduction of muscle strength associated with age.
Objective: To analyze the association between the combination of physical activity level and sedentary behavior in older adults with and without partial and total dynapenia.
Methods: This is a crosssectional study, carried out with individuals aged ≥ 60 years of both sexes. The diagnosis of dynapenia was made through handgrip strength (partial dynapenia HGS) and the sit-to-stand test (partial dynapenia STS). Physical activity level and sedentary behavior were assessed by the International Physical Activity Questionnaire (IPAQ).
Results: A total of 249 older adults participated in the study, of which 19.7% had prevalence of partial dynapenia HGS, 16.9% had partial dynapenia STS and 8% had total dynapenia. It was observed that 23.7% were insufficiently active and 20.8% presented high sedentary behavior. Total dynapenia was associated with the combination of low physical activity level with high sedentary behavior (OR = 5.92; 95% CI: 1.30-26.94; p = 0.022), indicating that older adults with this combination were approximately six times more likely to present total dynapenia. Regarding partial dynapenia, no significant associations were found between low physical activity level and high sedentary behavior (p > 0.05).
Conclusion: The combination of low physical activity level with high sedentary behavior was associated with total dynapenia, evidencing the importance of the interaction between these two behaviors for the simultaneous reduction of muscle strength in the upper and lower limbs.
Keywords:
Aging; Muscle weakness; Sedentary behavior; Physical activity
Resumo
Introdução: O envelhecimento populacional é um fenômeno global que traz consigo desafios significativos para a saúde pública, entre os quais se destaca a dinapenia, definida como a redução de força muscular associada à idade.
Objetivo: Analisar a associação entre a combinação do nível de atividade física e do comportamento sedentário em pessoas idosas com e sem dinapenia parcial e total.
Métodos: Trata se de um estudo de delineamento transversal, realizado com indivíduos com idade ≥ 60 anos de ambos os sexos. O diagnóstico de dinapenia foi realizado por meio da força de pressão manual (dinapenia parcial FPM) e pelo teste de sentar e levantar da cadeira (dinapenia parcial TSL). O nível de atividade física e o comportamento sedentário foram avaliados pelo International Physical Activity Questionnaire (IPAQ).
Resultados: Participaram do estudo 249 pessoas idosas, das quais 19,7% apresentaram prevalência de dinapenia parcial FPM, 16,9% dinapenia parcial TSL e 8% de dinapenia total. Observouse que 23,7% eram insuficientemente ativas e 20,8% apresentavam comportamento sedentário elevado. A dinapenia total esteve associada à combinação de baixo nível de atividade física com elevado comportamento sedentário (OR = 5,92; IC95%: 1,30-26,94; p = 0,022), indicando que pessoas idosas com essa combinação tiveram aproximadamente seis vezes mais chances de apresentar dinapenia total. Em relação à dinapenia parcial, não foram encontradas associações significativas entre baixo nível de atividade física e elevado comportamento sedentário (p > 0,05).
Conclusão: A combinação de baixo nível de atividade física com elevado comportamento sedentário esteve associada à dinapenia total, evidenciando a importância da interação entre esses dois comportamentos para a redução simultânea da força muscular de membros superiores e inferiores.
Palavras-chave:
Envelhecimento; Debilidade muscular; Com-portamento sedentário; Atividade física
Introduction
Population aging is a global phenomenon that brings with it significant challenges for public health, among which dynapenia stands out, defined as the reduction of muscle strength associated with age.1 This condition has an impact on the quality of life of older adults, increasing the risk of falls, frailty, functional disability, and mortality.2,3
The dynapenia is influenced by multiple factors, including the natural aging process, the presence of chronic diseases, and lifestyle, particularly physical inactivity and sedentary behavior.4,5
The assessment of muscle strength, essential for the diagnosis of dynapenia, is performed using methods widely disseminated in the literature, with well-established cut-off points. The latest European Consensus on Definition and Diagnosis of Sarcopenia recommends the use of handgrip strength (HGS) as the standard method for assessing upper limb muscle strength, while the chair sit-to-stand test (STS) is indicated for assessing lower limb strength.6
Some studies have assessed HGS using a hydraulic dynamometer as a criterion for classifying older adults with and without dynapenia.6-8 Although HGS is used as a marker of overall strength, commonly reported in the literature, the assessment of lower limb strength represents an important indicator for the health of older adults, and their weakness is related to various local and systemic impairments.9
Santos10 analyzed the concordance of low muscle strength or presarcopenia assessed by HGS and STS in a sample of 237 older adults. The study indicated that of the total number of older adults classified as having low strength using the HGS, only 47.1% were also classified as having low strength by the STS, showing a low coefficient of agreement (kappa = 0.46; p < 0.001). This shows that 52.9% of older adults did not present a reduction in muscle strength in both upper and lower limbs simultaneously.10 Thus, studies that aim to assess dynapenia are limited to identifying its presence or absence in isolation, evaluating only one segment of the body. Given the above, it is also essential to identify changes in muscle strength in both upper and lower limbs simultaneously, and for this reason we propose the classification of total dynapenia.
Regular physical activity is recognized as a protective factor against dynapenia, as it promotes the maintenance and increase of muscle mass and strength.4 On the other hand, sedentary behavior, characterized by excessive time spent on lowenergy expenditure activities, such as watching television or using a computer, is associated with a higher risk of developing this condition.5
Although the literature has already demonstrated that insufficient physical activity levels and sedentary behavior are associated with partial dynapenia,4,5 there is still a lack of studies exploring the combined association of these factors with total dynapenia.
Furthermore, little is known about how the interaction between physical activity and sedentary behavior can distinctly impact partial and total dynapenia.
Studies on dynapenia tend to focus on the reduction of muscle strength in isolation, whether in the upper or lower limbs. However, it is essential to understand the impacts generated by the reduction of muscle strength in a combined way, that is, in both limbs, since this condition can have broader and more severe implications for the functionality, mobility, and quality of life of older adults. Given this, we propose the term "total dynapenia" to study the relationship between the reduction of muscle strength in the upper and lower limbs and its effects on the health of the older population, aiming to fill this knowledge gap and contribute to more comprehensive and effective prevention and intervention strategies.
Thus, this study investigated the association between the combination of physical activity level and sedentary behavior with partial and total dynapenia in older adults living in the community.
Methods
This is a crosssectional study that used data from the epidemiological research entitled "Nutritional Status, Risk Behavior and Helath Conditions of older adults in Lafaiete Coutinho-BA". The study was conducted by researchers, members of the Center for Studies in the
Epidemiology of Aging, and was approved by the Research Ethics Committee of the Universidade Estadual do Sudoeste da Bahia (No. 491,661/2014). Participation was voluntary and all individuals signed a free and informed consent form.
The research was conducted with older adults residing in the municipality of Lafaiete Coutinho, located 356 km from the capital of Bahia. In the 2022 census, it had 4,075 inhabitants, with a population density of 8.18 inhabitants per square kilometer.11 Its territory occupies approximately 499 km2, the municipality has a Human Development Index (HDI) of 0.599, and the main source of income comes from agricultural services.12
Participants
The study included older adults residing in the urban area of the municipality, registered at the Family Health
Unit (FHU), aged ≥ 60 years. In 2014, 331 older adults were identified, who were sought to carry out interviews and assessments. Of these 331 people, three refusals were recorded and 10 individuals were excluded from the study because they could not be located after three home visits on different days and times, leaving 318 older adults.
Next, the inclusion and exclusion criteria were applied. The inclusion criteria were: having the cognitive capacity to participate in the research, based on the assessment of the Mini-Mental State Examination (MMSE), in its modified version,13 having performed the HGS test using a dynamometer and having performed the STS. Participants who had undergone surgery on their dominant arm or hand in the last three months and those who did not have the cognitive capacity to participate in the research or for some reason were unable to perform the tests were excluded. In the end, 249 older individuals remained, who fully completed both strength assessment tests (HGS and STS). Figure 1 presents the decision diagram for the inclusion process of the study population.
Data collection and instruments
Data collection was carried out in February 2014, in two stages. The first was conducted through a home interview using a specific form based on a questionnaire used in the Health, Well-being and Aging Survey in seven countries in Latin America and the Caribbean,14 to which the International Physical Activity Questionnaire (IPAQ), long form,15 and the Geriatric Depression Scale (GDS) in its Brazilian and abbreviated version with fifteen items were added.16 In this stage, functional performance tests were also performed, including the STS. The second stage was carried out in the two FHU of the municipality and consisted of carrying out anthropometric measurements and the HGS test.
Dependent variable
Dynapenia was classified according to three categories: partial dynapenia of the upper limbs, assessed by the HGS (partial dynapenia HGS); partial dynapenia of the lower limbs, assessed by the STS (partial dynapenia STS); and total dynapenia, when older adults presented a reduction in muscle strength in both the upper and lower limbs simultaneously.
For the classification of partial dynapenia HGS, a hydraulic dynamometer (Saehan Corporation SH5001, Korea) was used, with a movable handle adjusted according to the size of each older adult's hand. To perform the measurement, they were instructed to remain seated comfortably, feet supported on the floor, elbow flexed at 90° and supported on the table, forearm in a neutral position and with the wrist varying from 0° to 30° of extension. The test was performed using the dominant arm, twice, with a one-minute interval between measurements, and the highest value (kgf) was considered for analysis.17
To classify older adult with partial muscle weakness, HGS was adjusted according to sex and body mass index (BMI). Initially, BMI was classified into the following categories: underweight (< 22 kg/m2), adequate weight (22-27 kg/m2), and overweight (> 27 kg/m2).18 Then, the 25th percentile of HGS was used as a cutoff point, according to each BMI category and sex, to diagnose the older person with muscle weakness (Table 1).
Cut-off points adopted for insufficient muscle strength in the handgrip strength (HGS) test according to body mass index and sex
To identify lower limb muscle weakness, the STS was applied, according to the recommendations of Guralnilk et al.,19 using a chair approximately 45 cm high, where the older person had to cross their arms over their chest, sit down, and stand up five consecutive times as quickly as possible. The test was considered successful when performed in 60 seconds or less. To classify older adults with partial dynapenia in the STS, the 75th percentile was used as a cutoff point for the time spent performing the test according to sex (men: ≥ 14.16 s; women: ≥ 16.83 s).
Independent variables
Physical activity combined with sedentary behavior was used as an independent variable. The physical activity level (active or insufficiently active) was assessed using the IPAQ, long version,15 classifying as active those individuals who practiced 150 minutes or more of moderate or vigorous physical activity per week, and as insufficiently active those who practiced less than 150 minutes per week.20 Sedentary behavior was assessed using the fifth domain of the IPAQ, considering the time the elderly person spent sitting and/or lying down on a typical weekday and on a weekend day.
The calculation to identify the weighted average of time spent in exposure to sedentary behavior in a typical week was performed using the following equation: 5 x min weekday + 2 x min weekend day/7. The cutoff point used for the analysis of exposure to high sedentary behavior was according to the 75th percentile (> 75) of sitting time (min/day) of the weighted average. Older adults who presented values > 424.46 min/day were considered to have high sedentary behavior levels. The following categories were then created for the variable combining the physical activity level with sedentary behavior: active and normal sedentary behavior (≥ 150 min/week and < 424.46 min/day); insufficiently ative and normal sedentary behavior (< 150 min/week and < 424.46 min/day); active and high sedentary behavior levels (≥ 150 min/week and ≥ 424.46 min/day); insufficiently active and highly sedentary behavior (< 150 min/week and ≥ 424.46 min.
Characterization variables and statistical analysis Sociodemographic data, collected through self-report, included sex (female and male), age group (60-69, 70-79 and ≥ 80 years), literacy (yes and no) and family income (≤ 1 or > 1 minimum wage). The behavioral variables assessed were smoking (never smoked, exsmoker or smoker) and alcohol consumption (≤ 1 or ≥ 2 days/week).
Health conditions included depressive symptoms (yes or no), assessed using the GDS, using a cutoff point of ≥ 6 points for the presence of symptoms;16 cognitive deficit (yes or no), assessed using the MMSE, in which older adults with a score > 12 were considered without cognitive impairment;13 nutritional status (underweight, adequate or overweigh); hospitalization in the last 12 months (none, once, or more times); medication use (≥ 2 or < 2 medications); falls in the last 12 months (yes or no); chronic diseases (none, one, two or more); functional capacity, being independent or dependent in Instrumental Activities of Daily Living (IADL),21 using the Lawton and Brody scale,22 and in Basic Activities of Daily Living (BADL), assessed using the Katz et al. scales.23
Statistical analysis
For the descriptive analysis, absolute and relative frequencies, means and standard deviations were calculated. The association between dynapenia, through different diagnostic criteria, and the combination of physical activity level with sedentary behavior was verified through multinomial logistic regression with calculations of odds ratios (OR) values and their respective confidence intervals (95% CI). The significance level adopted was 5% (p ≤ 0.05). The analyses were performed using the Statistical Package for Social Sciences for Windows version 21.0 (IBM Corp, Armonk, NY, 2012).
Results
The study included 249 older individuals. It was observed that 56.2% were female, 23.7% belonged to the age group ≥ 80 years, 63.3% were illiterate, and 39.7% received at most one minimum wage (Table 2).
Regarding health conditions and lifestyle habits, we observed that 23.7% were insufficiently active, 20.8% presented high levels of sedentary behavior, 8.7% consumed alcoholic beverages two or more times per week, 7.9% were smokers, 16.5% presented depressive symptoms, 24.8% had cognitive impairment, 23% were underweight, 14.1% had one or more hospitalizations in the last 12 months, 40% used two or more medications, 20.7% had at least one fall in the last 12 months, 13.2% were dependent on IADL, and 47.4% had two or more chronic diseases. The prevalence of dynapenia varied according to the criteria adopted: 19.7% presented a prevalence of partial dynapenia HGS, while 16.9% presented partial dynapenia STS and 8% presented a prevalence of total dynapenia. The other characteristics of the study population can be seen in Table 2.
Table 3 shows the association between physical activity level, sedentary behavior, and the presence of dynapenia in older adults. Total dynapenia was significantly associated with insufficiently active older adults combined with high sedentary behavior (OR = 5.92; 95% CI: 1.30 - 26.94; p = 0.022). Thus, older adults with insufficient physical activity levels and high sedentary behavior were approximately six times more likely to have total dynapenia when compared to active older adults with normal sedentary behavior.
Association between dynapenia, physical activity level (PAL) and sedentary behavior (SB) in older adults
Discussion
This study highlighted the relationship between physical activity level, sedentary behavior, and partial and total dynapenia in older adults. The results obtained indicated an association between insufficient physical activity level, high sedentary behavior, and total dynapenia.
No studies were found in the literature that address the association between physical activity level, sedentary behavior, and total dynapenia in older adults. Existing studies on dynapenia, physical activity level, and/or sedentary behavior generally focus on the relationships with dynapenia, not directly addressing total dynapenia, a term proposed by the authors of this study.
Total dynapenia occurs when older adults experience a simultaneous reduction in upper and lower limb strength. Characterized by reduced muscle strength, dynapenia is a common problem in older adults and is associated with several negative outcomes, such as reduced functional mobility, functional disability, and lower quality of life.2,24
Previous studies had already established the individualized relationship between the level of physical activity and dynapenia, with regular physical activity being an important protective factor against the decline in muscle strength.25 However, the inclusion of sedentary behavior in the analysis provides a more comprehensive view of the older person's lifestyle and its impacts on muscle health. Low physical activity levels, characterized by behaviors involving little or insufficient physical activity, prove to be a strong predictor of dynapenia, and when combined with high sedentary behavior levels, it becomes even more significant.4 The reduction in muscle strength can be explained by several mechanisms, including decreased muscle mass, deterioration of neuromuscular function, and metabolic changes.24
It is worth highlighting that the combination of low physical activity levels and high sedentary behavior creates a scenario of double exposure to the risk of developing dynapenia. This situation can be even more concerning in older adults with additional risk factors, such as sarcopenia and chronic diseases.22,26
Physical activity offers several health benefits for older adults, reduces mortality, is a protective factor against cardiovascular diseases, reduces symptoms of anxiety and depression, and enables better health and quality of life.27 In contrast, sedentary behavior is identified as one of the main risk factors for health. According to Guerra et al.,27 high sedentary behavior is related to the risk of developing diseases such as type 2 diabetes, obesity, and hypertension.
In a study conducted by Silva et al.5 in Alcobaça, a Brazilian municipality with demographic characteristics and HDI similar to those of the municipality where the present research was carried out, a significant association was observed between dynapenia, sedentary behavior, and risk of mortality from all causes. Although this study did not investigate mortality, the findings of Silva et al.5 corroborate the importance of dynapenia and sedentary behavior as risk factors for negative outcomes in older adults. In both studies, the combination of low physical activity levels and high sedentary behavior levels proved to be particularly detrimental to health, reinforcing the need for interventions that address these two factors in an integrated manner.
In contrast to Reid et al.,28 who did not identify a significant association between sedentary behavior and muscle strength in older people, the findings of the present study reveal that older people with low levels of physical activity and high levels of sedentary behavior have a significantly higher risk of developing total dynapenia. While Reid et al.28 focused on isolated measures of muscle strength, this study concentrated on the simultaneous reduction in strength in the upper and lower limbs, a more comprehensive and clinically relevant outcome. This study's results suggest that the interaction between low physical activity and high sedentary behavior may have a cumulative impact on muscle health, highlighting the importance of considering these two factors in an integrated way in interventions aimed at preventing dynapenia in older adults.
The aforementioned results suggest that regular physical activity, combined with sedentary behavior within the parameters considered normal, can act as a protective factor against total dynapenia in older adults. Thus, adopting an active lifestyle, with frequent physical activity and fragmenting the time spent on sedentary behaviors, can be an effective strategy for human development and well-being, helping to enjoy a full life with better quality, improving disposition, autonomy, and independence to perform daily activities.29
The study's limitation is the assessment of physical activity and sedentary behavior, carried out using the IPAQ. The self-reported nature of this instrument may compromise the accuracy of the information collected, since the data are subject to memory and interpretation biases. However, the instrument is validated for older adults in Brazil. The use of objective instruments that directly measure movement would be fundamental to overcome this limitation.
Furthermore, the scientific literature still lacks studies that investigate in more depth the association between physical activity level, sedentary behavior, and partial and total dynapenia in older adults, which reinforces the need for future research in this area, especially longitudinal studies. We believe that the results of this research may contribute to the development of health promotion strategies in the older population.
Conclusion
The combination of low physical activity levels with high sedentary behavior levels is associated with total dynapenia, highlighting the importance of the interaction between these two behaviors for the simultaneous reduction of upper and lower limb muscle strength. Al-though no significant associations were observed for partial dynapenia, the results reinforce the need for strategies that promote physical activity and reduce sedentary behavior time in the older population.
Data availability statement
Data are available from upon reasonable request.
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Edited by
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Associate editor:
Ana Paula Cunha Loureiro
