Havana Woman. Body composition analysis and changes according to risk factors

Original Article

1. Abstract
2. Introduction
3. Material and
   Methods
4. Methods
5. Data
   processing
6. Results
7. Discussion
8. Conclusions
9. Bibliography
10. Tables

Abstract

Introduction: There are few studies
on risk factors about quality life on Cuban woman. One
well-recognized sequel of sedentary life habits is obesity.
Material and methods: In a population-based sample of 1074
women (age 20-70 years, obtained during the years from 1998 to
2002, taking into account ethnical origin and criteria from the
International Biological Program, we evaluated body composition
and bone density at total body and four skeletal sites by
dual-energy x-ray absorptiometry (DXA). Data are given as mean,
standard deviation and percentile distribution. In multivariate
analysis of determinants of total body composition among an
aged-stratified sample obesity frequency was studied, considering
those that were above 95th percentile of their native
critical limits for total body fat (%), adiposity index, body fat
trunk (%), body fat legs (%) and body fat arm (%). Bone mass loss
was estimated using odd ratio test by
Mantel-Haenszel with the following risk factors: physical
activity, coffee intake, and daily calcium intake on puberty and
previous week. Multiple regression analysis step by step was
performed. All data were recorded in a database system using SPSS
for Windows,
version 10.1

Results: Different patterns of age-related change
were found on our patients for adiposity index and regional fat
distribution. It was observed a strong tendency showing that body
fat arm, body fat trunk and body fat leg increased according with
age (p< 0.00). Obesity frequency considering adiposity index
was 48% on women between 50-59 years old. Conclusions: We
conclude there exists an increase probability risk of diabetes,
hypertension, osteoporosis and
cardiovascular disease in women from fifty years old on. Physical
activity habits, kind of daily diet at critical moments and
biosocial background on which the Cuban woman develops her life,
mark her quality life on aging.

Key words: adiposity index, obesity, body
composition, lean mass, risk, osteoporosis,
native critical limit and Havana woman.

Introduction

In spite of the concern that now-a –days exists in
the world by an esthetic ideal of slenderness, populations tend,
in an increasing way, to a life style that promotes obesity.
Additionally, there are evidences that obesity, type II diabetes and
cardiovascular disease share common genetic background, as well
as the environmental risk. 1, 2

In the Cuban environment these metabolic aspects in
women have been poorly studied. Author Teresa Lazka describes
that in the sixties of the last Century young women from Havana
presented development rhythms that were higher to the ones
described by Rouma in 1920, and comments the roll of this old
tendency that accomplishes during the years 1880 to 1950
increases of more than 1 cm by decade in
adults3,4..

This facts, together with a menarche at significant low
age, characterizes the young Cuban with an acceleration of mature
rhythms, that this researcher explained as a result of the
interaction between genetic and environmental factors, such as
climate, considering them as adjustment mechanisms.

It has been demonstrated that the dietetic consume of
calcium during puberty has a significant influence in both
physical and bone development in the Cuban population studied.
This information coincides with the appreciation of another
authors about the ingestion of calcium as protector factor during
the critical moments of growth5, 6,
7..

Body fat trunk and sedentary habits increase with age,
being more evident in women with amenorrhea of more than 5 years,
in contrast with women that are still in reproductive age7,
8, 9.

Remodeling changes of the corporal composition in young
women from the East and the West of our country, studied during
17 months during the years 1989 to 1990, presented significant
increases in lean mass and tricipital fat, that contrasted with
the diminishing of bicipital fat and that of the legs
[p<0,05)] after a controlled regime of daily physical
exercises and a well equilibrated diet10

The purpose of this research about female population is
to contribute to an integral evaluation of the problem related to
corporal composition and the expectation of quality life for
women during the third age in our environment.

Material and
Methods

This paper presents the results of a transversal
study11 about the corporal composition in total
bodies, as well as the figures of bone density in four anatomical
places in a Havana population of 1074 healthy women between 20
and 70 years old, obtained from1998 to 2002, that were considered
regarding the ethnical origin in accordance with the criteria of
the International Biological Program12.

The medical records were studied in order to disregard,
as an exclusion criteria, smoking habit, chronic kidney disease,
endocrinal, hepatic or metabolic disorders, early menopause or
ophorectomy before 50 years old, nephrolitiasis or use of
medication like corticoids, anticonvulsant, heparin or hormonal
replacement therapy and/or ingestion of mineral supplements. As
menopausal women were considered those with more than six months
of amenorrhea.

Methods

We established the composition of lean mass (kg),
adiposity index [fat tissue (kg)/lean mass (kg)], fat tissue (kg)
and its relative composition (%) for total body and by anatomical
regions (trunk, arms and legs), as well as the bone mineral
density (BMD) in grams and by square centimeter for lumbar
vertebras [L1 – L4] in anterior-posterior view, femur neck,
Ward triangle and trochanter for the whole sample, by the
measurement of the total body and of the regions using the
technique of dual-energy x-ray absorptiometry (DXA).

The data are considered and compared with the references
of bone density in Cuban female population from 20 to 39 years
old, Mexican and North American, as well as the peak of bone mass
for femur neck, Ward triangle, trochanter and lumbar vertebras
(anterior-posterior view) obtained in this investigation and the
percentiles distributions for each age group. Risk of
osteoporosis is evaluated by the criteria from the World Health
Organization13.

The frequency, by ages, of women with adiposity index
and corporal composition higher than percentile 95 and two
standard deviation above the mean of fat and lean mass,
determined by the technique of densitometry of total body in
absolute and relative values, as well as by anatomical regions
according to the peak expression in our population between 20 and
29 years old is established. This is compared with groups of
Cuban and Spanish population measured by anthropometrical
techniques14 15 16.

Variation coefficients for vertebras, femur neck and
total body were of 0, 8%, 1% and 0, 8% respectively.

Data
processing

Results are shown in percentiles, means and distribution
measurements, such as, standard deviation, analysis of variance
(Anova) and Student test for
independent samples, with the purpose of determining the
differences according to age, amenorrhea appearance and ethnical
origin in relation to the critical limits established by the
World Health Organization and peak values of bone density in
young Cuban population. Declination has been compared with the
maximum value of the peak obtained between 20 and 29 years old
(%). In order to avoid the influence of the body size on the
variables of
bone density, coefficients for height were used.

Risk variables,
such as calcium consumption in puberty (mg/day), coffee
consumption in the previous week of the study (cups/day) and
frequency of physical exercises (more than three times per week
in the previous two years) are analyzed in their association with
the loss of bone density, according to different anatomical
places (trabecular and cortical) in the female population less
than 40 years old. The study was made via control cases by
pairs as stipulates the criteria of Odds ratios from
Mantel-Haenszel, using confident intervals and Chi Square
estimation with a level of confidence of
95%17,18.

Dependent and independent character of the variables was
considered, by means of double classification analysis of
variance for normal distributions and Friedman test for
non-lineal ones. Logarithm transformation was applied to
variables with semilogarithm distribution.

The dietetic survey was performed using the criteria of
frequency of consumption through interviews made by a
nutritionist, emphasizing the ingestion of calcium during ages
between 11 and 16 years old and in the previous week of the
measurements. These figures have been compared with the ones
recommended by the European Economic Community that establish as
sufficient ingestion of calcium the amount of 700 mg per day and
as critical level 400 mg per day19. All the
statistical analysis was performed using the SPSS/PC software version 10, 01 from
Chicago, Illinois.

RESULTS

Women in this study, from the fourth decade of live on;
maintain a sustained increase in corporal fat that reaches its
maximum in the seventh decade of live (increase of 8,5 kg as
average after 30 years old). The percentile distribution of
corporal composition in Havana women from this research presents
interesting changes when women go from the third to the fourth
decade of life. The average increase is 6.6 kilogram of corporal
fat (+42,3% of change) with its corresponding outstanding
increase of fat in the analysis of the relative composition,
mainly taking into account that height, lean mass and bone
density do not experiment substantial changes in this stage of
live. (Tables 1 and 2, 2a, 2b).

Accumulation of fat in the region of trunk and arms are
the ones that are most impressive in this analysis, presenting
increases of +41,8% and +37,6% respectively and with changes that
are highly significant (p<0,001) from 34 years old on, as
shows the analysis of variance. (Graphics 1 and 2).

Fat in legs shows an interesting behavior. It presents a
sustained increase from 30 years old on as the rest of the
variables mentioned, but its main change occurs from 60 years old
on (+36,6% of change) that is highly significant according to the
analysis of variance (p<0,00).(table 2a and graph
2).

Sedentarily(leisure time) as a dependent variable,
presents a highly significant association (p<0,00) in the step
by step linear regression, with F values of 22,0; 20,8; 19.0;
18.6; 11.4; 11.4 and 10.4 for fat in arms, legs, trunk and whole
body (%) and for vertebral density, Ward triangle and trochanter
in the population under 40 years old.(table 2b).

Risk variables such as dietetic consumption of calcium
and coffee and systematic exercise, also showed significant
association and specific relation with the type of bone tissue
(trabecular and/or cortical).

Calcium consumption during puberty (p<0, 05) and
coffee ingestion in the week previous to this study (p<0,001)
resulted significantly associated with bone loss in the
anatomical places that are trabecular predominant. The index of
association between exercise and calcium consumption, in the
previous week to the measurements made, in relation to bone
density loss show a probability that is highly significant
(p<0,00) for both types of anatomical places. (Table
3)

The effect of the type of exercise on the adiposity at
different places can be clearly seen in Graphic 3 in women less
than 40 years old, emphasizing that activities such as dancing
and aerobic gymnasia produce changes in corporal remodeling with
significant differences for fat in arms (p<0,05) as a
multivariable analysis by linear regression shows.

A tendency to moderate the frequency of the estimation
in obese women according to the relative total fat (%) criteria
is observed, with values higher than percentile 95 of the
population of reference, that represent 48 % of the cases between
women from 50 to 59 years old. When the evaluation is made using
as limit two standard deviations above the average of the
population of reference, the frequency of obesity goes to 66%.
(Table 4)

The frequency of our young women above two standard
deviations from the average relative trunk fat is only 6 %, 6%
between 30 and 39 years old and 8% between 40 and 49 years
old.

From 50 years old on an increase in this regional
accumulation appears, and produces that 67% could be considered
obese of central type according to this criteria. These
differences by analysis of variance according to age are highly
significant for a t value of 7, 2 (p<0, 00). Table
5.

The analysis of corporal composition in relation with
the ethnical origin shows highly significant differences (t = 5,
12, p<0,000) regarding lean mass. The women in the European
ethnic group present a lower average than those with African
roots or half-breeds, in the stage below 30 years old and in all
the others.

Fat in arms and legs were significantly inferior (t =
3.14 and 2.3, p < 0, 05) in half-breeds and Havana Afro up to
39 years old, with no relation to the systematic practice of
exercise or not. The adiposity index does not present differences
regarding the ethnical origin.

Table 6 shows the risk of bone breaking in women from 50
to 59 years old in a comparative way to other authors. It can be
accepted that regarding hip fracture our average women has a
lower risk than those of the populations in the comparative
analysis; this risk is lower in the relation total body
density/height to that of the female population in
Minnesota34.

Taking into account the ethnic origin and anatomical
place of bone density of women between 50 and 59 years old, a
higher risk index was found for bone fracture in European ethnic
group women in the relation total body/height and femur neck and
Ward triangle in the hip. In half-breed women only predominates
the risk for lumbar vertebras with a highly significant
difference (p>0, 00). (Table 6)

The average age of the beginning of menopause in these
women, presents differences according to the ethnical origin,
corresponding to the Havana European ethnic group 47,3 years old,
50,7 years old to the half-breeds and 51,7 years old to the Afro
ones.

The time of amenorrhea and the changes that correspond
to the precocious postmenopausal period are evident starting from
49 years old, confirming that bone density in the different
anatomical places and relative fat trunk present changes
associated with climacteric in its first five years.

Declination for normalized bone mass according to the
relation with height present a regional and ethnical behavior,
being Ward triangle, femur neck and lumbar vertebras the places
more affected for our European type and half-breed women
(p<0,00) as the Student t test shows. On the other hand, in
the Havana Afro women declination changes associated to time of
amenorrhea are not significant.

Variations in fat composition regarding total body
associated with time of amenorrhea in women older than 45 years
old show an interesting behavior (p<0, 00) in the multiple
regression analysis; the dependent variable exercise practice
gives total fat a predominant place of first order (F 8, 2), to
trunk fat (F 7, 9) and to the variables fat in legs and lean mass
(F 7, 1 and F 4, 02). Trunk fat present highly significant
changes (p< 0,007). This is highlighted in Graphic
4.

Discussion

Increase from early stages of sedentarily attitudes, fat
deposited and its relation to type II diabetes, cardiovascular
disease and osteoporosis constitute a gloomy shadow over the
expectation in the quality of life of the third age
population20 21 22,23
24.

In our environment the tendency to abdominal adiposity
has been previously described by Díaz15, 16,
that although does not analyzes the ethnical origin and uses
indirect estimates that are based on anthropometrical techniques,
which limitations are well known now-a-days, does study with more
depth the distribution patterns of fat tissue in the body and
shows the modifications in the corporal composition regarding the
age in concordance with the relative reduction of lean mass,
results that correspond with our research too.

Alastrue in Spain has made an evaluation of the
anthropometry of adiposity, starting from estimates of skin fold
thickness in arm, abdomen and sub scapular. When changes are
analyzed according to age, the percentile distribution of the
relative corporal fat (%) in his women is similar to the one
found in our research using densitometry
techniques14.

Since the sixties, Durnin and Womersley had already
opened the door to estimates of adiposity though measures of skin
fold thickness. The appearance of the dual- photon absorptiometry
technique for studying the total bodies allowed the measurement
of the skeleton and the composition of soft parts. In the last 30
years this technique has been enhanced and constitutes a direct
technique that offers the highest resolution and precision for
the total body and its regions26 27
28 29,30.

The adiposity index presented in this study considers
the relation of two direct quantitative variables: lean mass and
fat tissue. It gives more precise information about the "gold
standard" of autochthones measurements by dual – photon
densitometry in total bodies. According to this indicator, our
women between 50 and 59 years old present an obesity frequency of
48%.

A necessary reflection is that simultaneously with the
changes observed in the composition of relative fat in our women
after 40 years old, a diminution of approximately 2 kilogram of
lean mass and a regional redistribution of fat mainly in trunk
and arms is observed.

According to these results and due to a predominant
model of fat distribution in trunk and arms, it is necessary to
meditate about its great probability of association with a higher
risk of hypertension, dislipidemia and type II diabetes for our
female population from 50 years old on. (Table 5)

This type of regional distribution of fat, "apple" type
has been extendedly commented by different authors for its
metabolic implications like insulin resistance, overload in the
flow of fat acids to the liver and its association with high
figures of arterial tension and higher secretion of cortisol by
stress 20,
21,22, 23.

Practice of systematic exercise is a protective factor
after 60 years old, as showed Nelson in his studies. This author
determines through hydrostatic weight that his sedentary women
has 26,8 kg of corporal fat, composition similar to the
percentile 50 of our women from 60 to 69 years old that sit for
11,2 hours a day35.

The research developed has demonstrated the importance
of some osteoporosis risk factors. This coincides with the alert
given by the MEDOS study that was completed in the Mediterranean
countries31, the Mexican consensus32 for
osteoporosis and some preliminary findings in Cuba7.
These findings state that age, height, calcium ingestion during
puberty, coffee intake, alcohol
consumption and systematic exercise or sport practice have a
significant association with bone mass loss. The results are
supported by multivariable analysis7.

Our women increase the number of hours they stay sitting
and coffee intake from 30 years old on. This raises the question
of how working environment and life style habits can be
influencing the consumption of a substance with proved antagonist
effects with calcium absorption, as well as introducing sedentary
life habits.

Another interesting appreciation is the protector
character of half-breeding in the ethnical origin. According to
some estimates our population is composed by 51% of half-breeds
and 37% of European origin, which constitutes an important factor
in the demographic composition of the current Cuban
population38.

We have to accept that in the complex phenomena studied
some evidences stated by another authors are corroborated. They
concur in affirming the effect of the variables studied and the
impossibility of isolating them in their multiple actions from
genetic factors, age, ethnical origin, climacteric time, type and
frequency of physical activity, diet and its action in determined
critical moments 1, 2,
39,40,41,42,43, 44.

.Conclusions

The Health World Organization has recently estimated
that more than 143 million people suffer from non-insulin
dependent diabetes. Our country was placed with a tendency from
75 to 349 people per 1000 habitants for the year
202525.

The results of our research show a clear tendency in the
women studied to develop fat accumulation in the body central
region, increase of sedentary habits and declination of bone mass
according to the cycle of life. These results coincide with
findings already described8,9,11,15,36,37.
Osteoporosis as a health problem occupies a special place in this
analysis about the expectation of the quality of life in the
third age women population.

The roll of environmental factors in the genesis of the
changing phenomena analyzed in this study can be considered
controversial. They could not be isolated from the demonstrated
polygenic character43 nor from the consensus to accept
that bone mass, corporal weight and gonad functions have common
endocrinal regulations44, 45.

These are only the first steps to an analysis in which
our ethnical mixture can not be ignored, as well as idiosyncrasy,
habits of time and type of physical activity, exposition to sun
light, diet composition in critical moments and bio-psycho-social
organization in which Cuban women develops.

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no.7,pp.915-921.

45.Karsenty G., 2002.Transgenic models to understand
osteoporosis.Osteoporosis Int; vol 13 (supp 1): S 2

Table
1

Body composition

Percentile distribution, n =
238

Women 20 – 29
years

Havana city, Cuba 2003

Table 1a

Body composition

Percentile distribution

30 – 39 years, n =285

Table 1b

Body composition

Percentile distribution

40 – 49 years, n = 161

Table 1c

Body composition

Percentile distribution

50 – 59 years, n = 280

Table 1d

Body composition

Percentile distribution

60 – 69 years, n = 110

Table 2

Body composition changes according
age

Median and variation ( % )
*

Havana city, Cuba

1998-2003

• * high significant difference change p
  <0.001
• ** significant difference change p
  <0.05

Table 2a

Body composition changes according
age

Median and variation (%)
*

Havana city, Cuba

1998-2003

* high significant difference change p
<0.001

Table 2b

Body composition changes according
age

Mean , standard deviation and
variation (%) *

Havana city, Cuba

1998-2003

• *high significant difference change p
  <0.001
• ** significant difference change p
  <0.05

Table 3

Odd ratio risk according skeletal site
(a)(b)

Female population under 40 years
old

Havana city, Cuba
1998-2003

• (a) lumbar vertebrae and Ward s
  triangle
• (b) femoral neck.

Table 4

Nutritional assessment
criteria

Above critical limit reference
frequency %

according female population body
composition indicators *

Havana city, Cuba
1998-2003

Table 5

Obesity assessment
criteria

Above critical limit reference *
frequency %

according female population body
composition indicators

Havana city, Cuba
1998-2003

• (a) variance analysis accordin age.. highly
  significant t 7.2, p<0.00,.
• (b) " " " t 9.85, p<0.00,
• ( c ) " " " t 6.9, p<0.00.

Table 6

Osteoporosis risk

Prevalence according skeletal site
(%)

Havana women 50-59 years old according
ethnical procedence

(> – 2,5 standard deviation
(a))

comparative analysis using different
reference data (b)(c)

Cuba, 2003

(b) Deleze ,M., Cons-Molina, F.,
Villa, A.R.,Morales-Torres, J., et al.Geographic differences in
bone mineral density of mexican women.Osteoporos Int (2000) 11:
562-569

(c ) Melton III,L.J., Khosla, S.,Achenbach, S.J.,
O´Connor, M.K., et al.Effects of body size and skeletal
site on the estimated prevalence of Osteoporosis in women and
men. Osteoporos Int (2000) 11: 977-983

Dra. Carmen Santos Hernandez

Centre of Medical Surgery Investigations. CIMEQ. Havana
city, Cuba