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The relationship between obesity and grip strength, a key indicator of sarcopenia, has been inconsistently reported. We aimed to examine associations between grip strength and both body mass index (BMI), a clinical indicator of total adiposity, and waist circumference (WC), an indicator of central adiposity. Cross-sectional study. Data collected from 8,441 men and women, aged 48–92 years old, who attended the third health examination of the European Prospective Investigation into Cancer-Norfolk study was used. Maximum grip strength (Smedley dynamometer), BMI (weight/height2) and WC (measured at the natural waist) were ascertained at a research clinic. The associations between grip strength and adiposity measures were explored using linear regression with adjustment for age, height, social class, physical activity, prevalent disease, smoking status and alcohol intake. Men and women were examined separately and those in the upper quartile of BMI were 2.70kg (95%CI 2.07, 3.33) and 1.46kg (95%CI 1.05, 1.86) stronger respectively than those in the bottom quartile (P trends <0.001). Grip strength also increased weakly with increasing WC. However, including both BMI and WC in the same regression model revealed an inverse association between grip strength and WC, whilst the previously observed association with BMI strengthened. For every 10cm increase in WC, grip strength was 3.56kg (95%CI 3.04, 4.08) lower in men and 1.00kg (95%CI 0.74, 1.24) lower in women. Larger overall body mass, indicated by higher BMI, is associated with stronger grip strength but high WC, a clinical indicator of central obesity, is associated with lower grip strength. Abdominal fat is the most metabolically active adipose tissue and this provides a clue to potential mechanisms underlying relationships between fat and skeletal muscle. Additionally, it reinforces the recommendation to measure WC in clinical practice, especially when BMI is below obese ranges.

Summary We recruited a population-based sample of 58 males and 74 females aged 20–79 from a primary care medical practice to provide normative and descriptive data for high-resolution peripheral quantitative computed tomography (pQCT) parameters. Important effects of ageing and contrasts in the effects of sex on the micro-architecture and strength of upper and lower limb bones were revealed. Introduction The advent of high-resolution pQCT scanners has permitted non-invasive assessment of structural data on cortical and trabecular bone. Methods We investigated age-related changes in pQCT and finite element (FE) modelling parameters at the distal radius and distal tibia in a population-based cross-sectional study of 58 males and 74 females aged 20–79 years. Linear regression models including quadratic terms for age were used for inference. Results Age-related changes and sex differences were generally similar for pQCT parameters at the radius and tibia. At each site, mean values for bone density, cortical thickness and trabecular micro-architecture (number, separation and thickness) were lower (trabecular separation higher) in women than men. Changes with age were most apparent for bone density and cortical thickness, which declined with age, in contrast to trabecular micro-architecture parameters which were not significantly associated with age ( p  > 0.05) in either sex. Cortical bone density and thickness declined faster in women than men after age 50 and trabecular bone density was consistently lower in women. FE-analysis predicted failure load decreased with age and percentage of load carried by trabecular bone increased ( p  < 0.05). Conclusions These data show contrasts in the effects of sex on the micro-architecture and strength of upper and lower limb bones with ageing. The faster decline in cortical bone thickness and density in women than men after age 50 and consistently lower trabecular bone density in women have implications for the excess risks of wrist and hip fractures in women.

PurposeTo describe the distribution, and demographic and socioeconomic correlates of refractive error and related ocular biometry in an older British population.MethodsRefractive error was measured using an auto-refractor without cycloplegia. Pseudophakic individuals and those who had undergone refractive surgery were excluded from analysis. Axial length and anterior chamber depth were measured using partial coherence laser interferometry. Occupation category and highest educational achievement were recorded.ResultsBiometric data were available for 2519 people (1090 men, 1429 women; 93.2% of all participants) aged 48 to 88 years. Refractive data were available for both eyes in 2210 bilaterally phakic participants. Among phakic individuals, axial length of the eye was strongly inversely correlated with refractive error in both men and women (p<0.001). Axial length of the eye was strongly, independently related to height, weight and social class, but most strongly related to educational achievement. In contrast, anterior chamber depth varied with age and sex, but not with socioeconomic status. There was a significant inverse association between anterior chamber depth and refraction in women (p<0.001) but not in men (p=0.495).ConclusionRefractive error in this predominantly white older UK population was associated with axial biometry and sociodemographic characteristics. Educational status was the strongest determinant of axial length.

We measured the impact of diet, anthropometry, physical activity and lifestyle variables on rates of hip bone mineral density (BMD) loss in 470 white men and 474 white women aged 67-79 years at recruitment dwelling in the community. The subjects were recruited from a prospective population-based diet and cancer study (EPIC-Norfolk) in Eastern England. Dietary intake was measured at baseline using 7-day food diaries and used to calculate intakes of some 31 nutrients and 22 food groups. Standardised questionnaires were used to collect data on anthropometry, physical activity and lifestyle variables. BMD loss (percent per annum; % p.a.) was measured using dual-energy X-ray absorptiometry performed on two occasions an average of 3 years apart (range 2-5 years). The mean rate of BMD change at the total hip region was -0.17% p.a. (SD 1.3% p.a.) in men and -0.41% p.a. (SD 1.2% p.a.) in women. In both men and women, weight gain protected against (and weight loss promoted) BMD loss ( P<0.0001). Markers of current physical activity were protective. In men, an increase of 1 l/s in FEV(1) was associated with an increase in BMD at an average rate of 0.25% p.a. ( P=0.013). In women, for every ten trips made per day climbing a flight of stairs, BMD increased at a rate of 0.22% p.a. ( P=0.005) and additionally a 10% increase in activities of daily living score was associated with BMD increasing at a rate of 0.12% p.a. ( P=0.011) in women. Nutritional variation appeared to have less impact on BMD loss. In men there was no evidence of an effect of any of the nutrients evaluated. However, in women, low intake of vitamin C was associated with faster rate of BMD loss. Women in the lowest tertile (7-57 mg/day) of vitamin C intake lost BMD at an average rate of -0.65% p.a., which was significantly faster compared to loss rates in the middle (58-98 mg/day) and upper (99-363 mg/day) tertiles of intake, which were -0.31% p.a. and -0.30% p.a., respectively ( P=0.016). There was no effect of fruits and vegetables, combined or separately, on rate of BMD loss. The results confirm that weight maintenance (or gain) and commonly practiced forms of physical activity appear to protect against BMD loss in this age group. Measures such as ensuring good general nutrition to guard against weight loss in the non-overweight elderly and maintenance of physical fitness could be valuable in protecting against BMD loss. The protective effect of vitamin C in women needs to be further investigated in other prospective cohort or intervention studies.

We hypothesized that measures of physical activity would have a closer relationship with section modulus (SM), an indicator of bending resistance, than with bone mineral density (BMD) because physical activity might expand the bony envelope, which tends to reduce BMD for a constant bone mineral content. Four hundred twenty-three men and 436 women (mean age 72 years, SD =3) were recruited from a prospective population-based cohort study to a study of hip bone loss. Hip BMD was measured on two occasions 2-5 years apart (mean 2.7, DXA-Hologic 1,000 W). Hip structural analysis (HSA) software was used to calculate SM and BMD from the DXA scans on three narrow regions: the narrow neck (NN), intertrochanter (IT) and shaft (S). A physical activity and lifestyle questionnaire was administered at baseline. Multivariate repeated measures analysis of variance was used to model the associations between personal attributes (weight, height, age), physical activity and lifestyle variables with SM, cross-sectional area (CSA), sub-periosteal diameter (PD) and BMD. Men and women were analysed together after tests for interactions with gender, which were found not to be significant. In all regions female gender was associated with having lower values of all outcomes, and body weight was positively associated with all outcomes, i.e., SM, CSA, PD and BMD ( P<0.0001). Sub-periosteal diameter was positively associated with reported lifetime physical activity (IT and S, P<0.0001). There was a significant decline of BMD with age at the NN and S regions ( P<0.026), and the PD increased with age (NN and S, P<0.019). Previous fracture history was associated with having lower values of BMD, SM and CSA (except for S; P<0.022). Both section modulus and CSA were positively associated with heavy physical activity after age 50 years in all regions ( P<0.019), whereas NN BMD was the only BMD associate of heavy physical activity after 50 ( P=0.036). Time spent per week on recreational activities classified as no impact activity was positively associated with BMD, CSA and SM (multivariate P<0.016). In conclusion, proximal femur diameter is associated positively with reported life-long physical activity. If this is mediated through a loading related effect on sub-periosteal expansion, BMD would be an unsatisfactory outcome measure in physical activity studies since it is inversely related to projected bone area. SM in contrast was associated with several measures of recent physical activity and relates more directly to the bending experienced by the proximal femur in response to a given load. These data are consistent with an effect of mechanical loading to regulate bone strength through an anabolic effect maximal in the subperiosteal cortex, where the highest loading-related strains are experienced.

Aims:To compare the efficacy and safety of an escalating energy protocol with a non-escalating energy protocol using an impedance compensated biphasic defibrillator for direct current cardioversion of atrial fibrillation (AF).Methods and results:This prospective multicentre randomised trial enrolled 380 patients (248 male, mean (SD) age 67 (10) years) with AF. Patients were randomised to either an escalating energy protocol (protocol A: 100 J, 150 J, 200 J, 200 J), or a non-escalating energy protocol (protocol B: 200 J, 200 J, 200 J). Cardioversion was performed using an impedance compensated biphasic waveform. First-shock success was significantly higher for those randomised to 200 J than 100 J (71% vs 48%; p<0.01) and for patients with a body mass index (BMI) >25 kg/m2 (75% vs 44%; p = 0.01). In patients with a normal BMI there was no significant difference in first-shock success. There was also no significant difference between subsequent shocks or overall success. The use of a non-escalating protocol (protocol B) resulted in fewer shocks but with a higher cumulative energy. There was no difference in duration of procedure, amount of sedation administered or post-shock erythema between the groups.Conclusion:First-shock success was significantly higher, particularly in patients with a BMI >25 kg/m2, when a non-escalating initial 200 J energy was selected. The overall success, duration of procedure and amount of sedation administered, however, did not differ significantly between the two protocols.

OBJECTIVE To compare the relative efficacy of anteroanterior vanteroposterior electrode pad positions for external cardioversion of atrial fibrillation. DESIGN Prospective randomised trial. SETTING Tertiary referral cardiology centre in the United Kingdom. PATIENTS 90 patients undergoing elective cardioversion for atrial fibrillation. INTERVENTIONS Cardioversion was attempted with self adhesive electrode pads with an area of 106 cm2 placed either in the anteroanterior (AA) or anteroposterior (AP) positions. Initial shock was 100 J which, if unsuccessful, was followed by 200 J, 300 J, and 360 J if required. Peak current and transthoracic impedance were measured. MAIN OUTCOME MEASURES Cardioversion success rate and energy requirements. RESULTS Cardioversion was successful in 81% of the patients (73/90). There was no statistically significant difference in the cardioversion success rate (AA 84%, 38/45 patients; AP 78%, 35/45 patients; p = 0.42) or mean (SD) energy requirement for all patients (AA 223 (96.1) J; AP 232 (110) J) or for patients who were successfully cardioverted (AA 197.9 (82.4) J; AP 195.4 (97.2) J; p = 0.9) between the two pad positions. The mean transthoracic impedance (TTI) for the first shock (AA 77.5 (18.4) ohms; AP 73.7 (18.7) ohms; p = 0.34) was not significantly different between the two groups. TTI correlated significantly with body mass index, percentage body fat, and chest AP diameter. There was a progressive decrease in TTI with serial shocks. While aetiology and TTI were the two independent significant predictive factors for energy requirement, duration of atrial fibrillation was the only independent predictor of cardioversion success in a multivariate analysis. CONCLUSIONS Electrode pad position is not a determinant of cardioversion success rate or energy requirement.

Vegetarian diets have been suggested to be beneficial for bone health due to increased consumption of plant foods, including soya, or reduced consumption of meat. However, meat may also be beneficial for bone health. The evidence relating diet to bone health is based largely on studies of women, often in those at high risk of osteoporosis. Few studies have investigated dietary inter-relationships in men as well as women from general populations. We examined broadband ultrasound attenuation (BUA) of the calcaneum, using a CUBA clinical instrument, in 6,369 men and 5,379 postmenopausal women. The population was divided into four groups according to vegetarian status and frequency of soya consumption, which was defined by response to a food frequency questionnaire that estimates frequency of consumption of food types over the year prior to completion. Regular soya consumers were defined as those who ate soya products with a frequency of between once a day and once a week. Calcaneum BUA in vegetarian men was significantly lower than omnivores by approximately 6% (5 dB/MHz) and was 15% (13.6 dB/MHz) lower in those who were also regular soya consumers. This difference remained after adjustment for age, height, weight, smoking habit, physical activity, selected foods and nutrients and exclusion of those with a prior history of osteoporosis, fractures or cancer. Calcaneum BUA in omnivorous men with regular soya consumption was not lower than the remaining population. In women, there were no significant differences by usual dietary pattern. This surprising finding indicates that regular soya intake is not associated with better bone indices in vegetarian men. The difference in BUA was not explained by the known common covariates; however, it is possible that other aspects of lifestyle associated with these eating behaviors might explain this observation. Plausible mechanisms exist for our findings; soya contains phytoestrogens, likened to naturally occurring estrogens, and meat has been shown to influence levels of IGF-1 and sex hormone binding globulin, which may be related to bone health. Our findings emphasize the need for further research and investigation into dietary inter-relationships and bone health and the effects of vegetarian status, including consumption of soya-based foods, in men as well as women.

Research in internal defibrillation has confirmed the superior efficacy of different waveforms for ventricular defibrillation. 10 The biphasic waveform produces experimentally lower defibrillation thresholds than the commonly employed monophasic waveform for transthoracic defibrillation. 11 Superior efficacy with biphasic waveforms was reported in the recently published multicentre, prospective, randomised comparison of monophasic (Edmark) versus biphasic (Gurvich) waveforms for transthoracic cardioversion/defibrillation of patients in the electrophysiology laboratory. 12 Patients were randomised in a blinded fashion to receive either a monophasic or biphasic waveform for the initial shock conversion of induced VF, monomorphic ventricular tachycardia, polymorphic ventricular tachycardia, or ventricular flutter. Research continues into other waveforms and shock pathways such as triphasic, sequential pulse, double pulse, and overlapping pulses.\\n Other electrode positions for cardioversion of atrial arrhythmias, such as anteroposterior, are not appropriate in the management of cardiac arrest when cardiopulmonary resuscitation is ongoing, and are not associated with any meaningful reduction in TTI as had previously been thought. 20 The clinical situation may also determine an individual's responsiveness to electric counter shock.

Abstract Objectives: To study associations between patterns of physical activity and ultrasound attenuation by the heel bone in men and women. Design: Cross sectional, population based study. Setting: Norfolk. Participants: 2296 men and 2914 women aged 45-74 registered with general practices participating in European Prospective Investigation into Cancer (EPIC Norfolk). Results: Self reported time spent in high impact physical activity was strongly and positively associated with ultrasound attenuation by the heel bone, independently of age, weight, and other confounding factors. Men who reported participating in 2 hours/week of high impact activity had 8.44 dB/MHz (95% confidence interval 4.49 to 12.40) or 9.5%, higher ultrasound attenuation than men who reported no activity of this type. In women, the difference in ultrasound attenuation between those reporting any high impact activity and those reporting none was 2.41 dB/MHz (0.45 to 4.37) or 3.4% higher. In women this effect was similar in size to that of an age difference of four years. Moderate impact activity had no effect. However, climbing stairs was strongly independently associated with ultrasound attenuation in women (0.64 dB/MHz (0.19 to 1.09) for each additional five flights of stairs). There was a significant negative association in women between time spent watching television or video and heel bone ultrasound attenuation, which decreased by 0.08 dB/MHz (0.02 to 0.14) for each additional hour of viewing a week. Conclusions: High impact physical activity is independently associated with ultrasound attenuation by the heel bone in men and women. As low ultrasound attenuation has been shown to predict increased risk of hip fracture, interventions to promote participation in high impact activities may help preserve bone density and reduce the risk of fracture. However, in older people such interventions may be inappropriate as they could increase the likelihood of falls.