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. 2021 Mar 8;16(3):e0248028. doi: 10.1371/journal.pone.0248028

Proposed cut-off points for anthropometric and bioelectrical measures based on overweight and obesity criteria in Spanish institutionalised elderly people

Jose Ramon Alvero-Cruz 1, Rosalia Fernandez Vazquez 1, Javier Martinez Blanco 2, Ignacio Rosety 3, Antonio Jesus Diaz 4, Miguel Angel Rosety 5, Manuel Rosety-Rodriguez 5, Francisco Javier Ordonez 5,*
Editor: Simone Perna6
PMCID: PMC7939364  PMID: 33684155

Abstract

The increasing prevalence of obesity among the institutionalised elderly population and its severe consequences on health requires an early and accurate diagnosis that can be easily achieved in any clinical setting. This study aimed to determine new cut-off values for anthropometric and bioelectrical impedance measures that are superior to body mass index criteria for overweight and obesity status in a sample of Spanish institutionalised elderly population. A total of 211 institutionalised older adults (132 women, aged 84.3±7.3 years; 79 men, aged 81.5±7.3 years) were enrolled in the current cross-sectional study. Anthropometric and bioelectrical impedance measures included the body mass index, waist circumference, gluteal circumference, waist-hip ratio, sagittal-abdominal diameter, trunk fat, and visceral-fat ratio. In women, the waist circumference, gluteal circumference, sagittal-abdominal diameter, trunk fat, and visceral-fat index presented strongly significant specificity and sensitivity (area under the curve [AUC], p<0.0001) and elevated discriminative values (receiver operating characteristic [ROC] curves: 0.827 to 0.867) for overweight and obesity status. In men, the waist-hip ratio, waist circumference, gluteal circumference, sagittal-abdominal diameter, trunk fat, and visceral-fat ratio were strongly significant AUC (p<0.0001), with moderate-to-high values (ROC curves: 0.757–0.871). In conclusion, our findings suggest that gluteal circumference, waist circumference, and sagittal-abdominal diameter in women and trunk fat, visceral-fat ratio, and waist circumference in men may represent more suitable cut-off values superior to body mass index criteria for overweight and obesity in the Spanish institutionalised elderly population.

Introduction

The prevalence of obesity among older European adults has reached epidemic proportions [1]. In Spain, increasing prevalence of obesity coupled with the growth of this population group has become a matter of major concern in recent decades [2]. Although most studies have focused on community-dwelling elderly [1–3], the prevalence of obesity could be even worse among institutionalised elderly individuals in nursing homes (NH) [4, 5]. In fact, obesity has been reported as a major risk factor for institutionalisation [6].

A recent systematic review has revealed an association between obesity with increased morbidity and functional decline [7]. More specifically, overweight and obesity status have been significantly associated with poor cognitive performance among Spanish institutionalised elderly individuals [8]. Furthermore, the obesity status of institutionalised residents may also have a negative impact on staff, equipment, and services provided in NH [9]. Accordingly, caring for obese residents is more expensive than caring for their normal weight counterparts [10]. In fact, obesity status has been considered a criterion of non-admission in NH when choosing prospective residents [9].

For the reasons mentioned above, the recommendation to maintain stable and healthy weight in later stages of life is widely accepted [11]. In order to achieve this goal, an early diagnosis of overweight and obesity that is easily achievable in the clinical setting may play a key role. In this respect, anthropometric findings could be applied across a large population because of its simplicity, cost-effectiveness, portability, and safety [12]. However, the cut-off values for defining both obesity and overweight are currently based on the adult non-elderly population, although there is an increasing body of evidence suggesting that regional fat distribution changes with aging [12, 13]. More specifically, anthropometric indices that rely on waist circumference (WC) are more accurate and reliable for predicting obesity-related comorbidities in elderly individuals as abdominal fat accumulation increases with aging [14].

Thus, the aim of the present study was to define new cut-off values for anthropometric and bioelectrical impedance measures with respect to body mass index (BMI) based overweight and obesity status in a Spanish institutionalised elderly population. We found that the most suitable diagnostic indicators of obesity in institutionalised elderly individuals were gluteal circumference, WC, and SAD for women and Tfat, VFR, and WC for men.

Materials and methods

Participants

A total of 210 individuals participated in a cross-sectional multicentre study of central obesity and metabolic syndrome (132 women and 78 men). The current study was conducted between May 2018 and May 2019. All participants were institutionalised in six public NH in the province of Malaga, in the southeast of Spain. Participants were recruited through contact with NH directors and by directly contacting elderly individuals. All participants received detailed information about the objectives and procedures of the current study. The inclusion criteria were as follows: 1) individuals institutionalised in public NH and 2) ability to sign a free and informed consent form. The exclusion criteria were as follows: 1) patients unable to remain in the supine decubitus position due to comorbidities (heart failure, chronic obstructive pulmonary disease, or balance and mobility disorders); 2) severe physical and/or cognitive impairment; 3) WC greater than 130 cm, a value which prevented reliable determination of abdominal bioelectrical impedance; and 4) difficulty in venous access.

The study was approved by the Ethics Committee Board of the University of Malaga (EMEFYDE report: 017–2019) and the Helsinki principles for human research were respected.

Anthropometric assessment

Weight was measured on a SECA 813 (Hamburg, Germany) calibrated electronic scale to the nearest 100 g. Height was measured on a SECA 216 wall mounted-stadiometer (Hamburg, Germany) with an accuracy of 0.1 cm.

The anthropometric indices BMI (weight in kg/height in square meters) and waist-hip ratio (WHR) were calculated, whereas the sagittal abdominal diameter (SAD) was obtained in the decubitus position at the umbilical reference with a Holtain anthropometer (Crymych, UK).

The WC was set at the level of the iliac crest. The gluteal circumference at the level of the maximum buttock protrusion and ahead at the pubic symphysis level. All values were measured with an inextensible tape to the nearest 1 mm (Lufkin, model W606PM, Cooper Tools, Mexico). The anthropometric measures were obtained in accordance with the guidelines of the International Society for Advancement in Kinanthropometry (ISAK) and were carried out by the same level 3 ISAK-accredited researcher and with a technical error of measurement of less than 1% for all measures.

Abdominal bioelectrical impedance

Measurements were obtained using the AB-140 model, ViScan® bioelectrical impedance device (Tanita, Japan). With the subject in supine decubitus position, the WC was initially measured at the umbilical level, according to the instrument protocol and by the manufacturer’s guidelines by the projection of light in the coronal plane. The values for trunk fat (Tfat) and visceral fat were obtained after positioning a belt with four electrodes, centrally around the umbilical level. Body composition variables were derived by extrapolating impedance measurements (6.2–50 kHz) defining the Tfat, and are expressed in percentage value (range 0%–75%), whereas the visceral fat level is expressed as the visceral fat ratio (VFR) (in arbitrary units, range 1–59). It should be pointed out that ViScan device has previously been reported to be equal to dual energy X-ray absorptiometry (DEXA) in estimating abdominal fat mass [15].

Definition of overweight and obesity status

Classification of overweight (BMI 25–29.9 kg/m2) and obesity (BMI > 30 kg/m2) status was based on the National Institutes for Health (NIH)/WHO guidelines for BMI classification [16].

Statistical analysis

A descriptive study was carried out to analyse the data. Continuous variables are presented as mean values ± standard deviation (SD). The Kolmogorov-Smirnov test was used to identify the normal distribution of the data. Receiver operating characteristics (ROC) curves were obtained to select cut-off values by evaluating the areas under the curve (AUC), as optimal measures of predictors of the cut-off vales able to correctly discriminate the high and the low risks of the condition. The optimal cut-off point was selected by maximising Youden’s index, which is the difference between the true positive rate (sensitivity) and the false positive rate (1-specificity) in the ROC curve. Finally, the Mann-Whitney test was performed to determine differences between sexes in anthropometric and abdominal bioelectrical impedance variables. All statistical analyses were carried out using the MedCalc program for Windows version 19.4.0 (Ostend, Belgium) and a p-value < 0.05 was indicative of statistically significant differences in all cases.

Results

Table 1 summarises the sex-based differences in the anthropometric measurements, and highlights significant differences observed in age, weight, height, and BMI (all, p < 0.05). There were also differences in WC, gluteal circumference, Tfat, and VFR (all p < 0.05). No differences were observed in the WHR and SAD (p > 0.05).

Table 1. Comparisons of anthropometric and bioelectrical impedance measures of central obesity between genders in an institutionalised elderly population.

Variable Males Females p
Mean SD Mean SD
Age (years) 81.51 7.29 84.27 7.27 0.0087
Weight (kg) 68.57 13.96 63.37 12.98 0.0069
Height (cm) 162.52 8.39 151.84 6.94 < 0.0001
BMI (kg/m2) 26.00 5.15 27.52 5.47 0.047
WHR 0.98 0.08 0.97 0.08 0.153
Waist (cm) 96.66 13.34 100.02 12.61 0.07
Gluteal (cm) 97.88 9.26 103.45 11.27 0.0004
SAD (cm) 21.24 3.91 21.77 3.85 0.35
Tfat (%) 29.73 8.79 41.59 8.46 <0.0001
VFR 15.47 6.34 12.81 5.18 0.017
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BMI: Body mass index, WHR: Waist to Hip Ratio, SAD: Sagittal abdominal diameter, Tfat: Trunk fat, VFR: Visceral Fat Ratio. Significance level was set at p< 0.05 in all cases.

ROC curves defining overweight status

Overweight status is defined as BMI 25–29.9 kg/m2. Among women, the WHR did not show significant differences as a predictor of overweight/obesity weight status in terms of AUC (p > 0.05) when compared to BMI. Conversely, the WC, gluteal circumference, SAD, Tfat, and VFR showed significantly different AUC values compared to BMI (all, p < 0.0001) with high AUC values (between 0.85 and 0.889) (Table 2). Among men, the WHR, WC, gluteal circumference, waist circumference, gluteal circumference, SAD, Tfat, and VFR presented very significant AUC values (all, p< 0.0001), with moderate-to-high values between 0.752 and 0.907 (Table 2).

Table 2. Receiver operating characteristics of anthropometric and bioelectrical impedance of central obesity variables in both genders for overweight (BMI = 25 to 29.9 kg/m2).

Gender  ROC curve WHR Waist Gluteal SAD Tfat VFR
Females AUC  0.601 0.889 0.88 0.863 0.859 0.85
SE 0.0531 0.0314 0.0341 0.0331 0.0344 0.0387
95% CI 0.509 to 0.689 0.820 to 0.938 0.809 to 0.932 0.789 to 0.918 0.785 to 0.916 0.774 to 0.909
P 0.0562 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Youden index J 0.219 0.6682 0.6445 0.5688 0.6208 0.6197
Males AUC  0.752 0.907 0.83 0.89 0.822 0.794
SE 0.0577 0.0331 0.0473 0.0409 0.0494 0.0525
95% CI 0.638 to 0.845 0.818 to 0.962 0.726 to 0.907 0.797 to 0.951 0.715 to 0.902 0.684 to 0.880
P <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
  Youden index J 0.4864 0.7329 0.5214 0.6792 0.5608 0.5068
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AUC: Area under curve, SE: Standard error, CI: Confidence Interval, p: p value, WHR: Waist to Hip Ratio, SAD: Sagittal abdominal diameter, Tfat: Trunk fat, VFR: Visceral Fat Ratio. Significance level was set at p< 0.05 in all cases.

Table 3 shows the new cut-off values in relation to overweight values defined by BMI and sensitivity (Sens) and specificity (Spec) for both men and women for each predictor evaluated in the study.

Table 3. Sensitivity and specificity of cut-off points for anthropometric and bioelectrical impedance variables in relation to body mass index for overweight criteria in an institutionalised elderly population.

Variable Cut-off Sensitivity 95% CI Specificity 95% CI +LR 95% CI -LR 95% CI
WHR >1 40.51 29.6 - 52.1 81.4 66.6 - 91.6 2.18 1.1 - 4.3 0.73 0.6 - 0.9
Waist >96 85 75.3 - 92.0 81.82 67.3 - 91.8 4.68 2.5 - 8.8 0.18 0.1 - 0.3
Gluteal >101.7 73.75 62.7 - 83.0 90.7 77.9 - 97.4 7.93 3.1 - 20.3 0.29 0.2 - 0.4
SAD >19.2 92.59 84.6 - 97.2 64.29 48.0 - 78.4 2.59 1.7 - 3.9 0.12 0.05 - 0.3
Tfat >40.9 78.75 68.2 - 87.1 83.33 68.6 - 93.0 4.73 2.4 - 9.4 0.26 0.2 - 0.4
VFR >11 81.01 70.6 - 89.0 80.95 65.9 - 91.4 4.25 2.3 - 8.0 0.23 0.1 - 0.4
WHR >0.97553 74.29 56.7 - 87.5 74.36 57.9 - 87.0 2.9 1.6 - 5.1 0.35 0.2 - 0.6
Waist >95.5 86.11 70.5 - 95.3 87.18 72.6 - 95.7 6.72 2.9 - 15.4 0.16 0.07 - 0.4
Gluteal >97.5 77.78 60.8 - 89.9 74.36 57.9 - 87.0 3.03 1.7 - 5.3 0.3 0.2 - 0.6
SAD >21.3 81.08 64.8 - 92.0 86.84 71.9 - 95.6 6.16 2.7 - 14.2 0.22 0.1 - 0.4
Tfat >29.8 75 57.8 - 87.9 81.08 64.8 - 92.0 3.96 2.0 - 7.9 0.31 0.2 - 0.6
VFR >15 75 57.8 - 87.9 75.68 58.8 - 88.2 3.08 1.7 - 5.6 0.33 0.2 - 0.6
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CI: Confidence Interval,LR: Likelihood ratio, WHR: Waist to Hip Ratio, SAD: Sagittal abdominal diameter, Tfat: Trunk fat, VFR: Visceral Fat Ratio. Significance level was set at p< 0.05 in all cases.

In women, the WC, gluteal circumference, SAD, Tfat, and VFR, had moderate-to-high Sens values (74%–93%) and Spec (65%–83%). Similarly, in men, anthropometric variables and indices had moderate-to-high Sens values (74%–86%) and Spec (74%–87%) (Table 3).

ROC curves associated with obesity (BMI >30 kg/m2)

Obesity status is defined as BMI >30 kg/m2. Among women, the stratification by WHR did not show significant AUC values (p > 0.05) to discriminate obesity status. In contrast, the WC, gluteal circumference, SAD, Tfat, and the VFR presented strongly significant AUC (all, p< 0.0001), with high values between 0.827 and 0.867 (Table 4). Among men, the WHR, WC, gluteal circumference, SAD, Tfat, and the VFR presented strongly significant AUC (all, p< 0.0001), with moderate-to-high predictor ROC curves, between 0.757–0.871 (Table 4).

Table 4. Receiver operating characteristics analysis of anthropometric and bioelectrical impedance of central obesity variables in both genders for obesity (BMI ≥ 30).

Gender ROC curve WHR Waist Gluteal SAD Tfat VFR
Females AUC  0.548 0.862 0.867 0.846 0.835 0.827
SE 0.0621 0.039 0.0347 0.0423 0.0392 0.0404
95% CI 0.456 to 0.639 0.789 to 0.918 0.793 to 0.921 0.770 to 0.905 0.757 to 0.896 0.748 to 0.890
P 0.4357 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
Youden index J 0.1475 0.6237 0.5903 0.6006 0.5801 0.5477
Males AUC  0.757 0.868 0.853 0.861 0.871 0.869
SE 0.0608 0.0554 0.0655 0.0674 0.0417 0.0406
95% CI 0.644 to 0.849 0.770 to 0.935 0.752 to 0.924 0.762 to 0.930 0.772 to 0.938 0.770 to 0.937
P <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001
  Youden index J 0.4667 0.6171 0.6171 0.7916 0.6897 0.75
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AUC: Area under curve, SE: Standard error, CI: Confidence Interval, p: p value, WHR: Waist to Hip Ratio, SAD: Sagittal abdominal diameter, Tfat: Trunk fat, VFR: Visceral Fat Ratio. Significance level was set at p< 0.05 in all cases.

Table 5 reports the cut-off points in relation to obesity status and the sensitivity (Sens) and specificity (Spec) for both female and male institutionalised elderly individuals for each predictor. Among women, the WC, gluteal circumference, SAD, Tfat, and VFR, showed moderate-to-high Sens values (75–89%) and Spec (66–85%). Among men, anthropometric indices also had moderate-to-high Sens values (86–100%) and Spec (69–93%) (Table 5).

Table 5. Sensitivity and specificity of cut-off points for anthropometric and bioelectrical impedance variables in relation to body mass index for obesity criteria in an institutionalised elderly population.

Gender Variable Cut-off Sensitivity 95% CI Specificity 95% CI +LR 95% CI -LR 95% CI
Females WHR >1.02 34.29 19.1 - 52.2 80.46 70.6 - 88.2 1.75 0.9 - 3.3 0.82 0.6 - 1.1
Waist >103 80.56 64.0 - 91.8 81.82 72.2 - 89.2 4.43 2.8 - 7.1 0.24 0.1 - 0.5
Gluteal >104 88.57 73.3 - 96.8 70.45 59.8 - 79.7 3 2.1 - 4.2 0.16 0.06 - 0.4
SAD >23 75 57.8 - 87.9 85.06 75.8 - 91.8 5.02 2.9 - 8.6 0.29 0.2 - 0.5
Tfat >45 77.78 60.8 - 89.9 80.23 70.2 - 88.0 3.93 2.5 - 6.2 0.28 0.1 - 0.5
VFR >12 88.89 73.9 - 96.9 65.88 54.8 - 75.8 2.61 1.9 - 3.6 0.17 0.07 - 0.4
Males WHR >0.949 100 76.8 - 100.0 46.67 33.7 - 60.0 1.87 1.5 - 2.4 0
Waist >96.2 92.86 66.1 - 99.8 68.85 55.7 - 80.1 2.98 2.0 - 4.4 0.1 0.02 - 0.7
Gluteal >98 92.86 66.1 - 99.8 68.85 55.7 - 80.1 2.98 2.0 - 4.4 0.1 0.02 - 0.7
SAD >24.6 85.71 57.2 - 98.2 93.44 84.1 - 98.2 13.07 4.9 - 34.5 0.15 0.04 - 0.6
Tfat >32.9 92.31 64.0 - 99.8 76.67 64.0 - 86.6 3.96 2.4 - 6.4 0.1 0.02 - 0.7
  VFR >17 100 75.3 - 100.0 75 62.1 - 85.3 4 2.6 - 6.2 0  
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CI: Confidence Interval, LR: Likelihood ratio, WHR: Waist to Hip Ratio, SAD: Sagittal abdominal diameter, Tfat: Trunk fat, VFR: Visceral Fat Ratio. Significance level was set at p< 0.05 in all cases.

Discussion

To the best of our knowledge, this is the first study to propose optimal cut-off points for anthropometric and bioelectrical measures corresponding to the BMI criteria for overweight and obesity status in a Spanish institutionalised elderly population. These findings could be of great interest in clinical practice considering that recent studies have emphasised the importance of determining population-specific cut-off values for more accurate techniques, such as computed tomography (CT) or DEXA [17].

According to the present study, the most suitable diagnostic indicators of obesity in institutionalised elderly individuals were gluteal circumference, WC, and SAD for women and Tfat, VFR, and WC for men. The WHR showed a lower discriminatory ability to predict obesity compared to the other indicators tested in our study, which was in contrast to previously reports for both women and men. With regard to overweight status, the WC, gluteal circumference, and SAD in women and WC, SAD and gluteal circumference in men showed a greater diagnostic ability than the other parameters tested.

In agreement with previous studies focused on German and Australian adults (aged 20–69 years-old) [18, 19], our findings revealed that there was a stronger correlation between WC and BMI when compared to WHR and BMI. In a recent study, Pinheiro et al. [20] found that the BMI underestimated the fat mass percentage in patients with non-dialysis chronic kidney disease because it was not possible to consider the loss of lean mass concomitant to fat gain. This finding could be of particular interest considering the high prevalence of sarcopenia among the institutionalised elderly population in Spain [21]. In fact, in this population group, BMI has been considered a marker of protein stores rather than of adiposity, which may ultimately explain, at least in part, the obesity paradox [22].

It is widely accepted that WC reflects abdominal obesity across the adult lifespan [23, 24]. More specifically, on the basis of our findings we propose that cut-off points for WC of 103 cm (80.5% Sens.; 81.8% Spec.) in women and 96.2 cm (92.8% Sens.; 68.8% Spec.) in men can better discriminate obesity status in the Spanish institutionalised elderly population. WC has been associated with risk factors for cardiovascular disease (CVD) to a greater extent than the BMI or the WHR in the elderly [25]. However, it should be pointed out that WC may overestimate or underestimate the risk of CVD as it does not consider differences in height [18]. In this respect, individuals of shorter height may have higher health risks than taller individuals in the moderately-to-large WC group for both sexes and across different ages among Japanese adults [26]. Furthermore, WC has also been associated with a significantly increased risk of dementia among older adults [27]. Additionally, abdominal obesity (WC > 88 cm) has also been positively associated with fragility fractures in a sample of community-dwelling elderly Israeli women [28]. In fact, central obesity, expressed as increased WC, was the only anthropometric parameter identified with negative effects on both the physical and mental domains of quality of life among community-dwelling older adults [29].

Several studies have pointed out that anthropometric and bioelectrical impedance measures are crucial for cardiometabolic risk assessment [23, 30, 31]. In fact, anthropometric indices have been positively correlated with levels of serum proinflammatory cytokines not only in relatively young older adults (aged 60–80 years) [32], but also in female nursing home residents aged ≥ 80 years [30]. Furthermore, several studies have emphasised that the cut-off values for these anthropometric indicators depend on age, sex, and race-ethnicity [23, 30]. In a previous study focusing on the same cohort of institutionalised elderly, we reported the cut-off values able to predict metabolic syndrome using BMI (26.81 and 23.53kg/m2), WC (102 and 91cm), SAD (22.1 and 20.7cm), Tfat (34% and 43.7%), and VFR (17 and 11.5) in men and women, respectively [23].

In particular, in women, the SAD, Tfat, and VFR cut-off values for metabolic syndrome ranged within those for overweight and obesity status. Conversely, the WC and WHR cut-offs for metabolic syndrome were higher than the optimal cut-off values defined for obesity among the institutionalised elderly population. In men, the SAD and VFR cut-offs for metabolic syndrome also ranged within the cut-off values established for overweight and obesity status. Conversely, the WC, gluteal circumference, WHR, and Tfat cut-offs for metabolic syndrome were higher than optimal cut-off values for obesity in the institutionalised elderly population [23].

The present study has numerous strengths. It is the first report to propose optimal cut-off values for anthropometric and bioelectrical indices to discriminate overweight and obesity status among the institutionalised elderly population in Spain. In this respect, the use of standardised procedures for anthropometric and bioelectrical determinations contributed to minimising measurement bias. Notably, the anthropometric data were obtained by level 3 ISAK-accredited technicians provided that the difficulties in collecting WC and height and ensuring their accuracy in elderly population [33]. Lastly, participants were recruited from a well-defined population, which represented a single ethnic group (Caucasian), aged above 65 years, and institutionalised in NH.

Conversely, several limitations to the study should also be recognised. The sample size is small and validation of the findings would benefit from a larger population. In addition, our study population comprised a cross-sectional cohort of institutionalised elderly individuals, and the results may not apply to the community-dwelling elderly. Finally, the exclusion of patients with WC > 130 cm could also be considered a limitation.

Conclusions

Our study showed that the gluteal circumference, WC, and SAD in women and Tfat, VFR, and WC in men were better indicators of obesity than other anthropometric and bioelectrical impedance measures in the Spanish institutionalised elderly population. Further multicentre studies with larger sample sizes are required to confirm the predictive value of the current optimal cut-off points of anthropometric and bioelectrical measurements in identifying overweight and obesity in institutionalised elderly. Our findings propose simple indices for accurate diagnosis of overweight and obesity that can be easily performed in a clinical setting, which will contribute to managing the severe consequences on health of this condition among elderly individuals in institutionalised settings.

Supporting information

S1 File

(XLSX)

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Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

References

  • 1.Peralta M, Ramos M, Lipert A, Martins J, Marques A. Prevalence and trends of overweight and obesity in older adults from 10 European countries from 2005 to 2013. Scand J Public Health. 2018. Jul;46(5):522–529. 10.1177/1403494818764810 [DOI] [PubMed] [Google Scholar]
  • 2.Gomez-Cabello A, Pedrero-Chamizo R, Olivares PR, Luzardo L, Juez-Bengoechea A, Mata E, et al. Prevalence of overweight and obesity in non-institutionalized people aged 65 or over from Spain: the elderly EXERNET multi-centre study. Obes Rev. 2011. Aug;12(8):583–92. 10.1111/j.1467-789X.2011.00878.x [DOI] [PubMed] [Google Scholar]
  • 3.Spadaccini D, Perna S, Peroni G, et al. DXA-Derived Visceral Adipose Tissue (VAT) in Elderly: Percentiles of Reference for Gender and Association with Metabolic Outcomes. Life (Basel). 2020;10(9):163. Published 2020 Aug 24. 10.3390/life10090163 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Zhang N, Field T, Mazor KM, Zhou Y, Lapane KL, Gurwitz JH. The Increasing Prevalence of Obesity in Residents of U.S. Nursing Homes: 2005–2015. J Gerontol A Biol Sci Med Sci. 2019;74(12):1929–1936. 10.1093/gerona/gly265 [DOI] [PubMed] [Google Scholar]
  • 5.Perna S, Alalwan TA, Spadaccini D, Al-Thawadi S, Gasparri C, Isu A, et al. Comparison between Bioimpedance Analysis and Dual-Energy X-ray Absorptiometry in assessment of body composition in a cohort of elderly patients aged 65–90 years. Adv Gerontol. 2019; 32(6): 1023–1033. [PubMed] [Google Scholar]
  • 6.Dimilia PR, Mittman AC, Batsis JA. Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity. Curr Diab Rep. 2019. Nov 4;19(11):114. 10.1007/s11892-019-1249-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Harris JA, Castle NG. Obesity and Nursing Home Care in the United States: A Systematic Review. Gerontologist. 2019. May 17;59(3):e196–e206. 10.1093/geront/gnx128 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Cebrián PD, Cauli O. Analysis of Functional and Cognitive Impairment in Institutionalized Individuals with Movement Disorders. Endocr Metab Immune Disord Drug Targets. 2019;19(7):1022–1031. 10.2174/1871530319666190311104247 [DOI] [PubMed] [Google Scholar]
  • 9.Harris JA, Engberg J, Castle NG. Obesity and intensive staffing needs of nursing home residents. Geriatr Nurs. 2018. Nov;39(6):696–701. 10.1016/j.gerinurse.2018.05.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Marihart CL, Brunt AR, Geraci AA. The high price of obesity in nursing homes. Care Manag J. 2015;16(1):14–19. 10.1891/1521-0987.16.1.14 [DOI] [PubMed] [Google Scholar]
  • 11.Porter Starr KN, McDonald SR, Weidner JA, Bales CW. Challenges in the Management of Geriatric Obesity in High Risk Populations. Nutrients. 2016. May 4;8(5):262. 10.3390/nu8050262 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Scafoglieri A, Clarys JP, Cattrysse E, Bautmans I. Use of anthropometry for the prediction of regional body tissue distribution in adults: benefits and limitations in clinical practice. Aging Dis. 2013. Dec 15;5(6):373–93. 10.14366/AD.2014.0500373 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Correa MM, Thumé E, De Oliveira ER, Tomasi E. Performance of the waist-to-height ratio in identifying obesity and predicting non-communicable diseases in the elderly population: A systematic literature review. Arch Gerontol Geriatr. 2016. Jul-Aug;65:174–82. 10.1016/j.archger.2016.03.021 [DOI] [PubMed] [Google Scholar]
  • 14.Scafoglieri A, Provyn S, Bautmans I, Van Roy P, Clarys JP. Direct relationship of body mass index and waist circumference with body tissue distribution in elderly persons. J Nutr Health Aging. 2011. December;15(10):924–31. 10.1007/s12603-010-0272-x [DOI] [PubMed] [Google Scholar]
  • 15.Manios Y, Kanellakis S, Moschonis G, Pipidis I, Skoufas E, Zafiropulos V. Estimation of abdominal fat mass: validity of abdominal bioelectrical impedance analysis and a new model based on anthropometry compared with dual-energy x-ray absorptiometry. Menopause. 2013. Dec;20(12):1280–3. 10.1097/GME.0b013e31828f5cd8 [DOI] [PubMed] [Google Scholar]
  • 16.World Health Organization. Obesity: Preventing and Managing the Global Epidemic;World Health Organization: Geneva, Switzerland, 1998 [PubMed] [Google Scholar]
  • 17.Tutunchi H, Ebrahimi-Mameghani M, Ostadrahimi A, Asghari-Jafarabadi M. What are the optimal cut-off points of anthropometric indices for prediction of overweight and obesity? Predictive validity of waist circumference, waist-to-hip and waist-to-height ratios. Health Promot Perspect. 2020. Mar 30;10(2):142–147. 10.34172/hpp.2020.23 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Schneider HJ, Klotsche J, Silber S, Stalla GK, Wittchen HU. Measuring abdominal obesity: effects of height on distribution of cardiometabolic risk factors risk using waist circumference and waist-to-height ratio. Diabetes care. 2011;34(1):e7 Epub 2011/01/05. 10.2337/dc10-1794 [DOI] [PubMed] [Google Scholar]
  • 19.Welborn TA, Dhaliwal SS. Preferred clinical measures of central obesity for predicting mortality. Eur J Clin Nutr. 2007;61(12):1373–9. 10.1038/sj.ejcn.1602656 [DOI] [PubMed] [Google Scholar]
  • 20.Pinheiro ACDB Filho NS, França AKTDC Fontenele AMM, Santos AMD. Sensitivity and specificity of the body mass index in the diagnosis of obesity in patients with non-dialysis chronic kidney disease: a comparison between gold standard methods and the cut-off value purpose. Nutr Hosp. 2019. Mar 7;36(1):73–79. English. 10.20960/nh.1880 [DOI] [PubMed] [Google Scholar]
  • 21.Bravo-José P, Moreno E, Espert M, Romeu M, Martínez P, Navarro C. Prevalence of sarcopenia and associated factors in institutionalised older adult patients. Clin Nutr ESPEN. 2018. Oct;27:113–119. 10.1016/j.clnesp.2018.05.008 [DOI] [PubMed] [Google Scholar]
  • 22.Cereda E, Pedrolli C, Zagami A, Vanotti A, Piffer S, Opizzi A, et al. Body mass index and mortality in institutionalized elderly. J Am Med Dir Assoc. 2011. Mar;12(3):174–8. 10.1016/j.jamda.2010.11.013 [DOI] [PubMed] [Google Scholar]
  • 23.Alvero-Cruz JR, Fernández Vázquez R, García Vega MDM, García Lavigne JA, Rodríguez Linares MV, Martínez Blanco J. Sensitivity and specificity of abdominal adiposity with metabolic syndrome in the elderly. Rev Esp Geriatr Gerontol. 2017;52(3):128–134. 10.1016/j.regg.2016.11.001 [DOI] [PubMed] [Google Scholar]
  • 24.Ghachem A, Paquin J, Brochu M, Dionne IJ. Should Waist Circumference Cutoffs in the Context of Cardiometabolic Risk Factor Assessment be Specific to Sex, Age, and BMI? Metab Syndr Relat Disord. 2018. Sep;16(7):366–374. 10.1089/met.2017.0177 [DOI] [PubMed] [Google Scholar]
  • 25.Huang KC, Lee MS, Lee SD, Chang YH, Lin YC, Tu SH, et al. Obesity in the elderly and its relationship with cardiovascular risk factors in Taiwan. Obes Res. 2005. Jan;13(1):170–8. 10.1038/oby.2005.22 [DOI] [PubMed] [Google Scholar]
  • 26.Hsieh SD, Yoshinaga H, Muto T. Waist-to-height ratio, a simple and practical index for assessing central fat distribution and metabolic risk in Japanese men and women. Int J Obes Relat Metab Disord. 2003. May;27(5):610–6. 10.1038/sj.ijo.0802259 [DOI] [PubMed] [Google Scholar]
  • 27.Cho GJ, Hwang SY, Lee KM, Choi KM, Hyun Baik S, et al. Association Between Waist Circumference and Dementia in Older Persons: A Nationwide Population-Based Study. Obesity (Silver Spring). 2019. Nov;27(11):1883–1891. 10.1002/oby.22609 [DOI] [PubMed] [Google Scholar]
  • 28.Ofir O, Buch A, Rouach V, Goldsmith R, Stern N, Monsonego-Ornan E. Association between abdominal obesity and fragility fractures among elderly Israeli women. Aging Clin Exp Res. 2020. Aug;32(8):1459–1467. 10.1007/s40520-019-01347-8 [DOI] [PubMed] [Google Scholar]
  • 29.Hwang AC, Lee WJ, Peng LN, Liu LK, Lin MH, Loh CH, et al. Unfavorable body composition and quality of life among community-dwelling middle-aged and older adults: What really matters? Maturitas. 2020. Oct;140:34–40. 10.1016/j.maturitas.2020.05.024 [DOI] [PubMed] [Google Scholar]
  • 30.Rodríguez-Guerrero E, Romero-Saldaña M, Fernández-Carbonell A, Molina-Luque R, Molina-Recio G. New Simplified Diagnostic Decision Trees for the Detention of Metabolic Syndrome in the Elderly. Int J Environ Res Public Health. 2020. Jul 18;17(14):5191. 10.3390/ijerph17145191 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Zarzeczny R, Nawrat-Szołtysik A, Polak A, Manasar A, Maliszewski J, Kiełtyka A, et al. The relationship between selected body fatness indices and the level of blood interleukin-6 in female nursing home residents aged 80+ years without inflammation: A pilot study. Exp Gerontol. 2018. Jul 15;108:240–246. 10.1016/j.exger.2018.04.016 [DOI] [PubMed] [Google Scholar]
  • 32.Dutra MT, Gadelha AB, Nóbrega OT, Lima RM. Body Adiposity Index, but not Visceral Adiposity Index, Correlates with Inflammatory Markers in Sarcopenic Obese Elderly Women. Exp Aging Res. 2017; 43: 291–304. 10.1080/0361073X.2017.1298959 [DOI] [PubMed] [Google Scholar]
  • 33.Sergi G, Perissinotto E, Pisent C, Buja A, Maggi S, Coin A, et al. An adequate threshold for body mass index to detect underweight condition in elderly persons: The Italian Longitudinal Study on Aging (ILSA). J Gerontol A Biol Sci Med Sci. 2005; 60: 866–871. 10.1093/gerona/60.7.866 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Simone Perna

9 Dec 2020

PONE-D-20-36065

Proposed cut-off points for anthropometric and bioelectrical measures based on overweight and obesity criteria in Spanish institutionalised elderly people.

PLOS ONE

Dear Dr. Ordonez,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Simone Perna, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments:

Dear Author

the following article is well written and worth it for the publication. Only minor comments should be addressed in according to the reviewers suggestions.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper is written in a good English, sections are quite complete in terms of information and discussion and data appear interesting, even if the argument is not particularly novel.

There are some aspects that should be addressed to improve the general quality of the article:

- ROC and AUC abbrevation should be explained also in abstract section

- Girth should be named "circumference" as latest research is generally using this term instead of girth, especially if WC (waist circumference) abbreviation is used.

- Introduction section is too long and should be reduced as the aspects discussed are quite well known and should not described in detail.

- Methods: Issues regarding the measure of waist circumference and height should be largely discussed, also in discussion section: waist circumference is a heavily operator dependent parameter and hard to measure especially in obese subjects due to skinfolds and fat rolls; height in elderly is hard to measure (hunched back) and is commonly approximated.

- BMI: Another sentence should be added discussing BMI classification also in methods section, these references may be useful:

Kvamme, J.M.; Holmen, J.; Wilsgaard, T.; Florholmen, J.; Midthjell, K.; Jacobsen, B.K. Body mass index and mortality in elderly men and women: The Tromsø and HUNT studies. J. Epidemiol. Community Health 2012, 66, 611–617.

Sergi, G.; Perissinotto, E.; Pisent, C.; Buja, A.; Maggi, S.; Coin, A.; Grigoletto, F.; Enzi, G. An adequate threshold for body mass index to detect underweight condition in elderly persons: The Italian Longitudinal Study on Aging (ILSA). Journals Gerontol. - Ser. A Biol. Sci. Med. Sci. 2005, 60, 866–871.

Janssen, I.; Mark, A.E. Elevated body mass index and mortality risk in the elderly. Obes. Rev. 2007, 8, 41–59.

- Line 99, too much data, should be put in results section

- Bioimpedance: Is the instrument validated for measuring trunk fat and visceral fat ratio in particular? add a reference.

- descriptive characteristics show that the mean age in men is 71.5 +- 7.3 y, please check if subjects are all older than 65 years old.

Reviewer #2: The study presented is well conducted with potential clinical impact. The analysis and conclusions are convincing and publication is recommended after a few minor issues are addressed.

In the abstract you need to mention what ROC and AUC stand for. Overall, all acronyms in the manuscript should be defined including BMI (L. 91), WHO (L. 141), CT and DEXA (L. 223).

The sentence starting from L. 63 to L. 81 in the introduction is too long. Please consider rephrasing.

The sentence in L. 81 is incomplete. Please add the word "persons" or "individuals" at the end.

Delete the word "of" in the sentence (L. 89)

The word "size" in L. 117 is incorrectly used in the definition of BMI and should be replaced with "height."

Delete "of" in L. 122.

Significance levels should be mentioned at the foot of all tables.

In the discussion, L.282, the following sentence should be changed: “several limitations to the study should be also recognized” to several limitations to the study should also be recognized.

Reviewer #3: This study is well-conducted and of great interest.

My additional comments:

- The age of subjects reported in the abstract is 74.3 and 71.5, while along the text and in the table it is 84.3 and 81.5. Which are the correct ones?

- The bioelectrical impedance used for the measures of trunk and visceral fat is validated and it is comparable to Dxa measure for visceral vat (core scan software)? You should include the validation study in the methods section.

- The exclusion of patients with waist girth greater than 130 cm could be referred as a limitation.

- I suggest to cite one of these 2 interested studies:

Perna et al. Comparison between Bioimpedance Analysis and Dual-Energy X-ray Absorptiometry in assessment of body composition in a cohort of elderly patients aged 65-90 years. Adv Gerontol

. 2019;32(6):1023-1033.

Spadaccini et al. DXA-Derived Visceral Adipose Tissue (VAT) in Elderly: Percentiles of Reference for Gender and Association with Metabolic Outcomes. Life (Basel). 2020 Aug 24;10(9):163.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2021 Mar 8;16(3):e0248028. doi: 10.1371/journal.pone.0248028.r002

Author response to Decision Letter 0

15 Feb 2021

Reviewer #1:

The paper is written in a good English, sections are quite complete in terms of information and discussion and data appear interesting, even if the argument is not particularly novel.

There are some aspects that should be addressed to improve the general quality of the article:

Q. ROC and AUC abbrevation should be explained also in abstract section

A. Thanks for this suggestion. We have detailed both items.

Q. Girth should be named "circumference" as latest research is generally using this term instead of girth, especially if WC (waist circumference) abbreviation is used.

A. Thanks. We do agree. It was changed throughout the text.

Q: Introduction section is too long and should be reduced as the aspects discussed are quite well known and should not described in detail.

A. We do agree. Accordingly, we have shortened it

Q. Methods: Issues regarding the measure of waist circumference and height should be largely discussed, also in discussion section: waist circumference is a heavily operator dependent parameter and hard to measure especially in obese subjects due to skinfolds and fat rolls; height in elderly is hard to measure (hunched back) and is commonly approximated.

A. We do understand your concern about this issue. In fact, all anthropometric measures (including both height and WC) were obtained in accordance with the guidelines of the International Society for Advancement in Kinanthropometry and carried out by the same researcher accredited with level 3 and with a technical error of measurement of less than 1% for all measures. Additionally, a sentence addressing this issue has also been included in the discussion section.

Q. BMI: Another sentence should be added discussing BMI classification also in methods section, these references may be useful:

Kvamme, J.M.; Holmen, J.; Wilsgaard, T.; Florholmen, J.; Midthjell, K.; Jacobsen, B.K. Body mass index and mortality in elderly men and women: The Tromsø and HUNT studies. J. Epidemiol. Community Health 2012, 66, 611–617.

Sergi, G.; Perissinotto, E.; Pisent, C.; Buja, A.; Maggi, S.; Coin, A.; Grigoletto, F.; Enzi, G. An adequate threshold for body mass index to detect underweight condition in elderly persons: The Italian Longitudinal Study on Aging (ILSA). Journals Gerontol. - Ser. A Biol. Sci. Med. Sci. 2005, 60, 866–871.

Janssen, I.; Mark, A.E. Elevated body mass index and mortality risk in the elderly. Obes. Rev. 2007, 8, 41–59.

A. We apologize but we have not fully understood this suggestion. To the best of our knowledge, the classification based on the National Institutes for Health (NIH)/WHO guidelines is still widely used both on research and in clinical practice.

Q. Line 99, too much data, should be put in results section

A. We do agree. Mainly if we take into account these data are available in Table 1. Accordingly, we have shortened it.

Q. Bioimpedance: Is the instrument validated for measuring trunk fat and visceral fat ratio in particular? add a reference.

A. We do agree it was necessary to include a validation study that could support it (Manios et al. 2013)

Q. descriptive characteristics show that the mean age in men is 71.5 +- 7.3 y, please check if subjects are all older than 65 years old.

A. Thanks for this suggestion. The correct ones are the listed in materials and tables. Accordingly, the abstract has been corrected. We apologize for this mistake.

Reviewer #2:

The study presented is well conducted with potential clinical impact. The analysis and conclusions are convincing and publication is recommended after a few minor issues are addressed.

Q. In the abstract you need to mention what ROC and AUC stand for. Overall, all acronyms in the manuscript should be defined including BMI (L. 91), WHO (L. 141), CT and DEXA (L. 223).

A. Thanks for this suggestions. We have corrected all items.

Q. The sentence starting from L. 63 to L. 81 in the introduction is too long. Please consider rephrasing.

A. We have changed it and shortened it

Q. The sentence in L. 81 is incomplete. Please add the word "persons" or "individuals" at the end.

A. This sentence was removed in order to shorten the section.

Q. Delete the word "of" in the sentence (L. 89)

A. Thanks. It was deleted.

Q. The word "size" in L. 117 is incorrectly used in the definition of BMI and should be replaced with "height."

A. Thanks. It was replaced.

Q. Delete "of" in L. 122.

A. Thanks. It was deleted.

Q. Significance levels should be mentioned at the foot of all tables.

A. It has been included at the foot of all tables.

Q. In the discussion, L.282, the following sentence should be changed: “several limitations to the study should be also recognized” to several limitations to the study should also be recognized.

A. Thanks. It was changed.

Reviewer #3:

This study is well-conducted and of great interest. My additional comments:

Q. The age of subjects reported in the abstract is 74.3 and 71.5, while along the text and in the table it is 84.3 and 81.5. Which are the correct ones?

A. Thanks for this suggestion. The correct ones are the listed in materials and tables. Accordingly, the abstract has been corrected. We apologize for this mistake.

Q. The bioelectrical impedance used for the measures of trunk and visceral fat is validated and it is comparable to Dxa measure for visceral vat (core scan software)? You should include the validation study in the methods section.

A. We do agree it was necessary to include a validation study that could support it (Manios et al. 2013)

Q. The exclusion of patients with waist girth greater than 130 cm could be referred as a limitation.

A. Thanks for that suggestion. We have reported it as a new limitation of the current study.

Q. I suggest to cite one of these 2 interested studies:

Perna et al. Comparison between Bioimpedance Analysis and Dual-Energy X-ray Absorptiometry in assessment of body composition in a cohort of elderly patients aged 65-90 years. Adv Gerontol. 2019;32(6):1023-1033.

Spadaccini et al. DXA-Derived Visceral Adipose Tissue (VAT) in Elderly: Percentiles of Reference for Gender and Association with Metabolic Outcomes. Life (Basel). 2020 Aug 24;10(9):163.

A. Thank for your recommendation. We do agree both references could be of great interest for our potential readers.

Attachment

Submitted filename: Response To Reviewers.docx

Click here for additional data file. (17.6KB, docx)

Decision Letter 1

Simone Perna

18 Feb 2021

Proposed cut-off points for anthropometric and bioelectrical measures based on overweight and obesity criteria in Spanish institutionalised elderly people.

PONE-D-20-36065R1

Dear Prof. Ordonez,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Prof Simone Perna, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Author

greetings,

After your careful revision, this article is valuable to be accepted on Plos One.

Thanks a lot for your cooperation

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: The authors have replied to all my comments raised during the revision of the manuscript. I have no further comments.

Reviewer #3: The authors have met all the requirements.

The article is suitable for publication without any additional corrections.

**********

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Reviewer #1: No

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Reviewer #3: No

Acceptance letter

Simone Perna

26 Feb 2021

PONE-D-20-36065R1

Proposed cut-off points for anthropometric and bioelectrical measures based on overweight and obesity criteria in Spanish institutionalised elderly people.  

Dear Dr. Ordonez:

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on behalf of

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