Influence of weight status on physical and mental health in Moroccan perimenopausal women

Introduction There is a lack of information about fitness and other health indicators in women from countries such as Morocco. This study aims to explore the association of weight status with physical and mental health in Moroccan perimenopausal women. Methods 151 women (45-65 years) from the North of Morocco were analyzed by standardized field-based fitness tests to assess cardiorespiratory fitness, muscular strength, flexibility, agility and balance. Quality of life was assessed by means of the Short-Form-36 Health Survey. Resting heart rate, blood pressure and plasma fasting glucose, total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were also measured. Results Blood pressure (P=0.001), plasma triglycerides (P=0.041) and the prevalence of metabolic syndrome (P<0.001) increased as weight status increased. Levels of cardiorespiratory fitness, upper-body flexibility (both, P<0.001), static balance (P<0.05) and dynamic balance (P<0.01) decreased as weight status increased. Pairwise comparisons showed differences mainly between normal-weight and overweight vs. obese groups. No differences between groups were observed on quality of life. Conclusion Cardiovascular and lipid profile and fitness, important indicators of cardiovascular disease risk, worsened as weight status increased, whereas quality of life appears to be independent of weight status. Exercise and nutritional programs focus on weight management may be advisable in this under studied population.


Introduction
A high BMI and a low physical fitness, particularly cardiorespiratory fitness, are powerful predictors of all-cause mortality, especially from cardiovascular disease (CVD) [1][2][3]. Moreover, loss of fitness has been shown to promote higher all-cause and CVD mortality risks regardless of BMI change [4,5]. Regarding the association between BMI and quality of life (QoL) the findings are less clear, and studies on relationships between BMI and different measurements of mental ill-health and QoL have reported contradictory results [6][7][8][9][10][11][12].
Menopause is frequently associated with weight gain and a shift in body-fat accumulation from the hips and the thighs to the trunk.
This android obesity can contribute to a reduction in insulin sensitivity and development of dyslipidemia, insulin resistance, and type 2 diabetes [13]. These are important risk factors for CVD, which represent the major causes of death among postmenopausal women [13]. The prevalence of overweight, obesity and metabolic syndrome (MS) among Moroccan perimenopausal women is extremely high [14,15]. Indeed, overweight and obesity have increased considerably in the last decades among this population, especially in women, and obesity has become one of the main public health problems in the country [14,16].
Consequently, CVD is currently the first cause of mortality among women in Morocco, as well as in Africa [17,18]. There still being a lack of information about fitness and other health indicators in adult women from developing countries such as Morocco, especially among midlife women. Because of cultural and religion features, it could be that women in Arabic countries such as Morocco have less possibility to get involved in exercise, and its unknown to what extent this could result in higher fatness, lower fitness and therefore higher risk for developing MS and CVD. Our group has published two studies analyzing fitness in Moroccan women [15,19]. The first one [15] described fitness and compared Moroccan with Spanish women with the same age. This was the first study performed in this topic in African women. The second study [19] was based on the relationship between cardiorespiratory fitness and the MS in this population, and the potential usefulness of fitness testing to establish MS in this specific population.However, we have not explored the influence of weight status on this population health until date. Therefore, the aim of the present study was to analyze the influence of weight status on cardiovascular and lipid profile, physical fitness and QoLin Moroccan perimenopausal women. informed about the study aims and procedures and signed a written informed consent to participate. All the measurements were performed by women, in a single day and by the same trained researchers to reduce inter-examiners error. The study was reviewed and approved by the Ethics Committee of the "Hospital Virgen de las Nieves" (Granada, Spain).

Anthropometry and body composition
A portable eight-polar tactile-electrode impedanciometer (In Body R20; Biospace, Gateshead, UK) was used to measure weight (kg), body fat (%) and skeletal muscle mass (kg). Height (cm) was

Cardiovascular profile
Systolic and diastolic blood pressure and resting heart rate were measured after 5 minutes of rest, two times, 2 minutes apart, with the person sitting down (M6 upper arm blood pressure monitor Omron. Omron Health Care Europe B.V. Hoolderdorp, The Netherlands). The average value of two trials was selected for the analysis.

Metabolic syndrome
The criteria recommended by the American Heart Association/National Heart, Lung, and Blood Institute [21] was used to establish MS. Presence of MS was considered when women met 3 or more criteria: waist circumference ≥88 cm, triglycerides ≥150 mg/dL, HDL-cholesterol <50 mg/dL, systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85mmHg, and fasting glucose ≥100 mg/dL.

Physical fitness
Due to the age range of the present sample, the "Functional Senior Fitness Test" battery was used because it is relatively easy to administer and requires minimal equipment, space and it is safe [22]. Additionally, we included handgrip strength and 30-s blind flamingo tests, because they are commonly used among this age group [23].This battery assesses aerobic fitness, muscle strength, flexibility, and motor agility.
Aerobic fitness. The "6-min walk test" was used to assess aerobic fitness. This test measures the maximum distance (in meters) that can be walked in 6 min along a 45.7 m rectangular course [24]. Japan) as previously described [25]. The women performed the test twice (alternately with both hands), with 1 minute rest between measures. The best value for each hand was chosen and the average score of both hands was used for further analyses.
Flexibility. In the "chair sit-and-reach" test, the women started in a sitting position with one leg extended, and slowly bended forward sliding the hands down the extended leg in an attempt to touch (or pass) the toes. The number of centimeters short of reaching the toe (minus score) or reaching beyond it (plus score) was recorded. The test was performed twice for every each leg, and the average of the best value from each of them was employed in the analyses. The "back scratch test" provides a measure of the overall shoulder range of motion, and involves measuring the distance between (or overlap of) the middle fingers behind the back with a ruler. They performed the test twice, alternately with both hands, and the best value was registered. The average of both hands was used in further analyses.
Static balance. In the "blind flamingo" test [26], the number of trials needed to complete 30 seconds of the static position is recorded, and the chronometer is stopped whenever the person does not comply with the protocol conditions. One trial was accomplished for each leg and the average of both values was selected for the analysis.
Motor agility/dynamic balance. The "8-feet up-and-go" test involves standing up from a chair, walking 8 feet to and around a cone, and returning to the chair in the shortest period of time [24]. The best time from two trials was recorded and used in the analyses.

Quality of life The Arabic version of the Short-Form-36 Health
Survey (SF36) was applied to assess QoL [27]. This questionnaire is composed of 36 items, grouped into eight scales assessing eight dimensions: physical functioning, physical role, bodily pain, vitality, social functioning, emotional role, mental health and general health.
Each subscale score is standardized and ranges from 0±100, where 0 indicates the worst possible health status and 100 the best possible. In the analysis of reliability as stability of such questionnaire, correlation coefficients between the test and retest  [28].

Statistical analysis
The association between weight status and the study outcomes was examined by one-way analysis of covariance (ANCOVA) after adjusting for age. The model was adjusted for age due to the fact that age is strongly positively associated to worse physical fitness and lower QoL [29]. The overall P value is that reported for the

Results
Anthropometric and body composition characteristics of the study participants are shown in Table 1 ischemic stroke [32] and its presence was clearly increased as weight status increased. Raised triglycerides are a component of the MS and are also strongly associated with future risk of type II diabetes as well as CVD [31]. In the present study sample, plasma triglycerides clearly increased across weight status categories.
Obese women scored worse than normal-weight or overweight women in most of the functional capacity tests. Cardiorespiratory fitness is not only an objective measure of regular physical activity, but also a useful diagnostic and prognostic health indicator for patients in clinical settings [19]. Although compelling evidence has shown that cardiorespiratory fitness is a strong and independent predictor of all-cause and CVD mortality, the importance of cardiorespiratory fitness is often overlooked from a clinical perspective compared with other risk factors such as obesity [2].
Several prospective studies indicate that cardiorespiratory fitness is at least as important as the traditional risk factors, and is often more strongly associated with mortality [2]. Moreover, cardiorespiratory fitness appears to attenuate the increased risk of death associated with obesity [2].
The "6-minutes walking test" is a good marker of cardiorespiratory fitness and has been suggested as a powerful predictor of survival in some diseases [33]. The distance covered by our Moroccan women decreased as weight status increased. A recent study investigated the independent associations and the possible interaction of BMI and perceived physical fitness and functional capability with the risk of mortality in a Finnish sample. Although BMI did not prove to be an independent risk factor for mortality from CVD, perceived physical fitness and functional capability did it [3]. Moreover, active-obese people often have similar or lower risk of CVD and mortality than inactive-healthy weight people [5]. Due to the fact that maintaining or improving fitness is associated with a lower risk of all-cause and CVD mortality, preventing age-associated fitness loss could be important for longevity regardless of BMI change [4,5]. Therefore, the present findings may suggest that recommendations regarding prevention of CVD in this population should be based on the interrelationships between physical fitness and obesity [34]. Indeed, our group has recently published, in the same sample, than those women who scored less than 480 meters in the 6-min walk test had almost 3 times higher risk for having MS [19]. To note is that the mean distance covered by the obese group was equal to 495 meters and this distance was ~40 meters less than those walked by the normal-weight and overweight groups.
Muscular strength is a predictor of functional capacity, morbidity and mortality [35,36], however we have not confirmed a relationship between higher weight status and lower upper-body or lower-body muscular strength. Flexibility is also important in adult people and is related with lower back pain, scoliosis and is an important outcome to maintaining and restoring mobility [37].
Overweight and obese women displayed lower upper-body flexibility, which could adversely impact the functionality of these women and their daily tasks. Finally, coordinative parameters may influence daily life functioning [38].Obesity appears to be associated with greater risk of falling in premenopausal, as well as a higher risk of greater disability in activities of daily living after a fall [39].
Overweight and obese Moroccan women displayed poor scores in static balance as well as in dynamic balance and motor agility (as assessed by the 8-feet up-and-go test). Moreover, the8-feet up-andgo test has shown to be reliable and able to differentiate patients with chronic stroke from their healthy peers [40].
Postmenopausal women are at a higher risk of hypertension, proatherogenic lipid changes, diabetes, and severe CVD as compared with their premenopausal counterparts [41]. Smoking, central obesity, blood pressure, and physical functioning are risk factors for mortality in this stage [2][3][4]42]. Based on the above showed evidence, health professionals should encourage Moroccan women to participate in moderate-intensity physical activity to reduce the risk of CVD [43,44], especially among overweight and obese women, who scored worse in most of the physical fitness outcomes studied. Based on the results of the present study, we cannot confirm a decline on QoL across weight status categories.
Results found in the literature regarding weight status and mental health are inconclusive. By one hand, a raised BMI could be associated to a diversity of mental ill-health conditions such as low self-esteem, poor self-image, depression and health-adverse behaviors; however, this association appears to be higher in individuals with a BMI above 40 [8,45]. On the other hand, in the population study by Atlantis and Baker [6], in which anxiety and depressive symptoms were the indicators of mental ill-health, the authors showed no association between BMI and mental ill-health.
Huang et al. [46] investigated a large population (n=14,221) and found that BMI was associated to physical ill-health but not to mental ill-health. The lack of agreement between studies can be due to methodological issues, like the use of different questionnaires or the factors considered when the association between obesity and QoL were analyze. In a systematic review, Bacon and Aphramor [47] noticed that epidemiological studies considering the connection between BMI and mental ill-health, rarely acknowledge factors like fitness, age, gender, physical activity, nutrients intake, weight or Page number not for citation purposes 6 socioeconomic status. When studies do control for these factors, increased risk of mental ill-health disappears or is significantly reduced [48,49]. Other explanation can be that the factors affecting QoL can be different in obese people. Lund et al. [48] observed that unemployment among the morbidly obese affected their QoL more than the weight did, and Loff and Crammond [49] found that the association between BMI and mental ill-health disappeared after control for individual's overall health status. In the general population, relative increases in cardiorespiratory fitness and habitual physical activity have been associated with lower depressive symptomatology and greater emotional well-being [50].
A combined diet and exercise intervention has positive effects on QOL and psychological health, which may be greater than that from exercise or diet alone [51].

Strengths and limitations
Some limitations need to be mentioned.