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PubMed2005

[Utility of cycle ergometer stress testing as a measure to assess health status and physical functioning for elderly people].

PURPOSE: This study was carried out to determine the prevalence of abnormal cardiovascular findings for elderly persons on exercise stress testing, and examine the relationship between exercise capacity estimated by the test and other physical functions or self-rated functional capacity cross-sectionally. METHODS: Participants of this study were 83 elderly persons (24 males and 59 females, mean age, 80 years old) who were planning to undergo a falls prevention program. A questionnaire asking about functional capacity, physical functional testing (maximum stride length, maximum speed walking for 10 meters, one leg standing time, and grip strength), and cycle ergometer exercise stress testing were applied. The initial work load of exercise testing was 15 watts, and this was progressively increased by 15 watts every 3 minutes. Exercise capacity was estimated with reference to working time and subjects were divided into tertiles for each gender. Comparisons of physical functional testing and self-rated functional capacity among the groups were then performed. RESULTS: Of 83 participants, 65 subjects (78.3%) could complete the exercise stress testing. Next to leg fatigue (46%), blood pressure elevation (26.2%) was the most common reason for termination of the test. No evidence of ischemia was found in any subject during exercise stress testing. The values for walking speed and walking pitch were highest among male participants in the third (uppermost) tertile group with statistical significance. In addition, the value for one foot standing time was highest among female participants in the third tertile group, again with statistical significance. Regarding self-rated functional capacity, the rates for subjects who reported being able to rise from a seat in a vehicle, jump over a puddle, and step on an escalator were highest among female participants in the third tertile group, with statistical significance, whereas no significant differences were seen among male participants. No one suffered falls in the previous one year in either gender in the third tertile group. CONCLUSION: As the major finding, higher exercise capacity mainly for lower-extremity work, was associated with better physical functions and self-rated functional capacity.

Accidental Falls↗

PubMed2002

Effects of resistance training on physical function in older disabled women with coronary heart disease.

We studied whether disabled older women with coronary heart disease can perform resistance training at an intensity sufficient to improve measured and self-reported physical function [n = 30, 70.6 +/- 4.5 (SD) yr]. Compared with the controls, the resistance-training group showed significant improvements in overall measured physical function score using the Continuous-Scale Physical Functional Performance Test (+24 vs. +3%). The Continuous-Scale Physical Functional Performance Test measures physical function for 15 practical activities, such as carrying groceries or climbing stairs. Resistance training led to improved measures for domains of upper body strength (+18 vs. +6%), lower body strength (+23 vs. +6%), endurance (+26 vs. +1%), balance and coordination (+29 vs. -2%), and 6-min walk (+15 vs. +7%). Women involved in the flexibility-control group showed essentially no improvement for physical function measures. No changes were observed for body composition, aerobic capacity, or self-reported physical function in either group. In conclusion, disabled older women with coronary heart disease who participate in strength training are able to train at an intensity sufficient to result in improvements in multiple domains of measured physical functional performance, despite no change in lean body mass.

Aged↗

PubMed2006

[Short and long-term changes in physical functions in the elderly in relation to comprehensive geriatric training].

AIM: The purpose of the present study was to investigate the changes of physical functions of subjects who participated in a progressive resistance and balance training program named Comprehensive Geriatric Training (CGT) before and after training, and following lyear. METHODS: Sixty-three community-dwelling elderly participated in CGT. Subject's physical functions (muscle strength, balance, walking speed) were measured. Moreover, we interviewed the subjects about their maintenance of exercise after training. RESULTS: Fifty-five subjects completed CGT, and physical functions were measured in 32 subjects. There were significant differences in all physical functions. In the post-hoc test, there were significant differences between before and after one year (one leg standing with open eyes, flexibility, functional reach, maximum walking speed, timed up and go). Of the 32 subjects, 21 kept training 1 or more days per week after training (TR), but 11 were desisted from training (DT). Between the 2 groups, the main effect at Group, Time, Group x Time interaction were significant with Functional Reach. It was significantly improved after 1 year compared with before training in TR. No physical functions in after 1 year were significantly lower than before training. CONCLUSION: The subjects improved, maintained the physical functions through CGT. Moreover, the physical functions after 1 year did not decrease significantly compared to before CGT. It is possible that this program controlled the decrease in physical functions at one year. This program provided an opportunity to begin and continue exercise training, because more than half of the subjects who did not previously exercise regularly continued resistance training.

Activities of Daily Living↗

PubMed1991

Predictors of physical functioning after a cardiac event.

An increased understanding of the factors that promote or hinder patients' return to optimal activity levels after a cardiac event is necessary to help them achieve this goal. Accordingly, the purpose of this study was to examine psychologic resources, depression, physical recovery, and illness severity for their relationships with subjective and objective physical functioning (exercise data). A correlational survey design was used to assess patients' (n = 46) illness responses 9 weeks after the cardiac event. Patients also participated in a symptom-limited exercise test. The findings suggested that the individual's return to greater activity levels after a cardiac illness was associated with less depression and illness severity, and higher levels of objective physical functioning, physical recovery, and self-esteem. Further, patients' objective physical functioning was associated not only with greater subjective physical functioning but also with greater levels of physical recovery and mastery.

Activities of Daily Living↗

PubMed2000

Quality of life in ALS depends on factors other than strength and physical function.

OBJECTIVES: To study patients with ALS to determine the following: 1) the relationship between physical function and quality of life (QOL); 2) the instruments that best reflect patients' own ratings of QOL; and 3) whether spiritual/religious factors play a role in determining QOL. METHODS: The authors prospectively studied 96 patients with ALS using several instruments, including the McGill Quality of Life (MQOL) instrument, the Idler Index of Religiosity, the Sickness Impact Profile (SIP)/ALS-19, and several measures of strength and physical function. RESULTS: QOL as assessed by patients (MQOL single item score) did not correlate with measures of physical function and strength, but correlated with the total MQOL score (p < 0.0005), the psychological and existential subscores of MQOL (p < 0. 0005), the support subscore of MQOL (p = 0.001), and the total Idler score (p = 0.001). In contrast, correlations between SIP/ALS-19 and these measures were not significant, although SIP/ALS-19 correlated with measures of physical function and strength. CONCLUSIONS: QOL, as assessed by the patient with ALS, does not correlate with measures of strength and physical function, but appears to depend on psychological and existential factors, and thus may be measured well by the MQOL scale. Spiritual factors and support systems appear to play roles as well. SIP/ALS-19 is a good measure of physical function, but not of overall QOL.

Activities of Daily Living↗

PubMed2001

Tai Chi, self-efficacy, and physical function in the elderly.

Using Tai Chi as an exercise mode, this study examined the association between self-efficacy and physical function. Ninety-four healthy, physically inactive older adults (M age = 72.8 years, SD = 5.1) were randomly assigned to either a 6-month, twice a week, Tai Chi condition or a wait-list control condition. Outcome variables included self-reports of movement efficacy and physical function assessed at baseline, middle, and termination of the study. Multisample latent curve analyses revealed a significant rate of change attributable to the Tai Chi intervention in both self-efficacy and physical function, with participants experiencing significant improvements over the course of the intervention. Analyses also showed a positive association between self-efficacy and physical function, indicating that improvements in older adults' self-efficacy of movement as a function of Tai Chi were related to increased levels of perceived physical capability. This study uncovered the need for further exploration of the relationship between exercise self-efficacy and physical function for enhancing health-related quality of life in older adults.

Activities of Daily Living↗

PubMedDate not supplied

Physical function, employment and quality of life in end-stage renal disease.

INTRODUCTION: The impact of end-stage renal disease (ESRD) on quality of life (QoL) can be measured in terms of physical, psychological and social consequences, including the ability to work. SUBJECTS AND METHODS: This multi-center, cross-sectional study explored relationships between QoL, employment status and physical function in ESRD patients aged 18-65 years, via a customised interviewer-administered questionnaire, which included the SF-36 health survey. The International Labour Office method was applied to describe employment rate. RESULTS: 144 patients (85 male, 49 female), comprising 49 haemodialysis (HD), 35 peritoneal dialysis (PD) and 60 renal transplant (TX) patients were studied. Mean age was 44 +/- 12 years. 32 were voluntarily not working, leaving 112 in the labour force. Of the latter, 49% were unemployed, in contrast with the concurrent national rate of 10%. QoL in the ESRD group was reduced in the SF-36 physical and social dimensions compared to population norms. Unemployed ESRD patients scored significantly lower than those employed in physical function, role physical, bodily pain, general health, vitality and role emotional scales. Logistic regression demonstrated that multiple comorbidities (p<0.005), a premorbid physical occupation (p<0.05) and poor physical function (p<0.05) predicted unemployment in ESRD independent of all other variables. Multiple regression showed that age (p<0.05), female sex (p<0.05) and a diagnosis of musculoskeletal disease (p<0.005) were independent predictors of poor physical function. CONCLUSIONS: These findings suggest that vocational rehabilitation of ESRD patients must consider physical function and occupational demands as well as co-morbidity and that musculoskeletal disease is key factor in impaired physical function.

Adolescent↗

PubMed1998

Behavioural and biological correlates of physical functioning in middle aged office workers: the UK whitehall II study.

STUDY OBJECTIVES: (1) To identify behavioural and biological correlates of poor physical functioning and (2) to determine whether such associations are independent of disease. DESIGN: Potential correlates were obtained from questionnaires and screening visits at baseline and five year follow up. Physical functioning was measured at follow up using the 10 item scale from the short-form 36 health survey. SETTING: London offices at baseline. PARTICIPANTS: 10,308 civil servants (6895 men and 3413 women), with a median age (range) of 49 years (39-63) at follow up. MAIN RESULTS: Multiple logistic regression showed that cigarette smoking, physical activity, body mass index (BMI), triglycerides, fibrinogen, and insulin were independently associated with poor physical functioning for men. For women, physical activity, eating habits, body mass index, fibrinogen, and insulin were independently associated with poor physical functioning. For example, among men, current smokers who had smoked more than 20 pack years were 1.89 (95% CI 1.35 to 2.67) times as likely to have poor physical functioning as never smokers. Men with BMI of 30 kg/m2 or more were 1.71 (95% CI 1.13 to 2.59) times as likely to have poor physical functioning as those with BMI < 20 kg/m2. The corresponding odds ratio for women was 2.66 (95% CI 1.80 to 3.93). With the exceptions of fibrinogen and insulin, associations remained on exclusion of subjects with physical disease. CONCLUSIONS: Risk factors established for physical diseases are associated with poor physical functioning in a population of working age. These associations may be independent of current disease.

Adult↗

PubMed1999

Exercise: effects on physical functional performance in independent older adults.

BACKGROUND: Age-related loss in physiologic capacities contributes to the decline in physical function in the elderly population. Despite the beneficial effects of exercise interventions on maximal physiologic capacity measures, the functional benefits have not been shown in independently living older adults. The objective of this study was to evaluate exercise in independent older adults for significant and meaningful improvements in physical function, not detected by commonly used measures of physical function. METHODS: In a randomized controlled study, 49 independently living men and women were assigned to either a nonexercise control group (Control; n = 26) or an exercise training group (Exercise; n = 23). Participants (age = 76+/-4) in good general health were recruited from retirement communities or apartments. The combined endurance and strength training was performed at 75% to 80% intensity; the groups met 3 times/week for 6 months of supervised sessions. Outcome measures included physical capacity, health status, and physical function using a newly developed performance test--the Continuous Scale-Physical Functional Performance test (CS-PFP). RESULTS: Compared to the Control group, the Exercise group showed significant increases in maximal oxygen consumption (11%) and muscle strength (33%). No significant differences were found between groups for changes in the Sickness Impact Profile, SF-36 scales, or the 6-minute walk. However, the CS-PFP score improved significantly in the Exercise group (14%, effect size 0.80). CONCLUSIONS: Independent older adults gain meaningful functional benefits from several months of exercise training. The public health importance of physical activity may relate not just to its role in preventing decline, but also to its role in enhancing physical function.

Activities of Daily Living↗

PubMed2003

Social inequalities in depressive symptoms and physical functioning in the Whitehall II study: exploring a common cause explanation.

STUDY OBJECTIVE: This study investigated which risk factors might explain social inequalities in both depressive symptoms and physical functioning and whether a common set of risk factors might account for the association between depressive symptoms and physical functioning. DESIGN: A longitudinal prospective occupational cohort study of female and male civil servants relating risk factors at baseline (phase 1: 1985-8) to employment grade gradients in depressive symptoms and physical functioning at follow up (phase 5: 1997-9). Analyses include the 7270 men and women who participated at phase 5. SETTING: Whitehall II Study: 20 London based white collar civil service departments. PARTICIPANTS: Male and female civil servants, 35-55 years at baseline. MAIN RESULTS: Depressive symptoms were measured by a subscale of items from the 30 item General Health Questionnaire. Physical functioning was measured by a subscale of the SF-36. Employment grade was used as a measure of socioeconomic position as it reflects both income and status. The grade gradient in depressive symptoms was entirely explained by risk factors including work characteristics, material disadvantage, social supports, and health behaviours. These risk factors only partially explained the gradient in physical functioning. The correlation between depressive symptoms and physical functioning was reduced by adjustment for risk factors and baseline health status but not much of the association was explained by adjustment for risk factors. Among women, the association between depression and physical functioning was significantly stronger in the lower grades both before and after adjustment for risk factors and baseline health. For women, there was only a significant grade gradient in depressive symptoms among those reporting physical ill health. CONCLUSIONS: Some risk factors contribute jointly to the explanation of social inequalities in mental and physical health although their relative importance differs. Work is most important for inequalities in depressive symptoms in men, and work and material disadvantage are equally important in explaining inequalities in depressive symptoms in women while health behaviours are more important for explaining inequalities in physical functioning. These risk factors did not account for the association between mental health and physical health or the greater comorbidity seen in women of lower socioeconomic status. The risk of secondary psychological distress among those with physical ill health is greater in the low employment grades.

Adult↗

PubMed2004

Comorbidity of somatic chronic diseases and decline in physical functioning:; the Longitudinal Aging Study Amsterdam.

OBJECTIVE: To assess the association of decline in physical functioning with number of chronic diseases and with specific comorbidity in different index diseases. METHODS: A longitudinal design was employed using data from 2,497 older adults participating in the Longitudinal Aging Study Amsterdam. Logistic regression analyses were used to determine influence of chronic diseases on change in physical functioning, operationalized using the Edwards-Nunnally index. RESULTS: Decline in physical functioning was associated with number of chronic diseases (adjusted ORs from 1.58 for 1, to 4.05 for > or =3 diseases). Comorbidity of chronic nonspecific lung disease and malignancies had the strongest exacerbating influence on decline. An exacerbating effect was also found for arthritis in subjects with diabetes or malignancies and for stroke in subjects with chronic nonspecific lung disease or malignancies. A weaker effect than expected was observed for diabetes in subjects with stroke, malignancies, cardiac disease, or peripheral atherosclerosis. CONCLUSION: Comorbidities involving chronic diseases that share etiologic factors or pathophysiologic mechanisms appear to have a weaker negative influence on decline in physical functioning than expected. Results indicate that combinations of diseases that both influence physical functioning, but through different mechanisms (locomotor symptoms vs. decreased endurance capacity) may be more detrimental than other combinations.

Aged↗

PubMedDate not supplied

Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment.

BACKGROUND AND OBJECTIVES: Using an instrument to measure physical functioning that was normed to the U.S. population, data were obtained from patients with a new diagnosis of breast, colon, lung, and prostate cancer. Two questions were addressed: (a) after controlling for age, and number of comorbid conditions, do site and stage of cancer predict functional limitations prior to diagnosis; (b) using age adjusted national norms on physical functioning, how well do age, number of comorbid conditions, stage, treatment and cluster of symptoms (pain, fatigue, and insomnia) explain changes in physical function between 3 months prior to and 8 weeks following diagnosis? METHODS: Patients 65 years of age and older were accrued from 24 community oncology settings. Consenting patients were interviewed within 8 weeks of initial treatment. The SF-36 was used to measure physical functioning. Comorbidity and symptom experience were assessed through patient report and site and stage of cancer from record audits. RESULTS: Prior to diagnosis of cancer, patients were comparable in physical functioning to the U.S. population aged 55-64, a full decade younger than the sample of cancer patients. Site and stage of disease did not account for variations in physical functioning prior to diagnosis. Compared against national norms, patients with more extensive treatments (surgery plus adjuvant therapy) reported greater loss in functioning. Pain, fatigue, and insomnia had a consistent and significant effect on losses in functioning unrelated to patients' treatments or their comorbid conditions. CONCLUSIONS: Site and stage of cancer prior to diagnosis do not affect functioning. Older cancer patients report higher functioning than their counterparts in the U.S. population. Changes in functioning following diagnosis varied by cancer site. Treatments were related to loss in functioning, but comorbidity was not. Pain, fatigue, and insomnia were significant and independent predictors of change in patient functioning. This underscores the importance of interventions to manage symptoms early in the course of treatment for individuals.

Activities of Daily Living↗

PubMed1999

Predictors of physical functioning among geriatric patients with small cell or non-small cell lung cancer 3 months after diagnosis.

This study investigated how treatment options, symptom severity, prediagnosis levels of physical functioning, comorbidity, gender, and age predicted current physical functioning in geriatric patients with small-cell or non-small-cell lung cancer, 12 weeks after their diagnosis. The study involved 146 patients aged 65 years and over with an incident diagnosis of lung cancer. Analysis of covariance revealed no significant differences in physical functioning according to treatment type, small-cell versus non-small-cell classification or gender. Significant predictors of current physical functioning were symptom severity and prior physical functioning. The characteristics of a high-risk profile for disruption in physical functioning of elderly lung cancer patients 12 weeks after their diagnosis would include preexisting physical impairment and high levels of symptomatology.

Aged↗

PubMed2002

Short-term change in physical function and disability: the Women's Health and Aging Study.

OBJECTIVES: Although measures of physical function are predictive of future disability, little is known about the short-term impact of changes in physical function on disability. METHODS: Data from 93 of the 102 women who participated in the Weekly Substudy of the Women's Health and Aging Study (WHAS) were used to explore the association of changes in physical function with disability. The WHAS Substudy included 24 weekly assessments of three standard performance tests and self-reported disability in activities of daily living (ADLs) and basic mobility. RESULTS: Using random-effects models, we found small but significant (ps <.01) changes in ADL and mobility disability during weekly follow-up. Baseline performance scores were significantly associated with both ADL and mobility disability (ps <.001), accounting for 27% and 36% of the between-person variability in each type of disability, respectively. After adjustment for baseline scores, change in performance scores was significantly associated with ADL disability (beta = 0.08, p <.01) and mobility disability (beta = 0.12, p <.001), but accounted only for a small proportion (<10%) of the variability in the rate of change in disability outcomes. There was no evidence for an additional effect on either type of disability because of having a single episode of a higher or lower than usual performance score, or because of periods of at least 4 consecutive higher or lower than usual performance test scores. DISCUSSION: Basic physical functions account for a substantial proportion of the heterogeneity in ADL and mobility disability among older disabled women, but have a relatively small impact on short-term changes in either type of disability. Effective prevention of disability may require attention to a wider array of risk factors than just limitations in basic physical functions.

Aged↗

PubMed1998

Perceived importance and satisfaction with physical function in patients with knee osteoarthritis.

This investigation examined the determinants of satisfaction with physical function for participants in an Observational Arthritis Study in Seniors (OASIS). The sample consisted of 480 men (51%) and women (49%) over the age of 65 years who had difficulty performing activities of daily living due to knee pain. As part of baseline testing for OASIS, participants completed a measure that assessed satisfaction with function for six physical activities. After controlling for relevant covariates, scores on the satisfaction index were regressed on seven conceptually relevant predictor variables. The results revealed that satisfaction with physical function is a distinct construct from level of function, irrespective of whether the latter variable is measured objectively or subjectively. When entered into a hierarchical regression model, 6-minute walk test data accounted for 11% of the variance in satisfaction scores, whereas perceived difficulty accounted for an additional 22%. Moreover, a significant interaction term between importance and perceived difficulty revealed that patients who rated the activities as important and who had high levels of perceived difficulty had the lowest satisfaction scores. Discussion focuses on the determinants of satisfaction with physical function with emphasis on the interaction between perceived difficulty and importance.

Activities of Daily Living↗

PubMed2004

Natural history of physical function in older men with intermittent claudication.

PURPOSE: This study was undertaken to determine the natural history of physical function in older men limited by intermittent claudication. METHODS: Forty-three men limited by intermittent claudication (mean age, 69 +/- 7 years) were recruited and followed up for 18 months. At baseline the patients reported a history of intermittent claudication for 6.1 +/- 6.1 years, and were able to walk for 1.9 +/- 1.6 blocks before experiencing claudication pain. Measurements during the 18-month study included ankle-brachial index (ABI), calf blood flow, 6-minute walk performance, monitored and self-reported physical activity, self-reported stability while walking, and summary performance score of physical function determined from a 4-m walk test, a chair stand test, and a tandem stand test. RESULTS: Pain-free walking distance during the 6-minute walk test decreased by 22% (P <.05) from baseline (185 +/- 96 m) to follow-up (144 +/- 93 m), and the total 6-minute walk distance decreased by 9% (P <.05), from 368 +/- 106 m to 334 +/- 90 m. Furthermore, monitored physical activity decreased by 31% (P <.05), from 159 +/- 151 kcal/d to 110 +/- 137 kcal/d; self-reported physical activity declined by 27% (P <.05), from 1.5 +/- 1.0 units to 1.1 +/- 0.8 units; tandem stance time declined by 14% (P <.05), from 9.46 +/- 1.83 seconds to 8.12 +/- 2.10 seconds; summary performance score of physical function decreased by 12% (P <.05), from 6.8 +/- 2.4 units to 6.0 +/- 2.4 units; and the percentage of patients reporting ambulatory unsteadiness and stumbling increased from 28% to 43% (P <.05). Calf blood flow measured at rest declined by 18% (P <.05), from 3.72 +/- 1.81 (mL/100 mL(-1)/min(-1)) to 3.04 +/- 1.43 mL/100 mL(-1)/min(-1), whereas ABI did not change (P >.05). CONCLUSION: Older men limited by intermittent claudication experienced decline in ambulatory function, physical activity, physical function, stability, and calf blood flow over 18 months of follow-up, despite no change in ABI.

Aged↗

PubMed1990

Short-term variability of measures of physical function in older people.

Self reported physical function was assessed in telephone interviews approximately 3 weeks apart for a sample of 193 persons aged 69 or older. Three measures of physical function were used: a modified Activities of Daily Living scale, three items proposed by Rosow and Breslau, and five items from among those used by Nagi. Agreement between first and second interviews was very good; most subjects reported no impairment in function at either interview. Among those who reported some impairment, the degree of limitation within the specific activities reported as limited and the total number of activities with any degree of limitation agreed exactly for most and within one level for almost all subjects. There was no evidence to suggest that age or cognitive impairment affected the variability of the responses, and reported declines and improvements in function were about equally common.

Activities of Daily Living↗

PubMed1998

Current obesity, steady weight change and weight fluctuation as predictors of physical functioning in middle aged office workers: the Whitehall II Study.

OBJECTIVES: (i) To investigate the effects of current obesity, steady weight change and weight fluctuation on physical functioning and (ii) to determine whether associations are independent of coronary heart disease. DESIGN: Prospective cohort study with body mass index (BMI) measurements at four time points between the ages of 25 and 63 y. SETTING: British civil servants based in London offices at baseline. PARTICIPANTS: 6895 men and 3413 women aged 35-55 y at baseline. MAIN OUTCOME MEASURE: Physical functioning was assessed using the 10-item scale from the Short Form 36 Health Survey, with a score in the lowest quartile indicating poor physical functioning. RESULTS: After adjustment for age and confounders (employment grade, smoking, alcohol, exercise and menopausal status), current BMI was monotonically associated with poor physical functioning in women whereas a threshold effect at a BMI of 27 kg/m2 was seen in men. The odds ratio of poor physical functioning was 1.55 (95% confidence interval (CI) 1.02-2.35) amongst women and 1.04 (95% CI 0.77-1.41) amongst men with BMI 23-24.9 kg/m2 compared to those with BMI < 21 kg/m2. Women in the upper, compared to the lower, tertile of steady weight change, had an odds ratio of poor physical functioning of 1.79 (1.24-2.60) after adjustment for age, confounders, current BMI and weight fluctuation. Women in the upper, compared to the lower, tertile of weight fluctuation had an odds ratio of poor physical functioning of 1.70 (1.23-2.34) adjusting for age, confounders, current BMI and steady weight change. Adjustment for the presence of coronary heart disease did not substantially alter any of these associations. Steady weight change and weight fluctuation had no independent effects in men. CONCLUSION: Among women, current obesity, steady weight change and weight fluctuation are independently and monotonically associated with poor physical functioning. Development of overt coronary heart disease is unlikely to be the mechanism for these associations.

Adult↗