Strength and Muscle Quality in a Well-Functioning Cohort of
Older Adults: The Health, Aging and Body Composition Study
Anne B. Newman, MD, MPH,* Catherine L. Haggerty, PhD,* Bret Goodpaster, PhD,*
Tamara Harris, MD, Steve Kritchevsky, PhD, Michael Nevitt, PhD, Toni P. Miles, MD, PhD,
and Marjolein Visser, PhD, for the Health, Aging, and Body Composition Research Group
OBJECTIVES: To determine whether lower lean mass
and higher fat mass have independent effects on the loss of
strength and muscle quality in older adults and might ex-
plain part of the effect of age.
DESIGN: Single-episode, cross-sectional analyses of a co-
hort of subjects in the Health, Aging and Body Composi-
tion (Health ABC) Study.
SETTING: Ambulatory clinic and research laboratory.
PARTICIPANTS: Two thousand six hundred twenty-
three men and women aged 70 to 79 from the Health ABC
Study.
MEASUREMENTS: Upper and lower extremity strength
was measured using isokinetic (knee extension) and iso-
metric (grip strength) dynamometers. Body composition
(lean mass and fat mass) was determined by measuring
lean mass of upper and lower extremities and the total
body by dual-energy x-ray absorptiometry. Muscle quality
was ascertained by taking the ratio of strength to muscle
mass for both upper and lower extremities.
RESULTS: Upper and lower extremity strength and mus-
cle quality decreased as age increased. Most of the ex-
plained variance in strength was due to differences in mus-
cle mass, but, in those at the extremes of body fat and
lower leg muscle quality, the association with body fat
was independent of the effect of age. Although blacks had
greater muscle strength and mass than whites, leg muscle
quality tended to be lower in blacks than in whites. Upper
extremity strength adjusted for lean mass and muscle qual-
ity were also associated inversely and independently with
age, body fat, and black race.
From the *Department of Medicine, University of Pittsburgh, Pittsburgh,
Pennsylvania; Epidemiology, Demography and Biometry Program, Na-
tional Institute on Aging, Bethesda, Maryland; Department of Preventive
Medicine, University of Tennessee, Memphis, Tennessee; Preventive Sciences
Group, University of California at San Francisco, San Francisco, California;
Department of Family Practice, University of Texas, San Antonio, Texas; and
Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam,
the Netherlands.
Supported by National Institute on Aging Contracts N01-AG-62101,
N01-AG-62103, and N01-AG-62106.
Address correspondence to Anne B. Newman, MD, MPH, 3520 5th
Avenue, Suite 300, University of Pittsburgh School of Medicine, Division of
Geriatric Medicine, Pittsburgh, PA 15213. E-mail: anewman@pitt.edu
JAGS 51:323330, 2003
2003 by the American Geriatrics Society
CONCLUSION: In this older cohort, lower strength
with older age was predominantly due to a lower muscle
mass. Age and body fat also had significant inverse associ-
ations with strength and muscle quality. Both preservation
of lean mass and prevention of gain in fat may be impor-
tant in maintaining strength and muscle quality in old age.
J Am Geriatr Soc 51:323330, 2003.
Key words: strength; muscle quality; sarcopenia; aging
T he loss in muscle mass with age, referred to as sar-
copenia, is a major contributor to decreased strength
in older adults. Strength is closely related to muscle size, so
loss of muscle mass will result in loss of strength. Muscle
size in turn is related to overall body size, so taller or more
obese individuals tend to be stronger than shorter or thin-
ner individuals on the basis of size alone. Before the ad-
vent of newer methods of body composition assessment,
muscle size was difficult to determine precisely in popula-
tion studies. With the use of computed tomography (CT)
scanning and dual-energy x-ray absorptiometry (DEXA)
muscle area, mass, and other aspects of body composition
can now be measured directly in large cohort studies.
Some studies show that the loss of strength is some-
what greater than loss of muscle mass with aging,18 im-
plying that the quality of the muscle remaining may be re-
duced. Accompanying the loss of lean mass with age is an
increase in fat mass, so the percentage of body fat is higher
in older adults, even if weight is not.9 With increasing obe-
sity, the proportion of body composition that is fat increases
more than the proportion that is lean. As with older indi-
viduals, obese individuals have also been shown to be
weaker than would be expected for their size.10 Although
there are few physiological data available to support a spe-
cific mechanism for these observations, it seems plausible
that higher body fat in older adults might account for part
of the effect of age on muscle quality.11
The Health, Aging and Body Composition (Health
ABC) Study was designed to characterize body composition
and strength in a large population of well-functioning men
0002-8614/03/$15.00
324 NEWMAN ET AL.
and women to evaluate factors that might be associated
with loss of strength and muscle mass and incident func-
tional limitation. This cross-sectional analysis describes
strength, muscle mass, and muscle quality in relationship
to age, race, and body composition. The authors hypothe-
sized that strength and muscle quality would be reduced
with age and that lower muscle mass and higher body fat
might independently influence this relationship.
METHODS
Population
The Health ABC Study cohort includes 3,075 men (48.4%)
and women (51.6%) aged 70 to 79, of whom 41.6% are
African American. Whites were recruited from a random
sample of Medicare beneficiaries in ZIP codes in Pitts-
burgh, Pennsylvania, and Memphis, Tennessee, and blacks
were recruited from all age-eligible people in these areas.
Sampled participants received a mailing followed by a tele-
phone eligibility screen. Eligibility criteria included age 70
to 79 during the recruitment period (March 1997 to July
1998), self-report of no difficulty walking one-quarter of a
mile or climbing 10 steps, no difficulty with basic activities
of daily living, no history of active treatment for cancer in
the prior 3 years, and no plan to move out of the area in
the next 3 years. Those eligible were recruited for a 4- to
5-hour comprehensive examination. All participants gave
informed consent, and the institutional review boards at
each field center approved the consent forms and protocol.
For the present analysis, only those with complete data for
isokinetic torque and body composition were included (n 
2,623); exclusions are discussed below.
Strength Assessments
Strength was measured in the lower and upper extremities,
using an isokinetic dynamometer (Kin-Com dynamometer,
125 AP, Chattanooga, TN) for knee extension and an iso-
metric dynamometer (Jaymar, JLW Instruments, Chicago,
IL) for grip strength. For knee extension, the right leg was
used unless contraindicated by pain or history of joint re-
placement. Participants with uncontrolled hypertension,
stroke, bilateral knee replacement, or severe bilateral knee
pain were excluded from the test, resulting in exclusion of
401 (13%) of the cohort. Those who were excluded were
of similar sex (48.9% men vs 51.1% women, P  .22) and
race (50% blacks vs 50% whites, P  .45), and were
slightly older (mean age 74.0 vs 73.6 years, P  .003) but
of similar body composition to those who were tested.
Maximal voluntary concentric isokinetic torque was
assessed in Newton-meters (N-m) at 60/s angular veloc-
ity. Start and stop angles were set at 90 and 30. At least
three, but no more than six, maximal efforts were allowed
to produce three overlying curves, and the mean maximal
torque production was recorded. An interexaminer reliabil-
ity study in 60 participants showed no significant differences
between examiners and a within-participant coefficient of
variation of about 11%. There was also a significant site
difference, so models were adjusted for study site.
Isometric grip strength was assessed for each hand.
Participants with severe hand pain or recent surgery were
excluded. The vast majority (96%) who had leg strength
MARCH 2003VOL. 51, NO. 3 JAGS
testing also had grip strength testing. For these analyses,
the maximum of the force from two trials was used for the
right upper extremity.
Body Composition
Lean mass of the upper and lower extremities and the total
body was assessed using DEXA (Hologic QDR 4500, soft-
ware version 8.21, Bedford, MA). The legs were defined
using a line bisecting the femoral neck and the arms by a
line through the head of the humerus and the scapula.
Bone mineral content was subtracted from the total and
regional lean mass to define total nonbone lean mass,
which represents primarily skeletal muscle in the extremi-
ties.12 Fat mass was estimated for the whole body as well.
Both the percentage of fat and total fat were examined in
these analyses. Body weight and height were measured in a
hospital gown with no shoes using a calibrated balance
beam scale and stadiometer, respectively. Body mass index
(BMI) in kg/m2 was also examined as a measure of body
composition. Finally, analyses for the lower extremity
were repeated using CT scan cross-sectional muscle area. 13
Muscle Quality
Similar to other reports in the literature, a measure of mus-
cle quality was created by taking the ratio of strength to
muscle mass for the upper and lower extremities. For the
lower extremity, the term specific torque is used for the
ratio of isokinetic torque in N-m at the knee to leg lean
mass in kg by DEXA. For the upper extremity, strength
was measured in kg of force, thus the term specific force is
used to describe the ratio of grip strength to arm lean mass.
Other Covariates
Physical activity, the total number of chronic conditions,
smoking, and site were all included in the final models as
possible confounders of the effects of age or race on strength
and muscle quality. Physical activity was assessed by self-
report as total kcal/wk expended on walking and exercise.14
Smoking history was assessed by questionnaire and classi-
fied as current, past, or never smokers. Comorbidity was as-
sessed as the total number of 11 chronic health conditions,
using self-report with confirmation by treatment and medi-
cations. These included cancer, myocardial infarction, con-
gestive heart failure, depression, diabetes mellitus, hyperten-
sion, knee osteoarthritis, osteoporosis, peripheral arterial
disease, pulmonary disease, and stomach/duodenal ulcer.
Statistical Analysis
Distributions were examined separately in men and women
and by race. The specific torque and force ratios were nor-
mally distributed. The relationships between (1) muscle
strength, lean mass, and specific torque and (2) age and fat
mass were examined separately in men and women by
race, using analysis of variance, and by inspection of scat-
terplots and moving average plots. Analyses are presented
by sex, because there was little overlap in body composi-
tion between men and women. Interactions with race
within sex were examined; none were found. Multiple lin-
ear regression was used to examine the relationship be-
tween strength and lean mass, adjusting for age, race, and
JAGS MARCH 2003VOL. 51, NO. 3 STRENGTH AND MUSCLE QUALITY 325

Table 1. Characteristics of Participants: The Health, Aging and Body Composition Study

White Men Black Men All Men White Women Black Women All Women Total
n  827 n  459 n  1,286 n  743 n  594 n  1,337 N  2,623

Characteristic Mean  Standard Deviation

Age 73.9  2.9 73.4  2.8 73.7  2.9* 73.5  2.8 73.3  2.9 73.4  2.8* 73.6  2.9
Height, m 1.7  0.06 1.7  0.07 1.7  0.07* 1.6  0.06 1.6  0.06 1.6  0.06* 1.7  0.09
Weight, kg 81.2  12.3 81.6  14.4 81.4  13.1* 66.3  12.3 75.5  15.4 70.4  14.5* 75.8  14.9
Body mass 27.0  3.7 27.2  4.3 27.0  3.9* 26.0  4.6 29.6  5.7 27.6  5.4* 27.3  4.7
index, kg/m2
Total % fat 26.1  4.9 24.0  5.6 25.3  5.2* 36.8  5.8 37.9  6.2 37.3  6.0* 31.4  8.2
Total fat, kg 21.7  6.7 20.3  7.3 21.2  7.0* 25.1  7.8 29.5  9.8 27.1  9.0* 24.2  8.6
Leg torque, Nm 130.55  30.67 135.04  36.99 132.15  33.12* 78.60  19.57 85.91  23.23 81.85  21.57* 106.51  37.52
Leg lean 9.01  1.24 9.67  1.55 9.24  1.40* 6.21  1.01 7.34  1.30 6.72  1.28* 7.95  1.84
mass, kg
Specific torque, 14.51  2.88 14.04  3.41 14.35  3.09* 12.73  2.74 11.90  3.14 12.36  2.95* 13.33  3.18
Nm/kg
*Gender difference at P  .01.
Racial difference at P  .05.

measures of adiposity in sex-specific models. Several mea- RESULTS

sures of fatness were evaluated, including total weight,
BMI, total fat mass, and percentage body fat. The relation-
ship between (1) muscle quality and (2) age and measures
of adiposity were also examined in sex-specific models.
Based on visual inspection of the bivariate analyses using
moving average plots, a quadratic term for adiposity was
added to the models. Finally, models were adjusted for po-
tential confounders, including physical activity, smoking,
and comorbidity. Site was also included in the final models.
The 2,623 study participants had a mean age of 73.6,
ranging from 70 to 79 (Table 1). Black and white men
were similar in weight and height, whereas black women
were significantly heavier than white women. These differ-
ences were also noted in the BMI and total and percentage
body fat. Men were stronger than women, and, within sex
groups, blacks were stronger than whites. Leg lean mass
was also higher in men than women and, within sex, in
blacks than in whites. Specific torque in the lower extrem-

Table 2. Leg Strength, Leg Lean Mass, and Muscle Quality by Age

Age

7071 7172 7374 7576 7778 79

Group Mean  Standard Deviation P-value

White men n  118 n  189 n  181 n  151 n  122 n  66

Leg torque, Nm 143.08  32.23 139.64  31.92 128.16  28.94 124.58  28.78 122.26  28.05 117.67  22.8 .0001
Leg lean mass, kg 9.28  1.15 9.30  1.27 8.93  1.31 8.91  1.23 8.69  1.13 8.66  1.09 .0001
Specific torque, 15.45  3.00 15.07  3.08 14.35  2.67 13.97  2.70 14.07  2.82 13.77  2.60 .0001
Nm/kg
Black men n  83 n  120 n  93 n  80 n  63 n  20
Leg torque, Nm 139.76  35.41 138.93  39.01 134.98  37.68 131.19  36.38 130.84  33.97 120.93  37.09 .2013
Leg lean mass, kg 9.92  1.62 9.80  1.61 9.53  37.68 9.70  1.49 9.43  1.56 9.19  0.63 .2141
Specific torque, 14.31  3.61 14.22  3.42 14.24  3.51 13.59  3.35 13.94  2.98 13.04  3.55 .5140
Nm/kg
White women n  121 n  180 n  178 n  130 n  94 n  38
Leg torque, Nm 84.19  19.99 81.57  19.57 80.32  19.73 74.87  19.30 71.06  16.91 69.96  14.28 .0001
Leg lean mass, kg 6.48  1.12 6.21  0.91 6.31  1.06 6.07  0.94 6.00  0.90 5.98  0.94 .0021
Specific torque, 13.15  2.76 13.22  2.81 12.78  2.57 12.40  2.76 11.91  2.66 11.95  2.68 .0006
Nm/kg
Black women n  116 n  169 n  110 n  85 n  84 n  30
Leg torque, Nm 94.13  21.93 87.40  23.55 85.56  24.64 82.96  21.85 79.83  21.97 72.37  16.15 .0001
Leg lean mass, kg 7.61  1.39 7.52  1.39 7.22  1.21 7.16  1.15 7.20  1.22 6.54  0.88 .0004
Specific torque, 12.59  2.99 11.82  3.22 12.03  3.51 11.70  2.87 11.30  3.01 11.35  2.39 .0695
Nm/kg
326 NEWMAN ET AL. MARCH 2003VOL. 51, NO. 3 JAGS

ity was also higher in men than women. In contrast to

0.03  0.004*
1.31  0.19*

1.04  0.50*
9.23  0.64*
1.22  0.27*
0.30  1.19
greater strength and lean mass in black men and women,

Model 4

0.2840
unadjusted leg muscle quality (specific torque) was lower
than in their white counterparts.
Even in this rather narrow age range, those who were
older had significantly lower strength and lean mass (Ta-
ble 2). The associations with age were somewhat stronger
for leg strength than for leg lean mass, resulting in a signif-

0.03  0.004*
1.33  0.19*

9.20  0.64*
1.25  0.26*
icant inverse relationship between lower extremity specific

0.80  1.17
Model 3

0.2403
torque and age. Leg lean mass was lower by about 0.1 kg

per year of age, or about 9% to 10% lower across the de-
cade of age in both men and women. Leg strength was
Women

lower by 2.5 N-m per year of age in men and 1.8 N-m per
year in women, across the decade of age.
The coefficient (standard error) for age in relation-
1.29  0.19*

6.58  0.47*

ship to strength was 2.52 (0.31), P  .05 for men and

0.27  1.19
Model 2

1.75 (0.20), P  .05 for women, adjusted for race. With

0.1986

added adjustment for leg lean mass, these coefficients were

substantially attenuated to 1.63 (0.28), P  .05 and
1.29 (0.19), P  .05 (Tables 3 and 4). Although the dif-
ferences associated with age were small, they translated to a
10% lower leg muscle quality in men and an 11% lower leg
1.75  0.20*
6.93  1.14*

muscle quality in women across the decade of age 70 to 79.

Table 3. Leg Strength (Nm): Associations with Age, Race, and Body Composition, Linear Regression Models

Model 1

0.0812

In a series of sex-specific regression models, body fat

  Standard Error

was added to models, first with leg strength as the dependent

variable and then with leg muscle quality as the dependent
variable (Tables 3 and 4). Although leg lean mass accounted
for a large proportion of the explained variance in lower ex-
tremity strength, body fat was also significantly associated
1.62  0.28*
4.05  1.83*

0.05  0.01*
1.48  0.71*
12.89  0.70*
1.53  0.50*

with leg strength. Based on an inverted U-shaped relation-

Model 4

0.3225

ship seen in moving average plots comparing muscle quality

with various measures of body fatness, a quadratic term for
fat mass was added to these models and found to be signifi-
cantly associated with strength adjusted for age, race and
muscle mass. These moving average plots (Figure 1A and
1.63  0.28*
4.98  1.77*

0.05  0.01*

1B) suggested that muscle quality in the lower extremities in

13.07  0.69*
1.46  0.50*
Model 3*

men was optimal at a percentage of body fat of approxi-

0.2881

mately 16% to 22% in men and 26% to 34% in women.

Nevertheless, body fat, although significantly associated

with leg strength and muscle quality, did not explain much
of the total variance in strength or muscle quality in men or
Men

women as seen in the small partial coefficient of determina-

1.63  0.28*
3.65  1.72*
11.35  0.60*

tion (R2). Age remained associated with lower extremity

Model 2

strength and muscle quality after adjustment for lean mass

0.2615

Adjusted also for physical activity, smoking status, and study site.

and body fat. Black men and women (borderline P-values)

still tended to have lower muscle quality in these models,
even after adjustment for differences in body composition.
These findings were essentially unchanged with further ad-
justment for smoking, physical activity, and comorbidity.
2.52  0.31*
3.37  1.89

There were also reduced upper extremity strength and

Model 1

0.0520

lean mass with older age, but these were more similar in

magnitude, thus the specific force in the upper extremity

was less strongly associated with age in men or women
R2  Coefficient of determination.

than was lower extremity specific torque (Table 5). Mus-

cle quality for the arm was slightly higher for women than
men and for whites than for blacks within sex groups. As
Leg lean mass, kg

with lower extremity strength, arm lean mass accounted

for the largest proportion of the variance in arm strength
Variable

Total fat2, kg
Comorbidity
Total fat, kg

(Tables 6 and 7). Age and higher body fat were inversely
associated with arm strength, although the effect of age
*P  .05.
Black

was borderline in men in the final model. No quadratic re-

Age

R2

lationship between body fat and arm strength was noted

JAGS MARCH 2003VOL. 51, NO. 3 STRENGTH AND MUSCLE QUALITY 327

Table 4. Leg Muscle Quality (Nm/kg): Associations with Age, Race and Body Composition, Linear Regression Models

Men Women

Model 1 Model 2 Model 3 Model 1 Model 2 Model 3

Variable   Standard Error

Age 0.16  0.03* 0.17  0.03* 0.17  0.03* 0.15  0.03* 0.19  0.03* 0.12  0.03*
Black 0.59  0.18* 0.52  0.18* 0.84  0.16* 0.41  0.16* 0.33  0.16*
0.55  0.18*
Total fat, kg 0.12  0.05* 0.13  0.05* 0.09  0.04* 0.09  0.04*
Total fat2 0.004  0.001* 0.004  0.001* 0.003  0.001* 0.003  0.0006*
Comorbidity 0.16  0.08* 0.17  0.07*
R2 0.0273 0.0663 0.0731 0.0386 0.1187 0.1243
R2  Coefficient of determination.
* P  .05.

Adjusted for physical activity, smoking status, and study site.

in the models, although the moving average plots sug-
gested that those at the extremes of fat had lower arm
muscle quality. In women, the association between upper
extremity strength and race was diminished after adjust-
ment for comorbidity. Similarly, arm muscle quality was
inversely associated with age, fatness, race, and comorbid-
ity (Table 6 and 7).
All models were reexamined with different measures
of adiposity substituted for percentage of body fat. Re-
gardless of the measure of adiposity (total weight, total fat
mass, BMI) there was an inverse quadratic association be-
tween fatness and leg strength after adjustment for leg lean
mass and leg muscle quality. These associations were the
same when thigh muscle area ascertained by CT scan was
substituted for lean mass (data not shown.)
DISCUSSION
This is the largest study to examine upper and lower ex-
tremity strength and muscle quality in well-functioning
community-dwelling older adults, including a large num-
ber of women and blacks. Previous work showing that
strength and muscle quality are lower at older ages were
confirmed and extended. The data also suggest that high
and low body fatness make an independent contribution
to the age-related decline in strength and muscle quality.
However, lower leg lean mass and higher body fat did not
fully explain the association between age and lower leg
strength. Comorbidity partly explained decreased arm
strength and muscle quality with age. Together, these fac-
tors explained only a small part of the variance in muscle
strength, compared with the large effect of muscle mass.
Using different methods to measure muscle size or
lean mass, lower muscle mass in older adults has previ-
ously been well documented.1518 These data confirm that
this lower muscle mass is a major factor for a lower
strength in old age. This suggests that efforts to preserve
lean mass itself should have a significant effect on preserv-
ing strength in old age. Given the restricted age range of
this cohort and that all participants were free of physical
limitation at baseline, relationships between age and
strength or muscle quality were not expected. Age-related
decrements in the quality of muscle have been described in
several other studies.48,19 Factors that account for this may
include a decreased proportion of type II fibers, increased
connective tissue, fatty infiltration, and altered muscle me-
tabolism.20,21 Intervention studies have demonstrated that
strength can be improved fairly dramatically, even if in-
creases in mass are small, suggesting that some aspect of
muscle quality can be modified.22,23 Modifiable risk factors
for the loss of muscle quality need to be identified and may
differ from those that are associated with the loss of mus-
cle mass.
The smaller effect of age on strength and muscle qual-
ity in the upper extremities in men and women is largely

Table 5. Arm Strength, Muscle Mass, and Muscle Quality in Men and Women

Women Men

White Black Total White Black Total

(n  743) (n  594) (n  1,337) (n  827) (n  459) (n  1,286)

Variable Mean  Standard Deviation

Grip strength, kg 23.26  5.32 26.02  6.95 24.48  6.25* 38.76  8.05 41.69  10.14 39.80  8.95*
Arm lean mass, kg 2.00  0.33 2.45  0.44 2.20  0.44* 3.51  0.53 3.91  0.66 3.66  0.61*
Specific force, kg force/kg mass 11.76  2.57 10.80  2.86 11.34  2.74* 11.10  2.15 10.76  2.54 10.98  2.30*
* Gender difference at P  .001.
Racial difference at P  .05.
328 NEWMAN ET AL. MARCH 2003VOL. 51, NO. 3 JAGS

0.20  0.05*

0.05  0.02*
0.48  0.15*
0.72  0.36*
5.87  0.46*
Model 4

0.2687
0.19  0.06*

0.06  0.02*
6.13  0.47*
0.27  0.37
Model 3

0.1815

Women

0.18  0.06*

5.44  0.42*
0.30  0.37
Model 2

0.1753


0.28  0.06*
2.70  0.34*
Table 6. Arm Strength (kg): Associations with Age, Race, and Body Composition (Linear Regression Models)

Model 1

0.0641



  Standard Error

0.27  0.08*

0.20  0.04*
0.62  0.20*
0.19  0.51
7.05  0.43
Model 4

0.2963
0.32  0.08*

0.23  0.04*
7.52  0.43*
0.51  0.50
Model 3

0.2464

Men

0.33  0.08*

6.28  0.40*
0.31  0.49
Model 2

0.2188

Adjusted for physical activity, smoking status, and study site.

Figure 1. Moving average plots: relationship of body fat to leg

muscle quality in men and women. A Moving average of spe-
cific torque (torque/leg lean mass) by total percentage fat, men.
B Moving average of specific torque (torque/leg lean mass) by
0.58  0.09*
2.66  0.51*

total percentage fat, women.

Model 1

0.0595

R2  Coefficient of determination.

consistent with differences between upper and lower ex-

tremities noted in the Baltimore Longitudinal Study on
Aging (BLSA), in spite of differing methods of assessing
body composition.24 Women in that study also had a
Arm lean mass

greater negative association between age and leg muscle

Comorbidity
Variable

quality than between age and arm muscle quality. This

Black race

* P  0.05.
Total fat

study did not directly compare men and women, because

womens body composition is different from that of men,
Age

R2

with little overlap in percentage of body fat. A major dif-

JAGS MARCH 2003VOL. 51, NO. 3
Table 7. Muscle Quality (kg/kg): Associations with Age, Race, and Body Composition
Men
Model 1 Model 2
Variable
Age (year) 0.04  0.02 0.06  0.02*
Black race 0.36  0.14* 0.49  0.13*
Total fat 0.09  0.01*
Comorbidity
Site
R2 0.0077 0.0842
* P  .05.
Adjusted also for physical activity, smoking status, and study site.
R2  Coefficient of determination.
ference between this study and the BLSA is the truncated
age range presented here. In both studies, the different
methods of assessing strength in upper and lower extremi-
ties may have influenced the results.
Strength and muscle mass in older blacks has not been
previously described. One study found that older blacks
had a lower muscle mass adjusted for age, sex, and weight,
based on DEXA and total body potassium, but strength
was not measured in that study.25 Adjustment for body fat
and comorbidity, in addition to lean mass, attenuated but
did not eliminate the relationship between lower leg
strength and black race in the men in this study. It is pos-
sible that better measures of comorbidity or subclinical
disease might explain this association with race. Although
more precise than anthropometry, DEXA may still not
fully capture important differences in body composition in
men and women and those in different ethnic groups. It
has been proposed that DEXA more accurately captures
known ethnic differences in body composition than an-
thropometric measures,26 suggesting that the differences
observed here are less likely to be due to ethnic biases in
methodology than to other factors associated with race. It
is hoped that these more-specific measures of body com-
position might allow better identification of risk factors
for loss of strength beyond the loss due to lower lean mass
per se.27
The quadratic relationship between body fat and
strength is a unique finding that warrants further investi-
gation. Those at the high and low extremes of percentage
of body fat had lower levels of leg muscle quality than
those in the midrange. This effect was small, but of similar
magnitude to that of age itself in its effect on muscle qual-
ity, in that the negative effect of a kg fat was similar to
that of a year of age. Body fat has been shown to have an
adverse effect on physical function.2,28 These data suggest
that lower muscle quality in obese individuals may par-
tially mediate this association. The optimal level of muscle
quality occurred at a much higher percentage of body fat
in women than in men. It may be that fat has positive and
negative effects on preserving lean mass but decreasing
muscle quality.29 There may be a sex-specific range of
body fat that is optimal for functioning. Lean mass mea-
sured with DEXA does not exclude all intermuscular fat
STRENGTH AND MUSCLE QUALITY 329
Women
Model 3 Model 1 Model 2 Model 3
  Standard Error
0.04  0.02 0.05  0.03 0.08  0.03* 0.08  0.03*
0.48  0.13* 0.96  0.15* 0.65  0.15* 0.51  0.15*
0.09  0.01* 0.07  0.01* 0.07  0.01*
0.17  0.06* 0.23  0.07*
0.57  0.12* 1.13  0.14*
0.1084 0.0323 0.0844 0.1366
from the lean mass estimate, nor does it distinguish con-
nective tissue from muscle tissue. This would not explain
these results, because those with both high and low fat had
lower muscle quality. In a related manuscript, the authors
reported that a lower muscle density assessed by a lower
x-ray attenuation on CT scan attenuation accounts for
part of the variation in strength and muscle quality, inde-
pendent of subcutaneous and intermuscular fat.13 More
basic physiological work is needed to determine whether
these findings reflect altered muscle metabolism, neuronal
recruitment, or biomechanics.
Several design features of this study must be consid-
ered when interpreting these results. This cohort was se-
lected to examine risk factors for future disability, exclud-
ing about 20% of older adults who have prevalent
impairment, reducing generalization to that group. Exclu-
sions from strength testing for knee pain and other disease
further limit generalizability. However, the range of body
composition and the prevalence of other disease character-
istics of this cohort have been well described and likely re-
flect the range of function of older adults being seen for
ambulatory medical care. Additionally, although both
blacks and whites selected were nondisabled, and adjust-
ments were made for potential confounders, there may
have been a differential rate in participation by race, and
these biases cannot be excluded as an explanation for
these findings. Finally, because strength was measured us-
ing a voluntary contraction, there may be motivational
and biomechanical factors that are related to age, sex,
race, or degree of body fat that could explain these find-
ings and that need to be explored further in studies of
muscle physiology.
In summary, lower lean mass and strength were ob-
served across the eighth decade of age in the upper and
lower extremities. Preservation of lean mass would be
likely to have the greatest effect on the maintenance of
strength in old age, but high or low body fat also has an
adverse association with strength and muscle quality in
old age. Preservation of lean mass and prevention of gain
in fat may both be important in preserving strength and
muscle quality in old age. Future studies of the risk factors
for loss of strength in old age must first carefully account
for the effects of body composition.
330 NEWMAN ET AL.
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