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INTRODUCTION
Chronic kidney disease (CKD) is one of the main public health issues today, as it shows a high prevalence and incidence1, as well as high morbidity and mortality2. Moreover, its is among the leading causes of death in the world with projections up to 20401. This upward trend can also be seen in the total number of people on hemodialysis in Brazil3.
The need for hemodialysis to keep the person alive can generate various symptoms, such as tiredness, lack of energy, muscle cramps and bone and joint pain4, as well as high levels of inflammatory biomarkers5. However, the concern for these people also involves other elements, such as dynapenia and abdominal obesity (AO). AO is the concentration of visceral fat, whereas dynapenia is the age-related loss of muscle strength6. There is a significant relationship between patients on hemodialysis and dynapenia6, as well as with AO7, which is associated with worse clinical outcomes8 and all-cause mortality7. Among people on hemodialysis, AO9 and dynapenia10 are more common among women.
Physical and sporting activities practiced during leisure time (AFL) by adults in the general population are, for the most part (70%), characterized by physical inactivity11. The same research shows that men are more active (43.3%) than women (20%) and practice AFL in a more collective and competitive way, while women have more difficulty staying active because public spaces provide characteristically masculine spaces (courtside).
Factors that contribute to reducing dynapenia and AO can help in the care of individuals on hemodialysis as these can cause changes in the immune system, increasing chronic inflammation, which is one of the main causes of mortality and morbidity in patients with CKD12. AO combined with dynapenia, dynapenic abdominal obesity (DAO), may be better related to the inflammatory profile than both separately12, presenting itself as a relevant risk factor in patients with CKD, as well as favoring functional incapacity in patients13. Leisure-time physical activity has been described as protective against sarcopenia14 and inflammatory markers15, as well as being associated with lower mortality16.
In addition to the extensively studied physical activity, other dimensions of leisure17,18,19 have only recently begun to be studied, with the validation of an instrument that measures people’s engagement in all different types of leisure20. Studies have shown that some elements act as are stress factors21 and negatively impact quality of life of individuals on hemodialysis2,22, such as CKD and hemodialysis treatment21. Leisure contributes to the quality of life and well-being of hemodialysis patients23,24.
DAO has been described recently, but the relationship with the various dimensions of leisure practices has not yet been investigated. Considering that these activities can provide benefits for individuals undergoing hemodialysis, the objective is to evaluate the association between leisure activities, abdominal obesity and dynapenia in individuals on hemodialysis treatment.
METHODS
This study is an epidemiological, cross-sectional and census survey involving patients undergoing hemodialysis treatment in the Metropolitan Region of Greater Vitória, located in southeastern Brazil. The sample included all individuals over the age of 18, of both sexes, who were on hemodialysis in public hospitals, philanthropic institutions and private clinics in the area studied, during the period from February to September 2019. Patients were excluded from the study if they were on contact precautions, did not live in the municipalities of the metropolitan region, had been transferred to hospitalization units, or had difficulties understanding or answering the questions due to acute or chronic medical conditions.
Variables
The information collected included abdominal obesity caracteristics, handgrip strength, leisure activities, and the age of the participants. These data were categorized as follows:
Abdominal obesity was defined by the conicity index estimated as waist circumference/0.109 x √weight/height and the cut-off points were 1.275 for men and 1.285 for women25.
To characterize dynapenia, handgrip strength was assessed using the Handgrip Strength test. A handheld hydraulic dynamometer SH 5001 – Saehan® was used. The test was conducted with the patient in sitting position. Participants were asked to squeeze the dynamometer with maximum force. This process was repeated three times, with a rest interval of 2 to 3 minutes between attempts. Then, the final result considered the average of the three attempts, which indicated the level of grip strength.
Dynapenic abdominal obesity was characterized by the coexistence of abdominal obesity together with decreased manual muscle strength.
Leisure was measured using the Leisure Practices Scale20 (LPS), which is a Likert-type scale that assesses eight leisure contents: social (going to church, hanging out with friends, going to parties, visiting family, etc.), physical and sports (going to the gym, playing ball, hiking, etc.), touristic (traveling, participating in excursions, taking short trips around the city, etc.), manual (gardening, cooking, making crafts, carpentry, etc.), artistic (going to the cinema, theater, musical concerts, participating in choral groups, etc.), contemplation and idleness (enjoying nature, sunsets, meditating, etc.), intellectual (participating in courses, reading, listening to or composing music, etc.), and virtual (browsing the internet, using social networks, playing video games), with 11 points (ranging from 0 to 10, in which 0 means that the patient never practices that leisure content and 10 that they always practice). The answers for each leisure content were categorized into “no” involvement for those who do not practice (zero answer) and tertiles referring to the level of involvement. To facilitate the analysis interpretation, terciles with the lowest, intermediate, and highest values were categorized as “low”, “moderate” and “high” leisure involvement.
The age of the individuals was categorized into adults, for people up to 59 years old, and the elderly, for people aged 60 or over.
Data collection
The research was conducted in hemodialysis units during the patient stay in the health facility. The study included 947 patients with chronic kidney disease undergoing hemodialysis treatment in all hemodialysis units in a metropolitan region in southeastern Brazil participated. The data was collected between February and September 2019.
A pilot test was also conducted with 58 residents in a municipality with more than 100,000 inhabitants, located outside the metropolitan region studied. The test-retest method was used, with an interval of 15 days between applications, to assess the reliability and reproducibility of the data collection instrument. McNemar’s tests showed that no variable held a significant tendency to disagree at the p-value <5% level, whereas the adjusted Kappa values expressed almost perfect agreement for the LPS variables with results ranging 0.89 to 0.99.
Statistical Analysis
The descriptive analysis was presented in absolute and relative frequencies. Pearson’s chi-squared test was used to assess the difference in proportions between the variables. A Binomial Logistic Regression model was applied to estimate the odds ratio for each leisure dimension with statistical significance of up to 5% in the association tests, adjusted for sex and race/color caracteristics. The significance level was set at 5% and the confidence interval at 95% (95%CI). The data was analyzed using the IBM SPSS Statistics® software version 25.
Ethics approval
The research was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Espírito Santo (UFES), under number 3.002.709 and CAAE 6852817.4.0000.5060 and met the criteria of Resolution Nº. 466/2012 of the Brazilian National Health Council. The hemodialysis patients were asked to sign an Informed Consent Form before completing the questionnaire. All methods were carried out following relevant guidelines and regulations.
RESULTS
Individuals undergoing treatment in hemodialysis units participated in this study. This sample was obtained from a total of 1351 patients, of which 215 were excluded (78 due to limited comprehension and 137 due to on contact precautions). In addition, there were 89 losses (67 due to admissions to hospital units and seven due to deaths that occurred after the interviewers had entered the unit, but before the data was collected). Eligible individuals who refused to take part were 23 (2.2%) and three did not answer the question on the independent variable of leisure and 77 did not have information collected on the dependent variable. Thus, a total of 947 individuals were included in this study.
In the bivariate analysis, abdominal obesity in adults was associated with the social (p = 0.039), physical and sports (p = 0.027), touristic (p = 0.048), manual (p < 0.001), artistic (p < 0.001), contemplation and idleness (p = 0.009) and virtual (p < 0.001) of the Leisure Practices Scale (EPL). No significant association was found among older adults (table 1).
Table 1 Data on abdominal obesity (conicity index) according to leisure contentes of adults and older adults, on hemodialysis from the metropolitan region of a capital in Southeastern Brazil, 2019
| Leisure Contents | Points on the scale | Adults | Older adults | ||||
|---|---|---|---|---|---|---|---|
| Absencen (%) | Presencen (%) | p-value* | Absence n(%) | Presence n(%) | p-value* | ||
| Social | 0.039 | 0.537 | |||||
| No | 0 | 25 (39.7) | 38 (60.3) | 12 (15.0) | 68 (85.0) | ||
| Low | 1-5 | 74 (45.7) | 88 (54.3) | 27 (21.4) | 99 (78.6) | ||
| Moderate | 6-8 | 102 (59.0) | 74 (42.0) | 25 (23.4) | 82 (76.6) | ||
| High | 9-10 | 77 (49.7) | 78 (50.3) | 15 (19.2) | 63 (80.8) | ||
| Physical and sports | 0.027 | 0.779 | |||||
| No | 0 | 153 (45.3) | 185 (54.7) | 54 (19.2) | 227 (80.8) | ||
| Low | 1-4 | 45 (61.6) | 28 (38.4) | 8 (20.0) | 32 (80.0) | ||
| Moderate | 5-7 | 38 (52.1) | 35 (47.9) | 9 (26.5) | 25 (73.5) | ||
| High | 8-10 | 42 (58.3) | 30 (31.7) | 8 (22.2) | 28 (77.8) | ||
| Touristic | 0.048 | 0.783 | |||||
| No | 0 | 113 (43.8) | 145 (56.2) | 52 (21.8) | 186 (78.2) | ||
| Low | 1-3 | 63 (57.3) | 47 (42.7) | 9 (17.0) | 44 (83.0) | ||
| Moderate | 4-5 | 45 (52.3) | 41 (47.7) | 9 (18.8) | 39 (81.2) | ||
| High | 6-10 | 57 (55.9) | 45 (44.1) | 9 (17.3) | 43 (82.7) | ||
| Manual | < 0.001 | 0.498 | |||||
| No | 0 | 58 (42.0) | 80 (58.0) | 19 (13.7) | 120 (86.3) | ||
| Low | 1-5 | 80 (55.6) | 64 (44.4) | 26 (22.8) | 88 (77.2) | ||
| Moderate | 6-8 | 66 (49.6) | 67 (50.4) | 17 (27.4) | 45 (72.6) | ||
| High | 9-10 | 74 (52.5) | 67 (47.5) | 17 (22.4) | 59 (77.6) | ||
| Artistic | < 0.001 | 0.498 | |||||
| No | 0 | 114 (40.4) | 168 (59.6) | 52 (19.2) | 219 (80.8) | ||
| Low | 1-4 | 49 (62.0) | 30 (38.0) | 11 (17.8) | 51 (82.2) | ||
| Moderate | 5-6 | 55 (58.5) | 39 (41.5) | 9 (27.3) | 24 (72.7) | ||
| High | 7-10 | 60 (59.4) | 41 (40.6) | 7 (28.0) | 18 (72.0) | ||
| Contemplation and idleness | 0.009 | 0.308 | |||||
| No | 0 | 41 (39.0) | 64 (61.0) | 10 (12.8) | 68 (87.2) | ||
| Low | 1-6 | 69 (50.4) | 68 (49.6) | 20 (20.4) | 78 (79.6) | ||
| Moderate | 7-9 | 91 (59.9) | 61 (40.1) | 25 (22.1) | 88 (77.9) | ||
| High | 10 | 77 (47.5) | 85 (52.5) | 24 (23.5) | 78 (76.5) | ||
| Intellectual | 0.406 | 0.466 | |||||
| No | 0 | 45 (42.9) | 60 (57.1) | 24 (20.9) | 91 (79.1) | ||
| Low | 1-5 | 78 (50.0) | 78 (50.0) | 17 (15.3) | 94 (84.7) | ||
| Moderate | 6-8 | 83 (52.5) | 75 (47.5) | 25 (23.6) | 81 (76.4) | ||
| High | 9-10 | 72 (52.6) | 65 (47.4) | 13 (22.0) | 46 (78.0) | ||
| Virtual | < 0.001 | 0.923 | |||||
| No | 0 | 67 (35.1) | 124 (64.9) | 57 (20.3) | 224 (79.7) | ||
| Low | 1-5 | 53 (50.0) | 53 (50.0) | 15 (21.1) | 56 (78.9) | ||
| Moderate | 6-8 | 71 (57.7) | 52 (42.3) | 4 (15.4) | 22 (84.6) | ||
| High | 9-10 | 87 (64.0) | 49 (36.0) | 3 (23.2) | 10 (76.8) | ||
ES, Espírito Santo State, Brazil. Source: elaborated by the authors.
In this study, the logistic regression showed that low involvement in manual activities increased the odds of developing AO by 1.79 times (OR = 1.79; p = 0.049), moderate involvement in virtual activities a increased the odds by 1.75 times (OR = 1.75; p = 0.036), and high involvement increased the odds by 2.76 times (OR = 2.76; p < 0.001). Moreover, moderate involvement in contemplation and idleness increased the AO odds by 2.07 times (OR = 2.07; p = 0.010) in adults (table 2).
Table 2 Binary logistic regression between absence or presence of abdominal obesity in adults according to leisure contents of individuals on hemodialysis from the metropolitan region of a capital city in Southeastern Brazil, 2019.
| Leisure Contents | Gross | Adjusted | ||
|---|---|---|---|---|
| p-value | OR (CI 95%) | p-value | OR (CI 95%) | |
| Manual | ||||
| No | - | - | ||
| Low | 0.089 | 1.64 (0.92-2.91) | 0.049 | 1.79 (1.00-3.22) |
| Moderate | 0.264 | 1.35 (0.79-2.31) | 0.188 | 1.44 (0.83-2.51) |
| High | 0.323 | 1.31 (0.76-2.26) | 0.315 | 1.33 (0.76-2.32) |
| Physical and sports | ||||
| No | - | - | ||
| Low | 0.215 | 1.43 (0.81-2.54) | 0.122 | 1.59 (0.88-2.88) |
| Moderate | 0.912 | 1.03 (0.59-1.78 | 0.456 | 1.24 (0.70-2.19) |
| High | 0.516 | 1.21 (0.67-2.16) | 0.286 | 1.38 (0.76-2.52) |
| Social | ||||
| No | - | - | ||
| Low | 0.509 | 0.80 (0.41-1.54) | 0.510 | 0.80 (0.41-1.55) |
| Moderate | 0.643 | 1.17 (0.60-2.27) | 0.634 | 1.17 (0.60-2.31) |
| High | 0.769 | 0.90 (0.45-1.77) | 0.606 | 0.83 (0.41-1.66) |
| Touristic | ||||
| No | - | - | ||
| Low | 0.520 | 1.18 (0.71-1.95) | 0.682 | 1.11 (0.66-1.87) |
| Moderate | 0.894 | 0.96 (0.55-1.66) | 0.951 | 1.01 (0.58-1.78) |
| High | 0.840 | 0.94 (0.53-1.65) | 0.669 | 0.88 (0.49-1.56) |
| Virtual | ||||
| No | - | - | ||
| Low | 0.186 | 1.41 (0.84-2.38) | 0.305 | 1.31 (0.77-2.24) |
| Moderate | 0.022 | 1.82 (1.09-3.04) | 0.036 | 1.75 (1.03-2.98) |
| High | < 0.001 | 2.71 (1.63-4.52) | <0.001 | 2.76 (1.64-4.63) |
| Contemplation and idleness | ||||
| No | - | - | ||
| Low | 0.298 | 1.34 (0.76-2.35) | 0.213 | 1.43 (0.81-2.54) |
| Moderate | 0.020 | 1.91 (1.10-3.30) | 0.010 | 2.07 (1.18-3.64) |
| High | 0.572 | 1.16 (0.68-1.99) | 0.474 | 1.22 (0.70-2.11) |
Logistic regression adjusted for sex and race/color.
Source; elaborated by the authors.
In the bivariate analysis between handgrip strength and age group, associations were found between manual (p < 0.001), artistic (p < 0.001) and virtual (p < 0.001) leisure contentes and handgrip strength in adults (table 3).
Table 3 Data on handgrip strength, according to leisure contents of individuals on hemodialysis from the metropolitan region of a capital in Southeastern Brazil, 2019
| Leisure Contents | Points on the scale | Adults | Elderly | ||||
|---|---|---|---|---|---|---|---|
| Decresed n(%) | Preserved n(%) | p-value* | Decreased n(%) | Preserved n(%) | p-value* | ||
| Social | 0.259 | 0.665 | |||||
| No | 0 | 42 (60.8) | 27 (40.2) | 67 (76.1) | 21 (23.9) | ||
| Low | 1-5 | 79 (48.9) | 86 (53.1) | 103 (76.3) | 32 (23.7) | ||
| Moderate | 6-8 | 88 (47.8) | 96 (52.2) | 91 (74.6) | 31 (25.4) | ||
| High | 9-10 | 79 (48.5) | 84 (51.5) | 56 (69.1) | 25 (30.9) | ||
| Physical and sports | 0.380 | 0.790 | |||||
| No | 0 | 187 (51.5) | 176 (48.5) | 239 (75.6) | 77 (24.4) | ||
| Low | 1-4 | 30 (40.5) | 44 (59.5) | 29 (72.5) | 11 (27.5) | ||
| Moderate | 5-7 | 35 (47.9) | 38 (52.1) | 23 (69.7) | 10 (30.3) | ||
| High | 8-10 | 36 (50.7) | 35 (49.3) | 26 (70.3) | 11 (29.7) | ||
| Touristic | 0.284 | 0.343 | |||||
| No | 0 | 147 (53.5) | 128 (46.5) | 203 (77.2) | 60 (22.8) | ||
| Low | 1-3 | 53 (46.9) | 60 (53.1) | 40 (72.7) | 15 (27.3) | ||
| Moderate | 4-5 | 37 (42.5) | 50 (57.5) | 36 (70.6) | 15 (29.4) | ||
| High | 6-10 | 51 (50.5) | 55 (54.5) | 38 (66.7) | 19 (33.3) | ||
| Manual | <0.001 | 0.173 | |||||
| No | 0 | 80 (53.3) | 70 (46.7) | 131 (82.4) | 28 (17.6) | ||
| Low | 1-5 | 65 (44.5) | 81 (55.5) | 93 (76.2) | 29 (23.8) | ||
| Moderate | 6-8 | 67 (48.5) | 71 (51.5) | 43 (64.2) | 24 (35.8) | ||
| High | 9-10 | 76 (51.7) | 71 (48.3) | 50 (64.1) | 28 (35.9) | ||
| Artistic | <0.001 | 0.173 | |||||
| No | 0 | 171 (56.8) | 130 (43.2) | 225 (76.8) | 68 (23.2) | ||
| Low | 1-4 | 37 (45.1) | 45 (54.9) | 48 (71.6) | 19 (28.4) | ||
| Moderate | 5-6 | 33 (34.7) | 62 (65.3) | 27 (72.97) | 10 (27.0) | ||
| High | 7-10 | 47 (45.6) | 56 (54.4) | 17 (58.6) | 12 (41.4) | ||
| Contemplation and idleness | 0.249 | 0.366 | |||||
| No | 0 | 58 (51.8) | 54 (48.2) | 73 (81.1) | 17 (18.9) | ||
| Low | 1-6 | 62 (43.1) | 82 (56.9) | 73 (73.73) | 26 (26.3) | ||
| Moderate | 7-9 | 78 (49.1) | 81 (50.9) | 91 (70.5) | 38 (29.5) | ||
| High | 10 | 90 (54.2) | 76 (45.7) | 80 (74.1) | 28 (23.9) | ||
| Intellectual | 0.709 | 0.817 | |||||
| No | 0 | 59 (53.2) | 52 (46.8) | 91 (72.2) | 35 (27.8) | ||
| Low | 1-5 | 78 (49.1) | 81 (50.9) | 89 (76.1) | 28 (22.2) | ||
| Moderate | 6-8 | 77 (46.4) | 89 (53.6) | 88 (73.3) | 32 (26.7) | ||
| High | 9-10 | 74 (51.0) | 71 (49.0) | 49 (77.8) | 14 (22.2) | ||
| Virtual | <0.001 | 0.111 | |||||
| No | 0 | 125 (62.2) | 76 (37.8) | 234 (76.7) | 71 (23.3) | ||
| Low | 1-5 | 46 (41.5) | 65 (58.5) | 55 (73.3) | 20 (27.7) | ||
| Moderate | 6-8 | 53 (41.1) | 76 (58.9) | 20 (64.5) | 11 (35.5) | ||
| High | 9-10 | 64 (45.7) | 76 (54.3) | 8 (53.3) | 7 (46.7) | ||
ES, Espírito Santo State, Brazil. Source: elaborated by the authors.
The study also found that low egagement in virtual activities increased the odds of dynapenia by 2.09 times (OR = 2.09, p = 0.003), moderate involvement increased the odds by 2.15 times (OR = 2.15, p = 0.002), and high envolvement increased the odds by 1.71 times (OR = 1.71, p = 0.027). Moreover, moderate participation in manual activities increased by almost twice (OR = 1.95, p = 0.010) the odds of reduced handgrip strength, characterizing the condition of dynapenia (table 4).
Table 4 Binary logistic regression between absence or presence of dynapenia in adults according to leisure contents of individuals on hemodialysis from the metropolitan region of a capital city in Southeastern Brazil, 2019
| Leisure contents | Gross | Adjusted | |||
|---|---|---|---|---|---|
| p-value | OR (CI 95%) | p-value | OR (CI 95%) | ||
| Manual | |||||
| No | - | - | |||
| Low | 0.334 | 1.28 (0.77-2.14) | 0.321 | 1.29 (0.77-2.18) | |
| Moderate | 0.007 | 1.99 (1.20-3.29) | 0.010 | 1.95 (1.16-3.26) | |
| High | 0.395 | 1.23 (0.75-2.01) | 0.556 | 1.16 (0.70-1.90) | |
| Virtual | |||||
| No | - | - | |||
| Low | 0.003 | 2.06 (1.26-3.36) | 0.003 | 2.09 (1.28-3.43) | |
| Moderate | 0.004 | 2.00 (1.23-3,24) | 0.002 | 2.15 (1.31-3.53) | |
| High | 0.037 | 1.65 (1.03-2.66) | 0.027 | 1.71 (1.06-2.76) | |
Logistic regression adjusted for sex and race/color.
Source: elaborate by the authors.
Associations were found between social (p = 0.010), touristic (p = 0.030), manual (p<0.001), artistic (p<0.001) and virtual (p<0.001) leisure contentes and the simultaneous presence of DAO in adults (table 5).
Table 5 Data on the absence or presence of dynapenic abdominal obesity, according to leisure contents, of individuals on hemodialysis from the metropolitan region of a capital city in Southeastern Brazil, 2019
| Leisure Contents | Points on the scale | Adults | Older adults | ||||
|---|---|---|---|---|---|---|---|
| Absence n(%) | Presence n(%) | p-value* | Absence n(%) | Presence n(%) | p-value* | ||
| Social | 0.010 | 0.627 | |||||
| No | 0 | 35 (56.6) | 27 (43.4) | 29 (37.7) | 48 (62.3) | ||
| Low | 1-5 | 116 (72.5) | 44 (27.5) | 50 (40.0) | 75 (60.0) | ||
| Moderate | 6-8 | 135 (78.0) | 38 (22.0) | 47 (45.2) | 57 (54.8) | ||
| High | 9-10 | 110 (71.0) | 45 (29.0) | 35 (46.0) | 41 (54.0) | ||
| Physical and sports | 0.361 | 0.863 | |||||
| No | 0 | 234 (69.4) | 103 (30.6) | 112 (40.8) | 162 (59.1) | ||
| Low | 1-4 | 55 (78.6) | 15 (21.4) | 17 (43.6) | 22 (56.4) | ||
| Moderate | 5-7 | 55 (75.3) | 18 (24.7) | 15 (45.5) | 18 (54.5) | ||
| High | 8-10 | 52 (74.3) | 18 (25.7) | 17 (47.2) | 19 (52.8) | ||
| Touristic | 0.030 | 0.51 | |||||
| No | 0 | 169 (66.0) | 87 (34.0) | 95 (41.0) | 137 (59.0) | ||
| Low | 1-3 | 83 (75.5) | 27 (24.5) | 19 (36.5) | 33 (63.5) | ||
| Moderate | 4-5 | 66 (79.5) | 17 (20.5) | 23 (50.0) | 23 (50.0) | ||
| High | 6-10 | 78 (77.2) | 23 (22.8) | 24 (46.2) | 28 (53.8) | ||
| Manual | <0.001 | 0.093 | |||||
| No | 0 | 89 (64.5) | 49 (35.5) | 41 (30.6) | 93 (69.4) | ||
| Low | 1-5 | 110 (78.6) | 30 (21.4) | 48 (42.9) | 64 (57.1) | ||
| Moderate | 6-8 | 96 (72.2) | 37 (27.8) | 35 (57.4) | 26 (42.6) | ||
| High | 9-10 | 101 (79.7) | 38 (27.3) | 37 (49.3) | 38 (50.7) | ||
| Artistic | <0.001 | 0.093 | |||||
| No | 0 | 177 (63.2) | 103 (36.8) | 103 (39.2) | 160 (60.8) | ||
| Low | 1-4 | 61 (80.3) | 15 (19.7) | 26 (42.6) | 35 (57.4) | ||
| Moderate | 5-6 | 76 (80.9) | 18 (19.1) | 16 (48.5) | 17 (51.5) | ||
| High | 7-10 | 82 (82) | 18 (18) | 16 (64) | 9 (36) | ||
| Contemplation and idleness | 0.088 | 0.111 | |||||
| No | 0 | 68 (65.4) | 36 (34.6) | 23 (29.9) | 54 (70.1) | ||
| Low | 1-6 | 102 (74.5) | 35 (25.5) | 42 (44.7) | 52 (55.3) | ||
| Moderate | 7-9 | 118 (78.1) | 33 (21.9) | 50 (45.0) | 61 (55.0) | ||
| High | 10 | 108 (69.7) | 50 (32.3) | 46 (46.0) | 54 (54.0) | ||
| Intellectual | 0.259 | 0.463 | |||||
| No | 0 | 68 (65.4) | 36 (36.6) | 53 (46.5) | 61 (53.5) | ||
| Low | 1-5 | 109 (70.8) | 45 (29.2) | 40 (37.7) | 66 (62.3) | ||
| Moderate | 6-8 | 120 (76.4) | 37 (23.6) | 46 (44.7) | 57 (55.3) | ||
| High | 9-10 | 99 (73.3) | 36 (26.7) | 22 (37.3) | 37 (62.7) | ||
| Virtual | <0.001 | 0.825 | |||||
| No | 0 | 107 (56.3) | 83 (43.7) | 112 (41.2) | 160 (58.8) | ||
| Low | 1-5 | 79 (77.5) | 23 (22.5) | 31 (43.7) | 40 (56.3) | ||
| Moderate | 6-8 | 101 (82.1) | 22 (17.9) | 11 (42.3) | 15 (57.7) | ||
| High | 9-10 | 109 (80.7) | 26 (19.3) | 7 (53.8) | 6 (46.2) | ||
ES, Espírito Santo State, Brazil. Source: elaborated by the authors.
The regression analysis showed that, for adults low engagement in virtual leisure activities increased the odds of DAO by 2.09 times (OR=2.09, p=0.012), moderate engagement increased the odds by 2.83 times (OR=2.83, p=<0.001) and high engagement increased the odds by 2.64 times (OR=2.64, p=<0.01). For older adults, a high involvement in manual activities reduced DAO odds by 54% (OR = 0.46; p = 0.043) (table 6).
Table 6 Binary logistic regression between the absence or presence of dynapenic abdominal obesityaccording to leisure contentes among adults and older adults on hemodialysis from the metropolitan region of a capital city in Southeastern Brazil, 2019
| Leisure Content and age group | Gross | Adjusted | ||
|---|---|---|---|---|
| p-value | OR (CI 95%) | p-value | OR (CI 95%) | |
| Manual - Adults | ||||
| No | - | - | ||
| Low | 0.251 | 1.47 (0.75-2.86) | 0.175 | 1.60 (0.80-3.17) |
| Moderate | 0.204 | 1.50 (0.80-2.82) | 0.229 | 1.48 (0.78-2.80) |
| High | 0.134 | 1.63 (0.85-3.12) | 0.156 | 1.60 (0.83-3.10) |
| Social - Adults | ||||
| No | - | - | ||
| Low | 0.390 | 1.33 (0.68-2.59) | 0.377 | 1.35 (0.69-2.63) |
| Moderate | 0.209 | 1.55 (0.77-3.10) | 0.176 | 1.61 (0.80-3.24) |
| High | 0.722 | 1.13 (0.56-2.26) | 0.719 | 1.13 (0.56-2.27) |
| Touristic - Adults | ||||
| No | - | - | ||
| Low | 0.952 | 0.98 (0.56-1.72) | 0.787 | 0.92 (0.52-1.63) |
| Moderate | 0.388 | 1.32 (0.69-2.52) | 0.406 | 1.31 (0.68-2.53) |
| High | 0.970 | 1.01 (0.54-1.89) | 0.883 | 0.95 (0.50-1.79) |
| Virtual - Adults | ||||
| No | - | - | ||
| Low | 0.009 | 2.14 (1.20-3.80) | 0.012 | 2.09 (1.17-3.75) |
| Moderate | 0.001 | 2.60 (1.45-4.69) | <0.001 | 2.83 (1.54-5.19) |
| High | <0.001 | 2.60 (1.47-4.59) | <0.001 | 2.64 (1.49-4.68) |
| Contemplation and idleness - adults | ||||
| No | - | - | ||
| Low | 0.634 | 1.15 (0.63-2.10) | 0.506 | 1.22 (0.66-2.25) |
| Moderate | 0.381 | 1.30 (0.71-2.38) | 0.349 | 1.33 (0.72-2.44) |
| High | 0.692 | 0.89 (0.50-1.57) | 0.820 | 0.93 (0.52-1.66) |
| Manual - the elderly | ||||
| No | - | - | ||
| Low | 0.861 | 1.05 (0.58-1.88) | 0.965 | 0.98 (0.54-1.79) |
| Moderate | 0.404 | 1.37 (0.65-2.90) | 0.311 | 1.47 (0.69-3.15) |
| High | 0.041 | 0.46 (0.35-0.85) | 0.043 | 0.46 (0.27-0.92) |
| Contemplation and idleness - the elderly | ||||
| No | - | - | ||
| Low | 0.065 | 1.83 (0.96-3.48) | 0.097 | 1.73 (0.90-3.33) |
| Moderate | 0.082 | 1.75 (0.93-3.32) | 0.082 | 1.76 (0.92-3.36) |
| High | 0.067 | 1.81 (0.95-3.42) | 0.141 | 1.62 (0.85-3.11) |
Logistic regression adjusted for sex and race/color.
Source: elaborated by the authors.
DISCUSSION
Our findings suggest that leisure activities that favor sedentary behavior, such as virtual activities, was found to increase the odds of adult patients on hemodialysis developing dynapenic abdominal obesity, whereas high engagement in activities that require some physical effort, such as manual activities, was found to act as a protective factor for older people. The sedentary/active behavior of this population, even in leisure activities, is crucial to increasing/decrising the odds of DAO. Therefore, knowledge of which leisure activities can contribute to improving the health of individuals undergoing hemodialysis is important, especially when we consider that physical and sports activities are rarely practiced by this population.
The association of AO with dynapenia has recently been recognized as a health problem associated with disability26, falls27, increased risk of mortality28 and worsening of the inflammatory profile of people with end- stage chronic kidney disease29. It is important to highlight that this study, for the first time, investigated the association between DAO and the 8 dimensions of leisure.
Leisure activities that favor sedentary behaviors may explain the reason for virtual activities among adults, regardless of engagement leves (low, moderate or high) were associated with increased chances of decreased handgrip strength, characterizing the dynapenic condition. This can be explained by the physical inactivity resulting from excessive use of screen-based leisure activities, such as using the internet, playing video games and using social networks23. These activities lead to a loss of muscle strength6 and contribute to sedentary behavior29, impacting on individuals quality of life.
On the other hand, studies show that the most frequent leisure activity among older adults is manual activities30. These often require some physical effort and have been shown to be protective factors related to loss of functionality31. Moreover, participating in manual activities contribute to positive self-rated health in this population, which is better when they participate in leisure activities32.
Authors have suggested in their studies33,34,35,36 that higher muscle fat content is associated with reduced muscle strength, thus providing a theoretical basis for the association with dynapenia37. They describe that the etiology of poor physical performance in dynapenia is a multifactorial and complex process with biological, psychological, environmental and sociological origins. This complexity may explain why this study found that moderate activity was associated with an almost twofold higher risk of dynapenia in adults. However, no comparative studies were found in the scientific literature.
There is a prevalence of abdominal obesity among individuals undergoing hemodialysis treatment. This screening, conducted using the conicity index, aids identify cardiovascular risk and metabolic complications38. Studies25,39 have found high prevalence rates of abdominal obesity among adults undergoing hemodialysis. The likelihood of developing AO was higher in adults with moderate contemplation and idleness activities wich tend to show sedentary characteristics due to physical inactivity.
Similarly, moderate and high engagement in virtual activities, as well as low engagement in manual activities, significantly contribute to the increased risk of AO in adults, as virtual activities are characterized by low energy expenditure, whereas manual activities are essential for maintaining an adequate level of physical activity and metabolism40. One study shows a high rate of sedentary behavior in individuals with obesity, as well as a positive risk association15. Therefore, moderate egagement in contemplation and idleness activities, moderate to high engagement in virtual activities, and low engagement in manual activities promote a more sedentary lifestily, which contributes to the development of abdominal obesity.
It is worth highlighting the main focus of the studies on the consequences of sedentary lifestyles caused by physical inactivity41. Considering that the hemodialysis population tends to show lower than expected levels of physical activity41, this study shows that leisure contentes can function as protective and risk factors, exploring the benefits of leisure practice in a population with low adherence to physical activity.
Among the main limitations of this study is quantitative focus on behavioral characteristics, despite using an instrument that addresses engagement (including subjective aspects of leisure practices). However, this is an unprecedented study in the literature and one of the few to investigate the leisure time of individuals on hemodialysis and dysthymia. Another limitation is that, as this is a cross- sectional study, the possibility of establishing temporal causality between the associations is very limited.
CONCLUSION
Virtual and manual leisure practices were associated with DAO in individuals undergoing hemodialysis treatment. Virtual activities, by encouraging sedentary behaviors, are risk factors for DAO among adults. For elderly people, manual activities appeared as protective factors.
These results suggest that leisure activities can be used to improve the health of people undergoing hemodialysis treatment because, by aligning the reality, preferences and real possibilities of leisure activities that each person has, the team expands the possibilities of care with activities that can prevent behaviors that worsen or lead to DAO.
