Exploring the Association Between Measures of Obesity and Measures of Trip-induced Fall Risk Among Older Adults

  • Noah J. Rosenblatt
    Corresponding author Noah J. Rosenblatt, PhD, Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd, North Chicago, IL 60064.
    Dr William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, North Chicago, IL
    Search for articles by this author
  • Michael L. Madigan
    Department of Industrial and Systems Engineering, Virginia Tech, Blacksburg, VA
    Search for articles by this author
Published:August 02, 2021DOI:



      To explore the association between measures of obesity and measures of trip-induced fall risk among community-dwelling older adults.




      Gait laboratory.


      Voluntary sample of 55 community-dwelling older adults (aged ≥65y; N=55) with body mass index (BMI) of 18.84-44.68 kg/m2.


      Not applicable.

      Main Outcome Measures

      Measures of obesity included 6 anthropometry-based measures (BMI; thigh, hip and waist circumferences; ratio of waist-to-hip circumference; index of central obesity) and 4 dual-energy x-ray absorptiometry–based measures (percentage trunk, leg, and total fat; fat mass index). Measures of risk of tripping during overground walking included median and interquartile range of toe clearance and area under the swing phase toe trajectory. Measures of trip recovery after a laboratory-induced trip included trunk angle and angular velocity at ground contact of the first recovery step, anteroposterior distance from stepping foot to center of mass at the same instant, and step time of the first recovery step.


      Risk of tripping was associated with waist-to-hip ratio and thigh circumference. After grouping participants by waist-to-hip ratio, those with high ratios (≥0.9 cm for men and ≥0.85 cm for women) exhibited significantly greater variability in toe clearance. Trip recovery was associated with hip circumference, thigh circumference, fat mass index, and total fat. After grouping participants by fat mass index, those with high indices (>9 kg/m2 for men and >13 kg/m2 for women) exhibited less favorable trunk kinematics after a laboratory-induced trip (Cohen d=0.84).


      Waist-to-hip ratio and fat mass index may more closely relate to trip-induced fall risk than BMI among community-dwelling older adults.


      List of abbreviations:

      BMI (body mass index), COM (center of mass), DEXA (dual-energy x-ray absorptiometry), IQR (interquartile range), PC (principal component), PCA (principal component analysis)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hales CM
        • Carroll MD
        • Fryar CD
        • Ogden CL.
        Prevalence of obesity and severe obesity among adults: United States, 2017-2018.
        NCHS Data Brief. 2020; Feb: 1-8
        • Neri SGR
        • Oliveira JS
        • Dario AB
        • Lima RM
        • Tiedemann A.
        Does obesity increase the risk and severity of falls in people aged 60 years and older? A systematic review and meta-analysis of observational studies.
        J Gerontol A Biol Sci Med Sci. 2020; 75: 952-960
        • Fjeldstad C
        • Fjeldstad AS
        • Acree LS
        • Nickel KJ
        • Gardner AW.
        The influence of obesity on falls and quality of life.
        Dyn Med. 2008; 7: 4
        • Srygley JM
        • Herman T
        • Giladi N
        • Hausdorff JM.
        Self-report of missteps in older adults: a valid proxy of fall risk?.
        Arch Phys Med Rehabil. 2009; 90: 786-792
        • Teno J
        • Kiel DP
        • Mor V.
        Multiple stumbles: a risk factor for falls in community-dwelling elderly; a prospective study.
        J Am Geriatr Soc. 1990; 38: 1321-1325
        • Sturnieks DL
        • Menant J
        • Delbaere K
        • et al.
        Force-controlled balance perturbations associated with falls in older people: a prospective cohort study.
        PLoS One. 2013; 8: e70981
        • Berg WP
        • Alessio HM
        • Mills EM
        • Tong C.
        Circumstances and consequences of falls in independent community-dwelling older adults.
        Age Ageing. 1997; 26: 261-268
        • Garman CR
        • Franck CT
        • Nussbaum MA
        • Madigan ML.
        A bootstrapping method to assess the influence of age, obesity, gender, and gait speed on probability of tripping as a function of obstacle height.
        J Biomech. 2015; 48: 1229-1232
        • Winter DA.
        Foot trajectory in human gait: a precise and multifactorial motor control task.
        Phys Ther. 1992; 72: 45-53
        • Garman CR
        • Nussbaum MA
        • Franck CT
        • Madigan ML.
        A pilot study exploring obesity-related differences in fall rate and kinematic response resulting from a laboratory-induced trip.
        IISE Trans Occup Ergon Hum Factors. 2016; 4: 211-221
        • Rosenblatt NJ
        • Grabiner MD.
        Relationship between obesity and falls by middle-aged and older women.
        Arch Phys Med Rehabil. 2012; 93: 718-722
        • Rothman KJ.
        BMI-related errors in the measurement of obesity.
        Int J Obes (Lond). 2008; 32: S56-S59
        • Shah NR
        • Braverman ER.
        Measuring adiposity in patients: the utility of body mass index (BMI), percent body fat, and leptin.
        PLoS One. 2012; 7: e33308
        • Sahakyan KR
        • Somers VK
        • Rodriguez-Escudero JP
        • et al.
        Normal-weight central obesity: implications for total and cardiovascular mortality.
        Annintern med. 2015; 163: 827-835
        • Cho BY
        • Seo DC
        • Lin HC
        • Lohrmann DK
        • Chomistek AK.
        BMI and central obesity with falls among community-dwelling older adults.
        Am J Prev Med. 2018; 54: e59-e66
        • Parikh RM
        • Joshi SR
        • Menon PS
        • Shah NS.
        Index of central obesity–a novel parameter.
        Med Hypotheses. 2007; 68: 1272-1275
        • McNeely MJ
        • Boyko EJ
        • Shofer JB
        • Newell-Morris L
        • Leonetti DL
        • Fujimoto WY.
        Standard definitions of overweight and central adiposity for determining diabetes risk in Japanese Americans.
        Am J Clin Nutr. 2001; 74: 101-107
        • Parikh RM
        • Joshi SR
        • Pandia K.
        Index of central obesity is better than waist circumference in defining metabolic syndrome.
        Metab Syndr Relat Disord. 2009; 7: 525-528
        • Kelly TL
        • Wilson KE
        • Heymsfield SB.
        Dual energy x-ray absorptiometry body composition reference values from NHANES.
        PLoS One. 2009; 4: e7038
        • Lerner ZF
        • Board WJ
        • Browning RC.
        Effects of an obesity-specific marker set on estimated muscle and joint forces in walking.
        Med Sci Sports Exerc. 2014; 46: 1261-1267
        • Byju AG
        • Nussbaum MA
        • Madigan ML.
        Alternative measures of toe trajectory more accurately predict the probability of tripping than minimum toe clearance.
        J Biomech. 2016; 49: 4016-4021
        • Pavol MJ
        • Owings TM
        • Foley KT
        • Grabiner MD.
        Mechanisms leading to a fall from an induced trip in healthy older adults.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M428-M437
        • Macek P
        • Biskup M
        • Terek-Derszniak M
        • et al.
        Optimal body fat percentage cut-off values in predicting the obesity-related cardiovascular risk factors: a cross-sectional cohort study. diabetes, metabolic syndrome and obesity: targets and therapy.
        Diabetes Metab Syndr Obes. 2020; 13: 1587-1597
        • Meng H
        • O'Connor DP
        • Lee BC
        • Layne CS
        • Gorniak SL
        Effects of adiposity on postural control and cognition.
        Gait Posture. 2016; 43: 31-37
        • Mainenti MR
        • Rodrigues Éde C
        • Oliveira JF
        • Ferreira Ade S
        • Dias CM
        • Silva AL.
        Adiposity and postural balance control: correlations between bioelectrical impedance and stabilometric signals in elderly Brazilian women.
        Clinics (Sao Paulo). 2011; 66: 1513-1518
        • Meng H
        • Gorniak SL.
        Effects of adiposity on postural control and cognition in older adults.
        Gait Posture. 2020; 82: 147-152
        • Neri SG
        • Tiedemann A
        • Gadelha AB
        • Lima RM.
        Body fat distribution in obesity and the association with falls: a cohort study of Brazilian women aged 60 years and over.
        Maturitas. 2020; 139: 64-68
        • Rosenblatt NJ
        • Bauer A
        • Rotter D
        • Grabiner MD.
        Active dorsiflexing prostheses may reduce trip-related fall risk in people with transtibial amputation.
        J Rehabil Res Dev. 2014; 51: 1229-1242
        • Moosabhoy MA
        • Gard SA.
        Methodology for determining the sensitivity of swing leg toe clearance and leg length to swing leg joint angles during gait.
        Gait Posture. 2006; 24: 493-501
        • Chen BB
        • Shih T
        • Hsu CY
        • et al.
        Thigh muscle volume predicted by anthropometric measurements and correlated with physical function in the older adults.
        J Nutr Health Aging. 2011; 15: 433-438
        • Pijnappels M
        • Reeves ND
        • Maganaris CN
        • Van Dieen JH.
        Tripping without falling; lower limb strength, a limitation for balance recovery and a target for training in the elderly.
        J Electromyogr Kinesiol. 2008; 18: 188-196
        • Koushyar H
        • Anderson DE
        • Nussbaum MA
        • Madigan ML.
        Relative effort while walking is higher among women who are obese, and older women.
        Med Sci Sports Exerc. 2020; 52: 105-111
        • Begg R
        • Best R
        • Dell'Oro L
        • Taylor S.
        Minimum foot clearance during walking: strategies for the minimisation of trip-related falls.
        Gait Posture. 2007; 25: 191-198
        • Best R
        • Begg R.
        A method for calculating the probability of tripping while walking.
        J Biomech. 2008; 41: 1147-1151
        • Khandoker AH
        • Taylor SB
        • Karmakar CK
        • Begg RK
        • Palaniswami M.
        Investigating scale invariant dynamics in minimum toe clearance variability of the young and elderly during treadmill walking.
        IEEE Trans Neural Syst Rehabil Eng. 2008; 16: 380-389
        • Crenshaw JR
        • Kaufman KR
        • Grabiner MD.
        Compensatory-step training of healthy, mobile people with unilateral, transfemoral or knee disarticulation amputations: a potential intervention for trip-related falls.
        Gait Posture. 2013; 38: 500-506
        • Honeycutt CF
        • Nevisipour M
        • Grabiner MD.
        Characteristics and adaptive strategies linked with falls in stroke survivors from analysis of laboratory-induced falls.
        J Biomech. 2016; 49: 3313-3319
        • Pater ML
        • Rosenblatt NJ
        • Grabiner MD.
        Knee osteoarthritis negatively affects the recovery step following large forward-directed postural perturbations.
        J Biomech. 2016; 49: 1128-1133
        • Crenshaw JR
        • Rosenblatt NJ
        • Hurt CP
        • Grabiner MD.
        The discriminant capabilities of stability measures, trunk kinematics, and step kinematics in classifying successful and failed compensatory stepping responses by young adults.
        J Biomech. 2012; 45: 129-133
        • Pijnappels M
        • Bobbert MF
        • van Dieën JH.
        Contribution of the support limb in control of angular momentum after tripping.
        J Biomech. 2004; 37: 1811-1818
        • Pryce R
        • Kriellaars D.
        Body segment inertial parameters and low back load in individuals with central adiposity.
        J Biomech. 2014; 47: 3080-3086
        • Matrangola SL
        • Madigan ML
        • Nussbaum MA
        • Ross R
        • Davy KP.
        Changes in body segment inertial parameters of obese individuals with weight loss.
        J Biomech. 2008; 41: 3278-3281
        • Maffiuletti NA
        • Ratel S
        • Sartorio A
        • Martin V.
        The impact of obesity on in vivo human skeletal muscle function.
        Curr Obes Rep. 2013; 2: 251-260
        • Tomlinson D
        • Erskine R
        • Morse C
        • Winwood K
        • Onambélé-Pearson G.
        The impact of obesity on skeletal muscle strength and structure through adolescence to old age.
        Biogerontology. 2016; 17: 467-483
        • Nevisipour M
        • Grabiner MD
        • Honeycutt CF.
        A single session of trip-specific training modifies trunk control following treadmill induced balance perturbations in stroke survivors.
        Gait Posture. 2019; 70: 222-228
        • Grabiner MD
        • Bareither ML
        • Gatts S
        • Marone J
        • Troy KL.
        Task-specific training reduces trip-related fall risk in women.
        Med Sci Sports Exerc. 2012; 44: 2410-2414
        • Wang Y
        • Wang S
        • Bolton R
        • Kaur T
        • Bhatt T.
        Effects of task-specific obstacle-induced trip-perturbation training: proactive and reactive adaptation to reduce fall-risk in community-dwelling older adults.
        Aging Clin Exp Res. 2020; 32: 893-905
        • Rosenblatt N
        • Marone J
        • Grabiner M.
        Preventing trip-related falls by community-dwelling adults: a prospective study.
        J Am Geriatr Soc. 2013; 61: 1629-1631
        • Rosenblatt NJ
        • Bauer A
        • Grabiner MD.
        Relating minimum toe clearance to prospective, self-reported, trip-related stumbles in the community.
        Prosthet Orthot Int. 2017; 41: 387-392