The journal of nutrition, health & aging

, Volume 19, Issue 2, pp 240–248 | Cite as

A review of the relationship between leg power and selected chronic disease in older adults

  • S. E. Strollo
  • P. Caserotti
  • R. E. Ward
  • N. W. Glynn
  • B. H. Goodpaster
  • Elsa S. StrotmeyerEmail author



This review investigates the relationship between leg muscle power and the chronic conditions of osteoarthritis, diabetes mellitus, and cardiovascular disease among older adults. Current literature assessing the impact of chronic disease on leg power has not yet been comprehensively characterized. Importantly, individuals with these conditions have shown improved leg power with training.


A search was performed using PubMed to identify original studies published in English from January 1998 to August 2013. Leg power studies, among older adults ≥ 50 years of age, which assessed associations with osteoarthritis, diabetes mellitus, and/or cardiovascular disease were selected. Studies concerning post-surgery rehabilitation, case studies, and articles that did not measure primary results were excluded.


Sixteen studies met inclusion criteria, addressing osteoarthritis (n=5), diabetes mellitus (n=5), and cardiovascular disease (n=6). Studies generally supported associations of lower leg power among older adults with chronic disease, although small sample sizes, cross-sectional data, homogenous populations, varied disease definitions, and inconsistent leg power methods limited conclusions.


Studies suggest that osteoarthritis, diabetes mellitus, and cardiovascular disease are associated with lower leg power compared to older adults without these conditions. These studies are limited, however, by the heterogeneity in study populations and a lack of standardized measurements of leg power. Future larger studies of more diverse older adults with well-defined chronic disease using standard measures of leg power and interventions to improve leg power in these older adults with chronic disease are needed.

Key words

Leg power older adults chronic disease aging muscle power 


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  1. 1.
    Bean JF, Kiely DK, Herman S, Leveille SG, Mizer K, Frontera WR, et al. The relationship between leg power and physical performance in mobility-limited older people. J Am Geriatr Soc. 2002;50:461–467.CrossRefPubMedGoogle Scholar
  2. 2.
    Evans WJ. Exercise strategies should be designed to increase muscle power. J Gerontol A Biol Sci Med Sci. 2000;55:M309–310.CrossRefGoogle Scholar
  3. 3.
    Skelton DA, Kennedy J, Rutherford OM. Explosive power and asymmetry in leg muscle function in frequent fallers and non-fallers aged over 65. Age Ageing. 2002;31:119–125.CrossRefPubMedGoogle Scholar
  4. 4.
    Caserotti P, Aagaard P, Larsen JB, Puggaard L. Explosive heavy-resistance training in old and very old adults: changes in rapid muscle force, strength and power. Scand J Med Sci Sports. 2008;18:773–782.CrossRefPubMedGoogle Scholar
  5. 5.
    Warburton DE, Gledhill N, Quinney A. Musculoskeletal fitness and health. Can J Appl Physiol. 2001;26:217–237.CrossRefPubMedGoogle Scholar
  6. 6.
    Edgerton VR, Roy RR, Gregor RJ, Rugg S. Morphological basis of skeletal muscle power output. In: Jones NL, McCartney N, McComas AJ (Eds.). Human muscle power. Champaign, IL: Human Kinetics; 1986.Google Scholar
  7. 7.
    Kraemer WJ, Newton RU. Training for muscular power. Phys Med Rehabil Clin N Am. 2000;11:341–368, vii.PubMedGoogle Scholar
  8. 8.
    Caserotti P, Harris TB, Vannozzi G, Aagaard P. Assessment of muscle power in older adults and association with functional performance. Gerontologist. 2009;49:210.Google Scholar
  9. 9.
    Jakobi JM, Rice CL. Voluntary muscle activation varies with age and muscle group. J Appl Physiol. 2002;93:457–462.PubMedGoogle Scholar
  10. 10.
    Klass M, Baudry S, Duchateau J. Age-related decline in rate of torque development is accompanied by lower maximal motor unit discharge frequency during fast contractions. J Appl Physiol. 2008;104:739–746.CrossRefPubMedGoogle Scholar
  11. 11.
    Foldvari M, Clark M, Laviolette LC, Bernstein MA, Kaliton D, Castaneda C, et al. Association of muscle power with functional status in community-dwelling elderly women. J Gerontol A Biol Sci Med Sci. 2000;55:M192–199.CrossRefGoogle Scholar
  12. 12.
    Reid KF, Fielding RA. Skeletal muscle power: a critical determinant of physical functioning in older adults. Exerc Sport Sci Rev. 2012;40:4–12.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007.Google Scholar
  14. 14.
    Brochu M, Savage P, Lee M, Dee J, Cress ME, Poehlman ET, et al. Effects of resistance training on physical function in older disabled women with coronary heart disease. J Appl Physiol. 2002;92:672–678.CrossRefPubMedGoogle Scholar
  15. 15.
    Gregg EW, Mangione CM, Cauley JA, Thompson TJ, Schwartz AV, Ensrud KE, et al. Diabetes and incidence of functional disability in older women. Diabetes Care. 2002;25:61–67.CrossRefPubMedGoogle Scholar
  16. 16.
    Hunter DJ, Felson DT. Osteoarthritis. BMJ. 2006;332:639–642.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Haq I, Murphy E, Dacre J. Osteoarthritis. Postgrad Med J. 2003;79:377–383.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Park SW, Goodpaster BH, Strotmeyer ES, de Rekeneire N, Harris TB, Schwartz AV, et al. Decreased muscle strength and quality in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes. 2006;55:1813–1818.CrossRefPubMedGoogle Scholar
  19. 19.
    Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, et al. Diabetes and physical disability among older U.S. adults. Diabetes Care. 2000;23:1272–1277.CrossRefPubMedGoogle Scholar
  20. 20.
    Andersen H, Nielsen S, Mogensen CE, Jakobsen J. Muscle strength in type 2 diabetes. Diabetes. 2004;53:1543–1548.CrossRefPubMedGoogle Scholar
  21. 21.
    Bean JF, Vora A, Frontera WR. Benefits of exercise for community-dwelling older adults. Arch Phys Med Rehabil. 2004;85:S31–44.CrossRefGoogle Scholar
  22. 22.
    Brum PC, Bacurau AV, Medeiros A, Ferreira JC, Vanzelli AS, Negrao CE. Aerobic exercise training in heart failure: impact on sympathetic hyperactivity and cardiac and skeletal muscle function. Braz J Med Biol Res. 2011;44:827–835.CrossRefPubMedGoogle Scholar
  23. 23.
    Suzuki K, Omiya K, Yamada S, Kobayashi T, Suzuki N, Osada N, et al. Relations between strength and endurance of leg skeletal muscle and cardiopulmonary exercise testing parameters in patients with chronic heart failure. J Cardiol. 2004;43:59–68.PubMedGoogle Scholar
  24. 24.
    Farinon AM, Marbini A, Gemignani F, Govoni E, Bragaglia MM, Sianesi M, et al. Skeletal muscle and peripheral nerve changes caused by chronic arterial insufficiency—significance and clinical correlations—histological, histochemical and ultrastructural study. Clin Neuropathol. 1984;3:240–252.PubMedGoogle Scholar
  25. 25.
    Hedberg B, Angquist KA, Henriksson-Larsen K, Sjostrom M. Fibre loss and distribution in skeletal muscle from patients with severe peripheral arterial insufficiency. Eur J Vasc Surg. 1989;3:315–322.CrossRefPubMedGoogle Scholar
  26. 26.
    Dieppe P. Strategies for the prevention of osteoarthritis. Int J Tissue React. 1993;15:93–97.PubMedGoogle Scholar
  27. 27.
    Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290:1884–1890.CrossRefPubMedGoogle Scholar
  28. 28.
    Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419.CrossRefPubMedCentralPubMedGoogle Scholar
  29. 29.
    Robertson S, Frost H, Doll H, O'Connor JJ. Leg extensor power and quadriceps strength: an assessment of repeatability in patients with osteoarthritic knees. Clin Rehabil. 1998;12:120–126.CrossRefPubMedGoogle Scholar
  30. 30.
    De Vito G, Bernardi M, Forte R, Pulejo C, Macaluso A, Figura F. Determinants of maximal instantaneous muscle power in women aged 50–75 years. Eur J Appl Physiol Occup Physiol. 1998;78:59–64.CrossRefPubMedGoogle Scholar
  31. 31.
    Macaluso A, De Vito G. Comparison between young and older women in explosive power output and its determinants during a single leg-press action after optimisation of load. Eur J Appl Physiol. 2003;90:458–463.CrossRefPubMedGoogle Scholar
  32. 32.
    Bassey EJ, Short AH. A new method for measuring power output in a single leg extension: feasibility, reliability and validity. Eur J Appl Physiol Occup Physiol. 1990;60:385–390.CrossRefPubMedGoogle Scholar
  33. 33.
    Forte R, Macaluso A. Relationship between performance-based and laboratory tests for lower-limb muscle strength and power assessment in healthy older women. J Sports Sci. 2008;26:1431–1436.CrossRefPubMedGoogle Scholar
  34. 34.
    Alexander NB, Galecki AT, Grenier ML, Nyquist LV, Hofmeyer MR, Grunawalt JC, et al. Task-specific resistance training to improve the ability of activities of daily living-impaired older adults to rise from a bed and from a chair. J Am Geriatr Soc. 2001;49:1418–1427.CrossRefPubMedGoogle Scholar
  35. 35.
    Caserotti P, Aagaard P, Simonsen EB, Puggaard L. Contraction-specific differences in maximal muscle power during stretch-shortening cycle movements in elderly males and females. Eur J Appl Physiol. 2001;84:206–212.CrossRefPubMedGoogle Scholar
  36. 36.
    Kuo HK, Leveille SG, Yen CJ, Chai HM, Chang CH, Yeh YC, et al. Exploring how peak leg power and usual gait speed are linked to late-life disability: data from the National Health and Nutrition Examination Survey (NHANES), 1999–2002. Am J Phys Med Rehabil. 2006;85:650–658.CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Orr R, Tsang T, Lam P, Comino E, Singh MF. Mobility impairment in type 2 diabetes: association with muscle power and effect of Tai Chi intervention. Diabetes Care. 2006;29:2120–2122.CrossRefPubMedGoogle Scholar
  38. 38.
    Sayers SP. High-speed power training: a novel approach to resistance training in older men and women. A brief review and pilot study. J Strength Cond Res. 2007;21:518–526.PubMedGoogle Scholar
  39. 39.
    Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54:226–229.CrossRefPubMedGoogle Scholar
  40. 40.
    American Geriatrics Society Panel on Exercise and Osteoarthritis. Exercise prescription for older adults with osteoarthritis pain: consensus practice recommendations. A supplement to the AGS Clinical Practice Guidelines on the management of chronic pain in older adults. J Am Geriatr Soc. 2001;49:808–823.CrossRefGoogle Scholar
  41. 41.
    Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum. 1987;30:914–918.CrossRefPubMedGoogle Scholar
  42. 42.
    Andersen H, Gadeberg PC, Brock B, Jakobsen J. Muscular atrophy in diabetic neuropathy: a stereological magnetic resonance imaging study. Diabetologia. 1997;40:1062–1069.CrossRefPubMedGoogle Scholar
  43. 43.
    Fielding RA, LeBrasseur NK, Cuoco A, Bean J, Mizer K, Fiatarone Singh MA. High-velocity resistance training increases skeletal muscle peak power in older women. J Am Geriatr Soc. 2002;50:655–662.CrossRefPubMedGoogle Scholar
  44. 44.
    Barker K, Lamb SE, Toye F, Jackson S, Barrington S. Association between radiographic joint space narrowing, function, pain and muscle power in severe osteoarthritis of the knee. Clin Rehabil. 2004;18:793–800.CrossRefPubMedGoogle Scholar
  45. 45.
    Juhakoski R, Tenhonen S, Anttonen T, Kauppinen T, Arokoski JP. Factors affecting self-reported pain and physical function in patients with hip osteoarthritis. Arch Phys Med Rehabil. 2008;89:1066–1073.CrossRefPubMedGoogle Scholar
  46. 46.
    Berger MJ, McKenzie CA, Chess DG, Goela A, Doherty TJ. Quadriceps neuromuscular function and self-reported functional ability in knee osteoarthritis. J Appl Physiol. 2012;113:255–262.CrossRefPubMedGoogle Scholar
  47. 47.
    Sayers SP, Gibson K. A comparison of high-speed power training and traditional slow-speed resistance training in older men and women. J Strength Cond Res. 2010;24:3369–3380.CrossRefPubMedGoogle Scholar
  48. 48.
    Sayers SP, Gibson K, Cook CR. Effect of high-speed power training on muscle performance, function, and pain in older adults with knee osteoarthritis: a pilot investigation. Arthritis Care Res (Hoboken). 2012;64:46–53.CrossRefPubMedGoogle Scholar
  49. 49.
    Health Education Authority and Sports Council. Allied Dunbar National Fitness Survey: main findings. Northampton: Belmont Press; 1992.Google Scholar
  50. 50.
    Bassey EJ, Fiatarone MA, O'Neill EF, Kelly M, Evans WJ, Lipsitz LA. Leg extensor power and functional performance in very old men and women. Clin Sci (Lond). 1992;82:321–327.PubMedGoogle Scholar
  51. 51.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840.PubMedGoogle Scholar
  52. 52.
    Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.Google Scholar
  53. 53.
    Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and worldwide. JAMA. 2003;289:1371–1373.CrossRefGoogle Scholar
  54. 54.
    Park SW, Goodpaster BH, Strotmeyer ES, Kuller LH, Broudeau R, Kammerer C, et al. Accelerated loss of skeletal muscle strength in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes Care. 2007;30:1507–1512.CrossRefPubMedGoogle Scholar
  55. 55.
    Kalyani RR, Saudek CD, Brancati FL, Selvin E. Association of diabetes, comorbidities, and A1C with functional disability in older adults: results from the National Health and Nutrition Examination Survey (NHANES), 1999–2006. Diabetes Care. 2010;33:1055–1060.CrossRefPubMedCentralPubMedGoogle Scholar
  56. 56.
    Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States. Atlanta, GA: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2005.Google Scholar
  57. 57.
    Strotmeyer ES, de Rekeneire N, Schwartz AV, Resnick HE, Goodpaster BH, Faulkner KA, et al. Sensory and motor peripheral nerve function and lower-extremity quadriceps strength: the health, aging and body composition study. J Am Geriatr Soc. 2009;57:2004–2010.CrossRefPubMedCentralPubMedGoogle Scholar
  58. 58.
    Strotmeyer ES, de Rekeneire N, Schwartz AV, Faulkner KA, Resnick HE, Goodpaster BH, et al. The relationship of reduced peripheral nerve function and diabetes with physical performance in older white and black adults: the Health, Aging, and Body Composition (Health ABC) study. Diabetes Care. 2008;31:1767–1772.CrossRefPubMedCentralPubMedGoogle Scholar
  59. 59.
    De Rekeneire N, Resnick HE, Schwartz AV, Shorr RI, Kuller LH, Simonsick EM, et al. Diabetes is associated with subclinical functional limitation in nondisabled older individuals: the Health, Aging, and Body Composition study. Diabetes Care. 2003;26:3257–3263.CrossRefPubMedGoogle Scholar
  60. 60.
    Hakkinen K, Kallinen M, Izquierdo M, Jokelainen K, Lassila H, Malkia E, et al. Changes in agonist-antagonist EMG, muscle CSA, and force during strength training in middle-aged and older people. J Appl Physiol (1985). 1998;84:1341–1349.Google Scholar
  61. 61.
    Hilton TN, Tuttle LJ, Bohnert KL, Mueller MJ, Sinacore DR. Excessive adipose tissue infiltration in skeletal muscle in individuals with obesity, diabetes mellitus, and peripheral neuropathy: association with performance and function. Phys Ther. 2008;88:1336–1344.CrossRefPubMedCentralPubMedGoogle Scholar
  62. 62.
    Volpato S, Bianchi L, Lauretani F, Lauretani F, Bandinelli S, Guralnik JM, et al. Role of muscle mass and muscle quality in the association between diabetes and gait speed. Diabetes Care. 2012;35:1672–1679.CrossRefPubMedCentralPubMedGoogle Scholar
  63. 63.
    Kalyani RR, Tra Y, Yeh HC, Egan JM, Ferrucci L, Brancati FL. Quadriceps strength, quadriceps power, and gait speed in older U.S. adults with diabetes mellitus: results from the National Health and Nutrition Examination Survey, 1999–2002. J Am Geriatr Soc. 2013;61:769–775.CrossRefPubMedCentralPubMedGoogle Scholar
  64. 64.
    Sacchetti M, Balducci S, Bazzucchi I, Carlucci F, Scotto di Palumbo A, Haxhi J, et al. Neuromuscular dysfunction in diabetes: role of nerve impairment and training status. Med Sci Sports Exerc. 2013;45:52–59.CrossRefPubMedGoogle Scholar
  65. 65.
    Ibanez J, Gorostiaga EM, Alonso AM, Forga L, Arguelles I, Larrion JL, et al. Lower muscle strength gains in older men with type 2 diabetes after resistance training. J Diabetes Complications. 2008;22:112–118.CrossRefPubMedGoogle Scholar
  66. 66.
    Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics—2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–e209.CrossRefPubMedGoogle Scholar
  67. 67.
    McDermott MM. The international pandemic of chronic cardiovascular disease. JAMA. 2007;297:1253–1255.CrossRefPubMedGoogle Scholar
  68. 68.
    McDermott MM, Guralnik JM, Albay M, Bandinelli S, Miniati B, Ferrucci L. Impairments of muscles and nerves associated with peripheral arterial disease and their relationship with lower extremity functioning: the InCHIANTI Study. J Am Geriatr Soc. 2004;52:405–410.CrossRefPubMedGoogle Scholar
  69. 69.
    McDermott MM, Tian L, Ferrucci L, Liu K, Guralnik JM, Liao Y, et al. Associations between lower extremity ischemia, upper and lower extremity strength, and functional impairment with peripheral arterial disease. J Am Geriatr Soc. 2008;56:724–729.CrossRefPubMedCentralPubMedGoogle Scholar
  70. 70.
    McDermott MM, Liu K, Tian L, Guralnik JM, Criqui MH, Liao Y, et al. Calf muscle characteristics, strength measures, and mortality in peripheral arterial disease: a longitudinal study. J Am Coll Cardiol. 2012;59:1159–1167.CrossRefPubMedCentralPubMedGoogle Scholar
  71. 71.
    Takata Y, Ansai T, Akifusa S, Soh I, Yoshitake Y, Kimura Y, et al. Physical fitness and 4-year mortality in an 80-year-old population. J Gerontol A Biol Sci Med Sci. 2007;62:851–858.CrossRefPubMedGoogle Scholar
  72. 72.
    Saunders DH, Greig CA, Young A, Mead GE. Association of activity limitations and lower-limb explosive extensor power in ambulatory people with stroke. Arch Phys Med Rehabil. 2008;89:677–683.CrossRefPubMedGoogle Scholar
  73. 73.
    Wilson JR, Wiener DH, Fink LI, Ferraro N. Vasodilatory behavior of skeletal muscle arterioles in patients with nonedematous chronic heart failure. Circulation. 1986;74:775–779.CrossRefPubMedGoogle Scholar
  74. 74.
    Zelis R, Nellis SH, Longhurst J, Lee G, Mason DT. Abnormalities in the regional circulations accompanying congestive heart failure. Prog Cardiovasc Dis. 1975;18:181–199.CrossRefPubMedGoogle Scholar
  75. 75.
    Coats AJ, Clark AL, Piepoli M, Volterrani M, Poole-Wilson PA. Symptoms and quality of life in heart failure: the muscle hypothesis. Br Heart J. 1994;72:S36–39.CrossRefGoogle Scholar
  76. 76.
    Bean J, Herman S, Kiely DK, Callahan D, Mizer K, Frontera WR, et al. Weighted stair climbing in mobility-limited older people: a pilot study. J Am Geriatr Soc. 2002;50:663–670.CrossRefPubMedGoogle Scholar
  77. 77.
    Bean JF, Herman S, Kiely DK, Frey IC, Leveille SG, Fielding RA, et al. Increased Velocity Exercise Specific to Task (InVEST) training: a pilot study exploring effects on leg power, balance, and mobility in community-dwelling older women. J Am Geriatr Soc. 2004;52:799–804.CrossRefPubMedGoogle Scholar
  78. 78.
    Blackwell T, Cawthon PM, Marshall LM, Brand R. Consistency of leg extension power assessments in older men: the Osteoporotic Fractures in Men (MrOS) Study. Am J Phys Med Rehabil. 2009;88:934–940.CrossRefPubMedCentralPubMedGoogle Scholar
  79. 79.
    Cuoco A, Callahan DM, Sayers S, Frontera WR, Bean J, Fielding RA. Impact of muscle power and force on gait speed in disabled older men and women. J Gerontol A Biol Sci Med Sci. 2004;59:1200–1206.CrossRefPubMedGoogle Scholar
  80. 80.
    Bean JF, Kiely DK, LaRose S, Alian J, Frontera WR. Is stair climb power a clinically relevant measure of leg power impairments in at-risk older adults? Arch Phys Med Rehabil. 2007;88:604–609.CrossRefPubMedGoogle Scholar
  81. 81.
    Thomas M, Fiatarone MA, Fielding RA. Leg power in young women: relationship to body composition, strength, and function. Med Sci Sports Exerc. 1996;28:1321–1326.CrossRefPubMedGoogle Scholar
  82. 82.
    Power GA, Dalton BH, Rice CL, Vandervoort AA. Reproducibility of velocitydependent power: before and after lengthening contractions. Appl Physiol Nutr Metab. 2011;36:626–633.CrossRefPubMedGoogle Scholar

Copyright information

© Serdi and Springer-Verlag France 2014

Authors and Affiliations

  • S. E. Strollo
    • 1
  • P. Caserotti
    • 2
  • R. E. Ward
    • 3
  • N. W. Glynn
    • 4
  • B. H. Goodpaster
    • 5
  • Elsa S. Strotmeyer
    • 4
    • 6
    Email author
  1. 1.National Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaUSA
  2. 2.Department of Sports Science and Clinical BiomechanicsUniversity of Southern DenmarkOdenseDenmark
  3. 3.Health and Disability Research InstituteBoston University, Spaulding Rehabilitation HospitalBostonUSA
  4. 4.Department of EpidemiologyUniversity of PittsburghPittsburghUSA
  5. 5.Sanford Burnham Medical Research InstituteOrlandoUSA
  6. 6.Department of EpidemiologyUniversity of PittsburghPittsburghUSA

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