falling not only results in physical injury but also limits the physical activity of 
 elderly people who have experienced falls , as the majority of elderly people with a history 
 of falling fear that they will fall again1 .
numerous studies have argued that elderly people living in 
 communities have a fear of falling , which acts as an obstacle to maintaining an independent 
 daily life2,3,4 .
not all falls lead to 
 physical injury , but approximately 20% of falling accidents require medical treatment ; for 
 those who are 75  years or older , this need for medical treatment is doubled5 .
an analysis of previous studies revealed that factors related to falls can be divided into 
 intrinsic and extrinsic factors6 . 

specifically , internal factors include the person s age , physical abilities including 
 strength and balance , pain , history of falls , orientation , cognitive abilities , and the fear 
 of falling ; external factors include medication intake and environmental factors7 , 8 . 
 among the internal factors , however , research on whether obesity directly affects the 
 occurrence of falls is limited .
statistically significant positive correlation was 
 previously observed between body mass index ( bmi ) and functional mobility in the elderly 
 population , and obesity was related to falls9 . among the existing research10 , a relationship between obesity in the elderly and falls has been 
 shown , and it has been proposed that a lower bmi leads to an increase in osteoporosis due to 
 insufficient nutritional supply , which eventually leads to severe injury from a fall11 .
the present examined the effects of bmi 
 after a fall rather than investigating the degree of obesity as a direct cause of falls .
the rate of obesity is increasing as a result of economic development and the 
 westernization of lifestyles , and this leads to various adult disease states12 .
however , it is difficult to define 
 obesity , and accurate measurement is very limited .
although the amount of fat tissue in the 
 body can be measured , its general use is unfeasible because the measurement method is very 
 difficult , time - consuming , and costly . nevertheless , the development of measurement methods 
 using bioelectric impedance analysis ( bia ) has allowed obesity to be measured more 
 specifically13 . among the various bia 
 instruments ,
the inbody 720 ( biospace , seoul , korea ) presents a very simple method of 
 analyzing body composition and is a very useful tool for predicting falls in the elderly . 

notably , existing bmi values provide measurements based on the weight  height ratio , and 
 their accuracy for the very young or elderly is limited12 .
computed tomography ( ct ) scans can be used to obtain an accurate 
 visceral fat measurement , but this method is also limited by its costliness .
however , the 
 measurement of visceral fat can be very useful because it is closely related to the risk of 
 coronary arterial diseases and lifestyle diseases14 .
the aforementioned limitations of other measurement methods can be 
 overcome with bia , which is useful in terms of cost and time reduction15 .
in addition to rehabilitative approaches after an acquired disability , occupational therapy 
 emphasizes health improvement and disease prevention so that people can lead healthy lives 
 by avoiding the onset of disabilities in the first place16 . to age successfully , it is very important for individuals to 
 participate continuously in their own lives17 .
therefore , reduced balance ability , muscle weakening , experience 
 of falling , walking ability limitations , and the fear of falling have been evaluated as part 
 of an effort to prevent falls in the elderly population18 , and various preventative intervention programs have been 
 implemented19 , 20 .
however , there have been very few studies on the effects of 
 obesity on falls in the elderly ; various evaluations and interventions have assigned very 
 little importance to obesity .
therefore , the present study attempted to investigate the 
 effects of obesity on falls as a practical means of identifying the necessity of 
 obesity - related interventions in future fall prevention programs .
the local government of a single rural community provided a list of elderly people living 
 in the community .
the 
 final number of study participants was 172 men and 179 women , who were surveyed for their 
 health and experience of falling between march and june 2011 .
we obtained written informed 
 consent in the form of a research participation agreement from each patient .
we trained raters for 1 week 
 on how to use the assessment tools to increase the reliability .
the fear of falling is defined as low perceived 
 self - efficacy or low sense of assurance at avoiding a fall , and fall efficacy is determined 
 by measuring this fear21 .
it consists of 10 
 questions on the degree of confidence related to fall prevention in daily life , with a 
 minimum score of 10 and a maximum score of 10022 .
the test  retest reliability was assessed with cronbach s  , which 
 was 0.9621 .
the state of excessive accumulation of 
 body fat so as to be harmful for health  ; however , as it is difficult to measure the amount 
 of body fat , the bmi was proposed as the index for obesity23 .
the present study measured the bmi and visceral fat area ( vfa ) 
 using a multi - frequency impedance meter ( inbody 720 ; biospace ) that measures the impedance 
 for each part of the body .
the bmi is a measurement based on the ratio between weight and 
 height . although it is inaccurate for the very young or very old and for individuals with 
 excessive muscle mass such as athletes , it is generally the most reliable measurement and is 
 recommended by the who24 .
kg / m and first - degree obesity as a bmi > 30  kg / m .
ct is 
 usually used as the basis for determining visceral fat accumulation , but the present study 
 used the vfa as determined with an inbody 720 , a measurement whose usefulness was confirmed 
 by gibson et al15 .
the vfa refers to the 
 fat that has accumulated inside organs or in the empty spaces between organs .
vfas exceeding 
 110  cm are indicative of visceral obesity ; it is notable that approximately 
 40% of all coronary arterial disease patients exhibit an excessive accumulation of visceral 
 fat ( > 120  cm)25 , 26 .
the validity of the inbody 720 used in the present study 
 was proposed by gibson et al.15 , who 
 showed that the correlation coefficient was 0.93 for both the dual energy x - ray 
 absorptiometry scan and the underwater weighing method , which were used as references for 
 the accuracy of body composition analysis .
the faces pain scale was previously used to measure pain in young children who had 
 difficulties expressing themselves27 . 

scherder and bouma also used the faces pain scale to measure pain in alzheimer s 
 patients28 .
the results of a validity 
 analysis using the visual analogue scale and colored analogue scale in pediatric subjects 
 were 0.92 and 0.92 , respectively29 .
the abilities assessed by the timed up and go ( tug ) test are movements such as mobility 
 after sitting down and then getting up , balance ability , the ability to walk a short 
 distance , and the ability to turn .
the test is carried out by measuring the time taken by 
 the subject to get up from an armchair upon the researcher s signal , walk 3 m , and return to 
 the chair30 .
the tug test was previously 
 performed on 60 elderly patients who utilized a day clinic , and it was found that the 
 inter - tester and intra - tester reliabilities were 0.98 and 0.99 , respectively31 . to test static balance ,
the person taking 
 the measurements demonstrated the standing pose before the test was administered .
subjects 
 were instructed to cross their arms , close their eyes , and stand on both legs before lifting 
 one leg so that the knee was bent at a 90 angle . the time was measured from the moment the 
 subject lifted one leg to when the lifted leg touched the floor or when the subject opened 
 his or her eyes .
measurements were performed 3 times while alternating between each foot , 
 and the highest value was selected32 .
descriptive statistics were used to determine the general characteristics of the study 
 participants as well as basic information for the variables . an independent sample t - test 

the correlations between the 
 variables were identified before confirming the causality for fall efficacy , i.e. , the 
 dependent variable , after which the final multiple regression analysis was carried out for 
 the dependent variable . a significance level of 95%
the descriptive statistics analysis results of the 351 study participants are summarized in 
 table 1table 1 .
descriptive analysis ( n=351)minimummaximummeansdfalls efficacy4.0010.009.080.81bmi17.1034.0024.513.42vfa5.00231.90127.5434.08pain1.0010.005.812.59mobility1.0023.7510.523.02balance0.0068.509.799.83age60.0093.0073.536.18gender0.001.000.490.50bmi : body mass index , vfa : visceral fat area , 
 gender : dummy variable ( 1=male , 0=female ) .
the mean fall efficacy was 9.08 ( 0.83 ) , while the mean bmi was 24.51 
 ( 3.42 )  kg / m , which was slightly lower than the overweight criterion of 
 25  kg / m .
the mean vfa was 127.54 ( 34.08 ) cm , which was higher than 
 the reference value of 110  cm ; therefore , visceral obesity was confirmed .
the 
 mean values for pain , locomotion speed , and balance ability were 5.81 ( 2.59 ) , 10.52 ( 3.02 ) 
 seconds , and 9.79 ( 9.83 ) , respectively .
for the demographic characteristics , the mean age 
 was 73.53 ( 6.18 ) years , and the sex ratio was 49.0% men and 51% women .
bmi : body mass index , vfa : visceral fat area , 
 gender : dummy variable ( 1=male , 0=female ) the results of the correlation analysis between the dependent variable fall efficacy and 
 the independent variables are summarized in table 
 2table 2 .
correlations among the variables ( n=351)falls efficacybmivfapainmobilitybalanceagebmi0.16*vfa0.120.75***pain0.40***0.030.06mobility0.41***0.010.020.30***balance0.25**0.080.20**0.23***0.26***age0.23**0.090.14 * 0.24***0.38***0.31***gender0.18*0.30***0.12*0.23***0.20***0.16**0.06*p<0.05 ; * * p<0.01 ; * * * p<0.001 . upon examining the statistically significant variables , it was clear that 
 balance ability had a positive correlation with fall efficacy , while there was a negative 
 correlation with the remaining variables ( pain , locomotion , bmi , visceral obesity , age , 
 sex ) .
in addition , the correlation between the independent variables showed that pain had a 
 positive correlation with locomotion , age , and sex and a negative correlation with balancing 
 ability .
there was a negative correlation between locomotion and balance ability , and a 
 negative correlation between age and sex .
the bmi , the index for obesity , had a positive 
 correlation with visceral fat and sex .
regression estimates for fall efficacy ( n=351)variablesmodel 1model 2model 3bbbbody factorbmi0.08*0.08*0.10**vfa0.000.000.00pain0.14***0.10***0.10***body functionmobility0.11***0.11***balance0.010.01demographicgender0.18age0.01constant11.51***12.33***13.40***f10.72***12.11***8.84***r0.190.310.31*p<0.05 ; * * p<0.01 ; * * * p<0.001 lists the results of the multiple regression analysis of the factors 
 determining the final dependent variable , fall efficacy .
model 1 was an analysis of the 
 physical factors bmi , vfa , and pain , while model 2 also included physical functions .
the 
 results of model 1 had an f - value of 10.72 and a p - value of 0.00 , suggesting that the model 
 was appropriate .
the r value , the explanatory power of the physical functions 
 included as variables to explain the dependent variable , was 18.80% .
model 2 had an f - value 
 of 12.11 and a p - value of 0.00 , suggesting that the model was appropriate . when mobility and 
 balance ability were also included as explanatory variables ,
model 3 had an f - value of 8.84 and a p - value of 0.00 , suggesting that the model was 
 appropriate , while r , the explanatory power when physical function , degree of 
 obesity , and demographic variables were included as explanatory variables , was 31.40% .
as 
 each model was appropriate , lower degrees of pain and obesity were associated with higher 
 fall efficacy in model 1 . in model 2 ,
fall efficacy was higher when the bmi , degree of pain , 
 and locomotion speed were low and moving ability was fast .
the results of model 3 were the 
 same as those of model 2 , and the demographic variables included as control variables were 
 not significant .
the present study showed that a high bmi has a negative effect on fall efficacy .
this 
 finding is consistent with the results , which showed that the degree of obesity affects fall 
 efficacy33 .
in other words , it is 
 believed that obesity reduces activity in the elderly , thereby increasing the fear of 
 falling . however , a relationship between obesity in the elderly and falls has been shown , 
 and it has been proposed that a lower bmi leads to a higher risk of severe injury11 . in women in particular ,
a low bmi and 
 rapid decrease in weight may lead to severe injury from a fall , as insufficient nutritional 
 supply leads to a higher risk of osteoporosis .
this finding emphasizes the influence of bmi 
 on the risk of injury after a fall rather than proposing the bmi itself as a direct 
 influence for a fall11 .
however , the 
 results of the present study indicate that the bmi does have a direct causal effect on fall 
 efficacy . according to a 2008 survey ,
46.20% of the korean population aged 6069  years was obese , 
 while 31.70% of the population aged 70  years and over was obese34 .
elderly people living in modern society tend to have a 
 high bmi due to excessive nutritional intake and low activity levels , and the relationship 
 between falls and obesity needs to be studied continuously . to this end , a variety of 
 methods in addition to the more superficial measurement of the bmi should be used to measure 
 the actual degree of obesity .
along with the bmi , the present study used the vfa , which 
 affects lifestyle diseases ; however , the analysis found that the vfa was not a significant 
 factor for fall efficacy .
in addition , mobility is an important factor that affects falls in the elderly35 , 36 . the elderly experience significant muscle loss , which amounts to 
 more than 25% in people aged over 65  years and approximately 50% in people over 80  years 
 old37 .
such a reduction in muscle mass 
 affects functional movement and increases the fear of falling38 .
the present study was also consistent with prior studies in that 
 fall efficacy was lower when locomotion time was longer .
the loss of muscle mass in the 
 elderly leads to reductions in physical strength , activity level , and the abilities required 
 for daily living , eventually rendering independent life impossible38 .
occupational therapy must understand the process of 
 physical change in the elderly accurately and actively participate in the promotion of 
 health .
physical factors include weakening of lower body strength , reduction in walking ability , 
 reduced balance ability , reduced grip , sensory deficits such as vision impairment , and 
 decreased sensory motor control39 . among 
 these
, balance ability has been proposed as an important factor for predicting falls in the 
 elderly35 , but it was not significant 
 in the present study .
it is 
 believed that dynamic balance , rather than static balance , is more meaningful when 
 considering balance ability for falls6 . in 
 future research ,
nevertheless , the results of examining the correlation between obesity and balance ability 
 showed that there was a statistically significant positive correlation with visceral 
 obesity .
these results are consistent with the findings of the study of han , in which the 
 weight of the obese group exerted an additional mean pressure of 5.12% on the heels , which 
 had a negative effect on balance ability10 .
therefore , it is believed that the risk of a fall is increased for 
 obese individuals because postural stability is compromised , thereby limiting movement . a literature review that analyzed the results of 51 studies on fall risk factors in the 
 elderly individuals living in communities found that pain affected physical function in the 
 elderly in addition to being a risk factor for falls40 . in the study by jeon et al .
, the mean age of the participants was 
 72  years , and most of them complained of physical discomfort such as joint pain ; this 
 discomfort was an important factor that determined fall efficacy33 . in the present study ,
accordingly , fall assessment and 
 intervention programs for the elderly must account for the influence of pain .
   [ purpose ] the aim of this study was to identify the effects of obesity on 
 falls as a practical verification of the importance of obesity - targeting interventions as 
 part of future fall prevention programs . [ subjects and methods ] the study involved 351 
 elderly people ( 172 men , 179 women ) living in rural areas . 
 the dependent variable , fall 
 efficacy , was measured using the falls efficacy scale , while the independent variables , 
 body mass index ( bmi ) and visceral fat , were measured using the inbody 720 . 
 the faces pain 
 scale was used to measure pain . 
 mobility was measured using the timed up and go test , and 
 balance ability was measured according to the duration subjects could stand on one foot 
 with their eyes closed . 
 hierarchical multiple regression analysis was performed for the 
 final data analysis . 
 [ results ] investigation of the correlations between the variables 
 revealed a negative correlation between fall efficacy and the other variables . 
 ultimatley , 
 investigation of the causality of fall efficacy revealed that the bmi , pain , and mobility 
 were influential factors . in other words , fall efficacy tends to be lower when there are 
 higher degrees of obesity , increased pain , and decreased mobility . 
 [ conclusion ] to improve 
 the fall efficacy of elderly people living in rural areas , pain management and the 
 maintenance of physical functionality are required . 
 the present study confirms that the 
 elderly need continuous obesity management to lead healthy lives . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION