Reply to: Comment on “Sarcopenic Obesity, Not Sarcopenia or Obesity Alone, Is Independently Associated With Urinary Incontinence in Older Women”

We thank the authors of the Letter to the Editor for their careful reading of our article and for their thoughtful and constructive critique. We welcome the opportunity to clarify several methodological and interpretative aspects of our study. With respect to the interpretation of phenotype-specific associations, we did not intend to imply a direct statistical superiority of sarcopenic obesity over the other phenotypes based on pairwise comparisons. Rather, all four body composition phenotypes were entered simultaneously into a single multivariable logistic regression model. Within this unified framework, sarcopenic obesity was the only phenotype that showed an independent association with urinary incontinence, whereas sarcopenia alone and obesity alone did not reach conventional levels of statistical significance. Our interpretation was therefore based on model-specific evidence of independent association rather than on explicit phenotype contrasts. To further illustrate this point, we present the same fully adjusted model using an alternative but mathematically equivalent parameterization in which sarcopenic obesity serves as the reference category. In this expression of the model, non-sarcopenic non-obese women exhibited significantly lower odds of urinary incontinence compared with sarcopenic obese women (OR 0.57, 95% CI 0.36–0.90, p = 0.015), while contrasts with other phenotypes remained non-significant. These findings are consistent with partial heterogeneity across phenotypes but do not imply statistically proven differences in effect size between all phenotype categories. We appreciate the concern regarding potential overadjustment due to inclusion of instrumental activities of daily living (IADL). In geriatric populations, IADL limitations often represent an earlier and more sensitive marker of functional vulnerability than basic activities of daily living (ADL), particularly in community-dwelling older adults. ADL and IADL measures are also highly correlated, and to avoid multicollinearity, both were not entered simultaneously into the model. We therefore selected IADL to account for baseline functional status within a geriatric assessment framework. At the same time, we acknowledge that IADL may partially lie on the causal pathway between adverse body composition and urinary incontinence, and thus some attenuation of total effects cannot be excluded in this cross-sectional analysis, which was designed to estimate adjusted associations rather than total causal effects. We acknowledge that different skeletal muscle mass indexing (SMMI) strategies may yield substantially different prevalence estimates and outcome associations in older populations. Our definition of sarcopenic obesity was guided by the ESPEN–EASO consensus, which conceptualizes sarcopenia in obesity as a relative reduction in skeletal muscle mass adjusted to body weight [1]. Accordingly, we used a weight-adjusted SMMI in combination with body fat percentage to operationalize sarcopenic obesity, consistent with recommendations for BIA-based assessments in older populations [1]. Prior studies have raised concerns regarding the performance of height-adjusted muscle indices in geriatric cohorts. In a large bioimpedance-based study of community-dwelling older adults, Bahat et al. demonstrated that height-adjusted SMMI produced markedly lower prevalence estimates compared with weight- or BMI-adjusted measures and showed weaker discrimination for functional outcomes [2]. Similar variability across muscle indexing strategies has also been recognized in recent European consensus reports, which emphasize that no single adjustment method is universally optimal and that operational definitions should be selected in accordance with population characteristics and study aims [3]. Consistent with these observations, applying height-adjusted cut-offs in our cohort resulted in very small numbers of participants classified as sarcopenic obesity, substantially limiting statistical power and the reliability of multivariable analyses. We therefore opted for a weight-adjusted SMMI to preserve analytic robustness and conceptual consistency with our body fat–based definition of obesity, while acknowledging that alternative definitions warrant evaluation in larger samples. Neslihan Hazel Önür drafted the response to the Letter to the Editor. Tuğba Erdoğan and Gülistan Bahat critically reviewed the manuscript and contributed to the interpretation and refinement of the responses. All authors approved the final version submitted for publication. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a related comment by Wang and Zhang. To view this article, visit https://doi.org/10.1111/jgs.70315.