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BMI and all-cause mortality in older adults: A meta-analysis
Abstract
Whether the association between body mass index (BMI) and all-cause mortality for older adults is the same as for younger adults is unclear.
The objective was to determine the association between BMI and all-cause mortality risk in adults ≥65 y of age.
A 2-stage random-effects meta-analysis was performed of studies published from 1990 to 2013 that reported the RRs of all-cause mortality for community-based adults aged ≥65 y.
Thirty-two studies met the inclusion criteria; these studies included 197,940 individuals with an average follow-up of 12 y. With the use of a BMI (in kg/m(2)) of 23.0-23.9 as the reference, there was a 12% greater risk of mortality for a BMI range of 21.0-21.9 and a 19% greater risk for a range of 20.0-20.9 [BMI of 21.0-21.9; HR (95% CI): 1.12 (1.10, 1.13); BMI of 20.0-20.9; HR (95% CI): 1.19 (1.17, 1.22)]. Mortality risk began to increase for BMI >33.0 [BMI of 33.0-33.9; HR (95% CI): 1.08 (1.00, 1.15)]. Self-reported anthropometric measurements, adjustment for intermediary factors, and exclusion of early deaths or preexisting disease did not markedly alter the associations, although there was a slight attenuation of the association in never-smokers.
For older populations, being overweight was not found to be associated with an increased risk of mortality; however, there was an increased risk for those at the lower end of the recommended BMI range for adults. Because the risk of mortality increased in older people with a BMI <23.0, it would seem appropriate to monitor weight status in this group to address any modifiable causes of weight loss promptly with due consideration of individual comorbidities.
... Conversely, a higher BMI was associated with a decreased risk of mortality and cardiac and respiratory complications. Our findings align with several previously published studies demonstrating that overweight and obese patients have a higher long-term survival rate (10,11), including after surgery (12). Conversely, those who are underweight face a higher risk of mortality (10) and developing post-operative complications (12) when compared to individuals with a higher BMI. ...
... They also found that BMI was a more effective predictor when treated as a continuous variable rather than a categorical variable, indicating that the risk of mortality and blood transfusion had a reverse J-shaped relationship with BMI (15). Moreover, those studies have also highlighted the limitations of using BMI alone as a predictor, especially in older individuals, emphasizing the need for a more nuanced approach to risk assessment in this population (10)(11)(12). ...
... In addition, sarcopenic patients are at risk of postoperative pulmonary complications such as aspiration and atelectasis due in part to impaired respiratory muscle function (25). Malnutrition, often associated with low BMI, can also be an overlapping condition contributing to poorer outcomes in older individuals (11,16,22). Regular physical activity, even at modest levels, can help frail older adults maintain muscle mass and mitigate the negative effects of aging and disease on body composition (26). ...
Introduction
This retrospective cohort study investigated the “Hajeer score” (age/BMI) as a predictor of 30-day postoperative outcomes pertaining to morbidity and mortality following total hip arthroplasty.
Methods
Using the National Surgical Quality Improvement Project database from 2011 to 2021, this study analyzed perioperative factors and 30-day postoperative complications in relation to age, BMI, and the Hajeer score. The complications evaluated included venous thromboembolism, pneumonia, acute myocardial infarction, readmission rates, and 30-day mortality. Patients were categorized based on their age, BMI, and Hajeer score and adjusted odds ratios (aORS) for morbidities and mortality were calculated by multivariate logistic regression.
Results
A total of 321,973 patients who underwent total hip arthroplasty were included in this study. Risk of mortality and various other outcomes (including cardiac, respiratory, urinary, and central nervous system diseases, thromboembolism, sepsis, blood transfusion, and composite morbidity) increased with age. Conversely, a higher BMI was linked to a lower risk of mortality, cardiac and respiratory diseases, and blood transfusion. A higher Hajeer score (>3) was strongly associated with an increased risk of mortality [adjusted odds ratio [OR]: 20.06, 95% confidence interval [CI]: 2.81–143.08, p < 0.05], cardiac diseases (adjusted OR: 8.53, 95% CI: 1.19–60.96, p < 0.0001), respiratory diseases (adjusted OR: 1.40, 95% CI: 1.40–1.41, p < 0.0001), and blood transfusion (adjusted OR: 2.12, 95% CI: 1.73–2.60, p < 0.05).
Conclusion
The Hajeer score could be a more effective predictor of short-term (30-day) postoperative outcomes than either age or BMI alone.
... Nevertheless, its rapidity and ease of assessment allow it to continue to be evaluated in clinical practice. In this sense, this marker is also a matter of debate because different studies have found controversial information with different anthropometric markers [29][30][31]. In fact, some authors have proposed other cut-off points to identify obesity in this population [29,31,32]. ...
... In this sense, this marker is also a matter of debate because different studies have found controversial information with different anthropometric markers [29][30][31]. In fact, some authors have proposed other cut-off points to identify obesity in this population [29,31,32]. In addition, this cutoff point could vary depending on the adverse event studied. ...
... In addition, this cutoff point could vary depending on the adverse event studied. For example, it is possible that the risk of disability starts to increase from a BMI of 28 [32], while the risk of death starts to increase from 33 [31,32]. In fact, a recent systematic review proposed that obesity impairs older adults' physical function with sarcopenia but increases their survival prognosis [33]. ...
Background: There is no gold standard definition of sarcopenic obesity (SO). Our objective is to evaluate the benefit of using the new definition proposed by the European Association for the Study of Obesity (EASO) in older people. Methods: Data from the Toledo Study of Healthy Aging, a study based on a cohort of community-dwelling older adults, were used. SO was defined according to the EASO and by a composite of the Foundation for the National Institute of Health (FNIH) for the diagnosis of sarcopenia and the WHO’s criteria for obesity (Body Mass Index, BMI ≥ 30 kg/m2; waist circumference, >88 cm for women and >102 cm for men). Frailty [Frailty Phenotype (FFP) and Frailty Trait Scale-5 (FTS5)] and disability (Katz Index) statuses were assessed at baseline and at the follow-up (median 2.99 years). Mortality at a 5-year follow-up was also assessed. The Logistic and Cox regression models were used to assess the associations. Results: Of the 1559 subjects (age 74.79 ± 5.76 years; 45.54% men), 30.15% (EASO/ESPEN) vs. 16.36% (FNIH) met the SO criteria (Kappa = 0.42). SO was associated with the prevalence of frailty by both the EASO’s [OR(95%CI): FFP: 1.70 (1.33–2.16); FTS-5 binary: 2.29 (1.60–3.27); β(95%CI): FTS-5 continuous 3.63 (3.00–4.27)] and FNIH+WHO’s criteria [OR (95%CI): 2.20 (1.61, 3.00)]. The FNIH + WHO’s criteria were cross-sectionally associated with disability [OR: 1.52 (1.07, 2.16); p-value 0.018], while the EASO’s criteria were not. The EASO’s criteria did not show any association at the follow-up, while the FNIH + WHO’s criteria were associated with incident frailty. Conclusions: The EASO’s new criteria for sarcopenic obesity demonstrate moderate agreement with the traditional definition and are cross-sectionally associated with adverse events, but they do not effectively predict the outcomes generally associated with sarcopenic obesity in older adults. Therefore, the performance of the EASO’s criteria in older people raises the need for refinement before recommending it for generalized use in this population.
... Some of the main predictors found in this study are already known risk factors for all-cause mortality, such as age and BMI 19,20 . With advancing age, the risk of mortality increases, as this is to be expected, especially in older adults with chronic problems. ...
... On the other hand, a metaanalysis of cohort studies showed that healthy ageing reduces the risk of allcause mortality by 50% 25 , demonstrating the importance of building healthy habits throughout life. While our results showed BMI as an important predictor of mortality, interestingly, in older populations, a meta-analysis showed that overweight was not a risk factor for mortality 19 , which may be related to survival bias in this population. ...
... While the World Health Organization suggests that a healthy BMI for adults ranges from 18.5 to 24.9 kg/m 2 on the basis of relative risk of some diseases related to overweight or obesity [11], this may not be suitable for older adults due to multiple factors including age-related physiological changes and chronic disease [12]. A higher BMI range of 25-35 kg/m 2 has been proposed based on reduced mortality risk in older adults [12][13][14]. ...
... While the World Health Organization suggests that a healthy BMI for adults ranges from 18.5 to 24.9 kg/m 2 on the basis of relative risk of some diseases related to overweight or obesity [11], this may not be suitable for older adults due to multiple factors including age-related physiological changes and chronic disease [12]. A higher BMI range of 25-35 kg/m 2 has been proposed based on reduced mortality risk in older adults [12][13][14]. A prior publication assessing the effect of baseline subgroups on the efficacy of tirzepatide in adults with T2D found that neither baseline age (< 65 years, ≥ 65 years) nor BMI (< 30, 30 to < 35, ≥ 35 kg/m 2 ) had a significant effect on the ability of participants to achieve HbA1c ≤ 6.5%, attain a weight reduction of ≥ 10%, or increase the risk of hypoglycemia [15]. ...
Tirzepatide, a once-weekly glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 receptor agonist approved in the US for treating type 2 diabetes (T2D) and obesity, has demonstrated significant improvements in glycated hemoglobin A1c (HbA1c) and clinically meaningful weight loss in the SURPASS-1 to -5 clinical trials. This post hoc analysis examined the safety and efficacy results for tirzepatide in older participants with T2D who do not have obesity.
A post hoc analysis was conducted on a subgroup of participants aged ≥ 65 years with a body mass index (BMI) < 30 kg/m2 amongst the pooled SURPASS-1 through -5 clinical trial populations. Primary efficacy endpoints and safety were assessed for both this subgroup and overall pooled populations.
Participants aged ≥ 65 years with BMI < 30 kg/m2 treated with tirzepatide experienced clinically meaningful HbA1c reduction (− 1.97 to − 2.10%) regardless of the assigned randomized maintenance dose. In contrast, a dose-proportional HbA1c decrease was observed in the overall population. Weight reduction in this subgroup was dose-proportional but numerically lower than in the overall population. Older participants without obesity were more likely to discontinue treatment due to adverse events (AEs), although the overall incidence of AEs was low in this subgroup. The incidence of hypoglycemia in this group was consistent with that of the overall cohort, regardless of concurrent insulin or sulfonylurea use.
Tirzepatide may be an effective treatment for older adults without obesity, and in this post hoc analysis, it was associated with clinically relevant HbA1c reduction and dose-proportional weight loss without increasing hypoglycemic risk.
... By 2030, one in six individuals worldwide will be aged 60 years or older [1]. Older adults are particularly vulnerable to undernutrition due to impaired taste and smell, reduced appetite, chronic diseases, polypharmacy, and psychosocial changes [2,3]. Undernutrition has been associated with an increased risk of all-cause mortality [2,4,5]. ...
... Older adults are particularly vulnerable to undernutrition due to impaired taste and smell, reduced appetite, chronic diseases, polypharmacy, and psychosocial changes [2,3]. Undernutrition has been associated with an increased risk of all-cause mortality [2,4,5]. Studies on older adults have indicated that overweight and mild obesity are associated with similar or lower overall mortality risk compared with normal-weight individuals [6,7]. ...
... Somewhat paradoxically, those aged 65 to 75 years are at greater risk of both excess body mass and low body mass, compared with young and mid-life adults [183]. Though it is a low body mass and a loss of mass, rather than excess body mass or gains in mass, that pose the greatest risk of mortality in older adults [184,185] Consequently, research exploring the physiology of appetite control in later life has predominantly focused on the association between age-related alterations in appetite and the development of undernutrition, as opposed to overweight and obesity. ...
... In both studies, a novel multicriteria classification model was used to phenotype older adults with low appetite. Older adults were considered to have suppressed appetite if 2 of the following 4 criteria were met: low weight (BMI <23 kg m −2 [184,193]), score of <15 on the Simplified Nutritional Appetite Questionnaire [194], habitual energy intake <75% of estimated daily total energy requirements (as identified by the World Health Organization as indicative of undernutrition), and a laboratory-measured ad libitum lunch intake of <25% of estimated total energy requirements (based on a typical lunch energy intake of ∼27% of total energy intake in UK adults [195]). Holliday et al [47] determined total and acyl-ghrelin concentrations in older adults with low appetite, older adults exhibiting a healthy appetite, and young adults in both the fasted and fed states. ...
Appetite-related hormones are secreted from the gut, signaling the presence of nutrients. Such signaling allows for cross-talk between the gut and the appetite-control regions of the brain, influencing appetite and food intake. As nutritional requirements change throughout the life course, it is perhaps unsurprising that appetite and eating behavior are not constant. Changes in appetite-related gut hormones may underpin these alterations in appetite and eating.
In this article, we review evidence of how the release of appetite-related gut hormones changes throughout the life course and how this impacts appetite and eating behaviour. We focus on hormones for which there is the strongest evidence of impact on appetite, food intake, and body weight: the anorexigenic glucagon like peptide-1, peptide tyrosine tyrosine, and cholecystokinin, and the orexigenic ghrelin. We consider hormone concentrations, particularly in response to feeding, from the very early days of life, through childhood and adolescence, where responses may reflect energy requirements to support growth and development. We discuss the period of adulthood and midlife, with a particular focus on sex differences and the effect of menstruation, pregnancy, and menopause, as well as the potential influence of appetite-related gut hormones on body composition and weight status. We then discuss recent advancements in our understanding of how unfavorable changes in appetite-related gut hormone responses to feeding in later life may contribute to undernutrition and a detrimental aging trajectory. Finally, we briefly highlight priorities for future research.
... The Body Mass Index (BMI) was widely used for classifying obesity due to its simplicity and cost-effectiveness [5], but its reliability has been increasingly questioned [6], as individuals with the same BMI may have a different body composition and health status [7]. The relationship of BMI with all-cause mortality remains controversial; several metaanalyses reported a positive association with BMI starting from values > 25 kg/m 2 [8][9][10], while others showed that patients with overweight or class I obesity may face similar or even diminished risks for all-cause mortality compared to normal weight subjects [11][12][13]. ...
... However, it is interesting to note that, although the EOSS classification already summarizes most of the information regarding obesityrelated comorbidities, BMI per se still retained an independent predictive role for the risk of all-cause mortality. In particular, consistent with the existing literature [11][12][13], significantly worse survival outcomes were observed for patients with obesity class II and III, independently of prevalent comorbidities classified by EOSS. ...
Objective: To assess the complementary role of the Body Mass Index (BMI) and Edmonton Obesity Staging System (EOSS) in predicting all-cause and cause-specific mortality in people living with overweight and obesity (PLwOW/O). Methods: A longitudinal analysis of prospectively collected data from the 1999–2018 cycles of the National Health and Nutrition Examination Survey (NHANES) was conducted. The association between BMI, EOSS, and mortality was evaluated through Cox regression models, adjusted for confounders. Results: The analysis included 36,529 subjects; 5329 deaths occurred over a median follow-up of 9.1 years (range: 0–20.8). An increased mortality risk was observed for obesity class II and III (HR = 1.21, 95% CI 1.08–1.36, p = 0.001 and HR = 1.58, 95% CI 1.39–1.80, p < 0.001; compared to overweight), and for EOSS stage 2 and 3 (HR = 1.36, 95% CI 1.16–1.58, p < 0.001 and HR = 2.66, 95% CI 2.26–3.14, p < 0.001; compared to stage 0/1). The prognostic role of BMI was more pronounced in younger patients, males, and non-Black individuals, while that of EOSS was stronger in women. Both BMI and EOSS independently predicted cardiovascular- and diabetes-related mortality. EOSS stage 3 was the only predictor of death from malignancy or renal causes. Conclusions: BMI and EOSS independently predict all-cause and cause-specific mortality in PLwOW/O. Their integrated use seems advisable to best define the obesity-related mortality risk.
... the relative risk of poorer outcomes attributable to higher BMI is often ameliorated in older adults [35,36]. Therefore, it is possible that the associations between UPF intake and disease are attenuated in older adults due to the potential benefit in maintaining nutritional reserve (higher BMI) in this age group. ...
... This frailty index has been previously shown in the ASPREE population to stratify groups at risk of reduced disability-free survival [54]. BMI cut-offs were stratified as underweight < 23 kg/m 2 , normal weight 23-28 kg/m 2 , overweight 28-33 kg/m 2 , or obese ≥ 33 kg/m 2 due to different optimal BMIs for older adults than younger adults [35]. Central adiposity was defined as ≥88 cm (female) and ≥102 cm (male) [56]. ...
Dietary patterns contribute to overall health and diseases of ageing but are understudied in older adults. As such, we first aimed to develop dietary indices to quantify Mediterranean Diet Score (MDS) utilisation and Ultra-processed Food (UPF) intake in a well-characterised cohort of relatively healthy community-dwelling older Australian adults. Second, we aimed to understand the relationship between these scores and the association of these scores with prevalent cardiometabolic disease and frailty. Our major findings are that in this population of older adults, (a) pre-frailty and frailty are associated with reduced MDS and increased UPF intake; (b) adherence to MDS eating patterns does not preclude relatively high intake of UPF (and vice versa); and (c) high utilisation of an MDS eating pattern does not prevent an increased risk of frailty with higher UPF intakes. As such, the Mediterranean Diet pattern should be encouraged in older adults to potentially reduce the risk of frailty, while the impact of UPF intake should be further explored given the convenience these foods provide to a population whose access to unprocessed food may be limited due to socioeconomic, health, and lifestyle factors.
... For some of the health markers, we also found significant change correlations in the expected directions, suggesting that increases or decreases in sense of purpose go hand in hand with better or worse health, respectively. We found these long-term change associations across the 12 years covered in this study for self-reported health, vision, hearing, walking speed, BMI differences from 26 (absolute difference to a suggested ideal BMI for older adults [Winter et al., 2014]), and physical conditions. In addition to these long-term change associations, we also found that participants reported a weaker sense of purpose in the years in which they also reported worse self-rated health, more physical conditions or limitations with activities of daily living (both basic and instrumental; B/IADLs). ...
Sense of purpose is a key construct explaining individual differences in health. However, much is still unclear about how sense of purpose and health affect each other over time in older age. Using four waves of data from the Health and Retirement Study ( N = 11,390, 50+ years old) spanning 12 years, we investigated the reciprocal associations between sense of purpose and multiple objective and subjective markers of health (e.g., self-reported health; grip strength). Across the 12 years, better health was associated with higher levels of purpose for all investigated health markers. Cross-lagged panel models implied reciprocal associations for 6 of the 11 health markers. When looking at within-person associations (i.e., random intercept cross-lagged models), purpose emerged as a stronger predictor of later health than the other way around, with purpose changes predicting subsequent within-person changes in five health markers while changes in only two health markers predicted later changes in purpose. Taken together, these findings further support the notion that sense of purpose has protective effects against health decline. We discuss the findings in the context of lifespan theory and emphasize the potential benefit of considering sense of purpose as a target for public health interventions.
... In general, obesity increases mortality or morbidity in patients with ICH [4][5][6]. However, several reports have shown that the obesity paradox leads to lower mortality in overweight and obese patients with ICH [5,7,8]. ...
Background:
Body mass index (BMI) is associated with the sites of intracerebral hemorrhage (ICH), which affect functional decline. However, the optimal BMI range for minimizing functional decline remains unclear. This study aimed to clarify the relationship between BMI and ICH-related functional decline.
Methods:
ICH survivors registered in the Japanese Registry Of All Cardiac and Vascular Diseases Diagnosis Procedure Combination (JROAD-DPC) database from April 2016 to March 2020 were included. BMI was categorized according to the World Health Organization Asia-Pacific classification. The primary outcome was ICH-related functional decline, defined as an increase in the modified Rankin Scale (mRS) score at discharge compared to pre-stroke.
Results:
This study included 155,211 patients with ICH, with a mean BMI of 22.3 kg/m2. Among these patients, 74.1% experienced ICH-related functional decline. The overweight group (23.0 < BMI ≤ 25.0 kg/m2) exhibited the lowest rate of functional decline (Odds ratio: 0.90, 95% CI: 0.85-0.94). The relationship between BMI and ICH-related functional decline followed a U-shaped curve, indicating that a BMI range of 22.2-30.4 kg/m2 was associated with reduced odds of functional decline.
Conclusion:
In patients with ICH, both extremely low and high BMIs were associated with a higher likelihood of functional decline post-ICH onset. Maintaining a BMI within the range of 22.2-30.4 kg/m2 may be beneficial for reducing the risk of functional decline.
... Given the variability in study quality and outcomes of previous studies, the relationship between tooth loss and risk of cognitive impairment in older adults is inconclusive. Low body weight is particularly common in old age and is strongly associated with the risk of all-cause death and adverse outcomes in older adults [13]. Only one study investigated the mediating role of BMI in the relationship between tooth loss and cognitive impairment [14]. ...
Objective
Our study aimed to investigate the relationship between the number of teeth remaining and cognitive impairment among Chinese older adults, and to explore the role of low body weight in this association.
Methods
Data were drawn from 2011 to 2014 surveys of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), involving 4056 respondents who had no cognitive decline and aged ≥ 65 years at baseline. Cognitive function was measured by the Mini-Mental Status Examination (MMSE), and the cognitive impairment was classified according to the length of education. Number of natural teeth was self-reported (classified as ≥ 20, 10–19, 1–9, and 0). Low body weight was defined as having a body mass index (BMI) of less than 18.5 kg/m². Cox proportional hazards regression and mediation effect analyses were applied in the study.
Results
Comparing with participants with ≥ 20 teeth, 10–19 teeth and 1–9 teeth, those with 0 teeth (HR:2.14, 95% CI: 1.51, 3.03) were significantly associated with higher cognitive impairment risk in the fully adjusted model. Compared with denture users, the fully adjusted HR (95% CI) for non-denture users was 1.33 (1.04, 1.70). no teeth with non-denture users had the highest cognitive impairment risk (HR:1.63, 95% CI: 1.10, 2.41). Low body weight mediated 6.74% (ranging from 3.49 to 11%) of the association between the number of teeth remaining and cognitive impairment.
Conclusion
Tooth loss increases the risk of cognitive decline, and low body weight partially mediates this association.
Clinical trial number
This is a retrospective cohort study targeting a population survey, which does not involve clinical trials and does not have clinical trial numbers.
... Les experts sont généralement d'accord sur le fait qu'il n' est le plus souvent pas nécessaire que les personnes âgées en surpoids perdent du poids [275][276][277][278][279]. Les méta-analyses indiquent que le risque de décès chez les personnes âgées en bonne santé est le plus faible dans la plage de surpoids [280][281][282]. De plus, la perte de poids, qu' elle soit intentionnelle ou non, aggrave la diminution de la masse musculaire liée à l'âge, augmentant ainsi le risque de sarcopénie, de fragilité, de déclin fonctionnel, de fracture et de dénutrition [277,283,284]. ...
... The ramifications of these nutritional extremes are particularly pronounced in numerous low-and middle-income countries [20]. In the context of older populations, being overweight does not appear to be correlated with an augmented mortality risk; on the contrary, individuals at the lower boundary of the recommended BMI range for adults are observed to confront a heightened risk [21]. A systematic review undertaken in 2021 uncovered that both obesity and underweight are linked to an increased susceptibility to frailty in community-dwelling older adults [22]. ...
Background
The influence of Body Mass Index (BMI) on the functional capacity for daily activities in older adults is a significant concern. Our study is designed to delineate the longitudinal relationship between BMI and the ability of daily living activities among older adults.
Methods
Two researchers conducted a comprehensive literature search and independent screening of articles in PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), the Database for Chinese Technical Periodicals (VIP), and Wanfang, covering the period from January 2000 to May 2024. Studies were selected based on predefined inclusion and exclusion criteria, and relevant data were extracted for subsequent meta-analysis using the Cochrane Collaboration’s Review Manager 5.3 software.
Results
After rigorous selection, four longitudinal studies were incorporated into our meta-analysis. The findings indicated that underweight older adults exhibited a higher likelihood of experiencing difficulties with basic activities of daily living (BADL) (odds ratio [OR] = 1.33, 95% confidence interval [CI]: [1.03, 1.72]; P = 0.03). Conversely, overweight older adults were found to have a reduced likelihood of BADL (odds ratio [OR] = 0.81, 95% confidence interval [CI]: [0.79, 0.83]; P < 0.001). However, overweight and obese older adults demonstrated an increased likelihood of challenges with Instrumental Activities of Daily Living (IADL) (odds ratio [OR] = 1.58, 95% confidence interval [CI]: [1.25, 2.00]; P < 0.01).
Conclusions
Our longitudinal meta-analysis substantiates the correlation between underweight status and the impairment of BADL in older adults, irrespective of gender. It also reveals that overweight older adults have a lower risk of BADL difficulties, yet a higher risk of IADL challenges, which is further exacerbated in obesity. The early identification and management of BMI in this population could be instrumental in preventing a decline in ADL. Recognizing the role of BMI categories in this context is essential for developing targeted preventative strategies for the elderly, while also accounting for other modifiable risk factors such as pain and depression.
... A meta-analysis reported the lowest mortality in individuals with a BMI of 27.0-27.9 kg/m 2 in Europe and America [7]. However, in Asia, the lowest mortality rate was reported for individuals with a BMI of 23.0-24.9 ...
Background: Obesity and weight loss are associated with increased mortality. Understanding the association between weight change and mortality is critical and can help inform effective prevention and intervention strategies. Therefore, this study aimed to investigate the association between weight change and mortality based on body mass index (BMI) intervals using data from a 12-year follow-up survey in Korea.Methods: We used data from the Korean Longitudinal Study of Aging from 2006 to 2018. Individuals aged 45–69 years without a history of malignancy and chronic obstructive pulmonary disease at baseline were selected. Cox regression analysis was used to compare mortality based on body mass index and weight change.Results: Compared with individuals with a body mass index of 20.0–25.0 kg/m2 and an increase in body weight of <5 kg, mortality was 3.8 times higher in the group with a body mass index of <20.0 kg/m2 and a weight loss of <5 kg, two times higher in the group with a body mass index of 20.0–25.0 kg/m2 and weight loss of >10 kg, and 4.3 times higher in the group with a body mass index of ≥25.0 kg/m2 and weight gain of ≥10 kg. Conclusions: Weight loss in underweight or normal-weight individuals and weight gain in individuals with obesity increased the mortality rate compared with individuals with normal weight and less weight change. This suggests that body weight and the changes in the weight of individuals are crucial, and weight loss in patients with underweight and weight gain in patients with obesity are closely related to increased mortality.
... The BMI values were adjusted to the older adult population according to literature advice (Winter et al., 2014). The normal weight was defined as a BMI value between 23 and 30, underweight < 23, and overweight > 31. ...
... A previous study has suggested that underweight older adults are expected to live the shortest lives and spend the fewest years in an active state [17]. In addition, pre-obesity is not associated with an increased mortality risk, while underweight has an increased mortality risk [56]. ...
Background
The high prevalence of underweight individuals is an important issue that has become increasingly common. Therefore, this study investigated the association between body mass index (BMI) and health-related quality of life (HRQoL) among Korean older adults using a nationwide population-based survey.
Methods
Data from the 2021 Community Health Survey were used for this study. The study population was a total of 70,700 respondents. HRQoL was assessed using the EuroQoL health-related quality of life scale. Multiple logistic regression was applied to analyze the ORs for moderate or severe problems in the five EQ-5D dimensions. In addition, we performed multiple linear regression to identify the association between the total EQ-5D score and BMI after adjusting for age, marital status, income, education, health behaviors, and the presence of diabetes or hypertension.
Results
Of the participants, 4.3% were underweight (3.3% of men and 5.1% of women). Being underweight is associated with poor HRQoL in both men and women. The relationship between obesity and HRQoL varied by sex. Men with pre-obesity and obesity were less likely to have “moderate or severe” problems in all EQ-5D dimensions, excluding mobility. However, women with obesity were more likely to have “moderate or severe” problems across EQ-5D dimensions, excluding anxiety/depression.
Conclusions
Being underweight is associated with poor HRQoL among Korean older adults. Policy attention must be directed toward maintaining proper weight and promoting nutritional health at older ages, given that the number of older adults is expected to continue to increase.
... Older people, as a high-risk group for impaired health, are similarly more susceptible to chronic diseases and a variety of other diseases, making all-cause mortality more common among older people. With the general trend of population aging, the incidence of CVD and mortality among older persons has increased accordingly (3,4). Specifically, ischemic heart disease was the second leading cause of death among the Chinese population in 2016. ...
Background
Previous studies suggest that frailty increases the risk of mortality, but the risk of cardiovascular disease (CVD) and all-cause mortality in Chinese community-dwelling older adults remains understudied. Our aim was to explore the effect of frailty on cardiovascular and all-cause mortality in older adults based on a large-scale prospective survey of community-dwelling older adults in China.
Methods
We utilized the 2014–2018 cohort of the Chinese Longitudinal Healthy Longevity Survey and constructed a frailty index (FI) to assess frailty status. Propensity score matching was used to equalize the baseline characteristics of participants to strengthen the reliability of the findings. Hazard ratios and 95% confidence intervals (CIs) were estimated using multivariate Cox models, adjusting for potential confounders, to assess the association between frailty and cardiovascular and all-cause mortality. The relationship between frailty and cardiovascular mortality was further explored using a competing risk model considering death as a competing event. The dose–response relationships between them were estimated using restricted cubic spline models.
Results
The results of the multivariate Cox model found that the frailty group had a higher risk of CVD mortality (1.94, 95% CI: 1.43–2.63) and all-cause mortality (1.87, 95% CI: 1.63–2.14) in compared with the non-frailty group. The multivariate competing risks model suggested a higher risk of CVD mortality in the frailty group (1.94, 95% CI: 1.48–2.53). The analysis found no non-linear relationship between FI and the risk of CVD mortality but a non-linear dose–response relationship with the risk of all-cause mortality.
Conclusions
Frail older adults demonstrated a stronger risk of CVD and all-cause mortality. Reversing frailty in older adults is therefore expected to reduce the risk of death in older adults.
... In line with the findings of a previous study [45], BMI was not associated with rehabilitation efficiency, although few of our patients had high BMIs and therefore our study may have lacked power for this purpose. We used a high threshold of 35 kg/m 2 to identify obese patients, as some studies has suggested that the optimal BMI for older people may be higher than for the young (who are considered obese for BMI ≥ 25 kg/ m 2 ) [46,47]. A BMI > 30 was nonetheless associated with higher costs in the study by Vincent [45]; and this is a point that should not be overlooked. ...
Background
Patient Reported Outcome Measures (PROMs) are questionnaires that collect health data directly from the patient, without any intervention from a third party. The aim of rehabilitation units is to restore function. Functional gain can be evaluated with classic scales, such as the locomotor subscale of the Functional Independence Measure. This study aimed to assess the accuracy of a new self-assessment questionnaire pertaining to physical, sensory and cognitive ability (abbreviated SEPCO) for the prediction of functional prognosis in older patients admitted to a rehabilitation unit.
Methods
In this multicentre observational study including patients admitted to 12 rehabilitation centres in France, all included patients completed the SEPCO on admission. Poor response to rehabilitation was defined as relative effectiveness < 40% on the evolution of the locomotor FIM subscale. Components of the questionnaire potentially associated with the outcome of rehabilitation were confirmed for inclusion upon expert review and summed to form an overall score. The final score had five components: the depression score of the HADS, the SOFRESC vision score, the SOFRESC balance score, the stress urinary incontinence subscale of the USP, and the EPICES socio-economic deprivation score. A logistic regression model adjusted for baseline characteristics assessed the performance of the SEPCO score to predict change in functional status, defined by the relative functional gain for the locomotion subscale of the Functional Independence Measure (FIM).
Results
A total of 153 patients (mean age 79.2 ± 8.1 years, 72.5% women) were included. By multivariate analysis, a 5-scale SEPCO score ≥ 1.1 predicted worse functional improvement with an odds ratio (OR) of 2.575, 95% Confidence Interval (CI) 1.081 to 6.133, p = 0.03. Sensitivity for this threshold was 67.4% (95% CI 52.0–80.5%), with a specificity of 58.8% (95% CI 46.2–70.6%). Having a SEPCO ≥ 1.1 almost doubled the probability of poor response to rehabilitation (from 27.3 to 52.5%).
Conclusion
The SEPCO score can predict poor functional gain from rehabilitation. Future studies should validate this score on an external cohort. The SEPCO could serve as a complement to the initial clinical evaluation performed by physicians, and assist physicians in setting each patient’s rehabilitation goals.
... This paradox indicates that being overweight, contrary to what is expected, can offer a certain level of protection against conditions of frailty and functional loss, possibly due to greater energy reserves or muscle mass that allows for greater resistance to falls, for example [35]. However, other studies indicate that this association may vary with time and advanced age, suggesting that the benefits of being overweight may be specific to certain age groups and clinical conditions, rather than representing a general rule [36]. ...
Background: Europe’s aging population presents challenges such as a shrinking labor force, pressure on health services, and increased demand for long-term care. This study assesses the functional profile, depressive symptoms, and quality of life of older adults in the Central Alentejo region of Portugal. Methods: A cross-sectional, descriptive study was conducted with a convenience sample of 868 older adults in Portuguese long-term care facilities across the Évora district. A structured questionnaire collected sociodemographic data, elderly nursing core set patient information, a health questionnaire with nine responses, and WHO Quality of Life Assessment (short version) scores. Results: Nearly half of the participants needed assistance with care. Women (OR = 1.46) and those with cognitive impairment (OR = 10.83) had higher impaired functionality, while education (OR = 0.52) and being overweight (OR = 0.52) were inversely related to functional dependence. Quality of life scores ranged from 56.4 (physical) to 66.6 (environmental). Moderate depressive symptoms were found in 17.1% of participants, with 9% having moderately severe to severe symptoms. Higher dependence doubled the likelihood of depressive symptoms (OR = 2.18). Discussion and Conclusions: High rates of depression and functional dependence correlate with a low perception of quality of life, highlighting the need for research to promote and protect the health of older adults.
... Hasil penelitian ini didukung adanya hubungan antara rumination terhadap ketergantungan terhadap telepon genggam (Kong et al., 2020). Orang yang berada pada situasi rumination akan mencoba untuk melarikan diri dari kehidupan nyata dengan menghabiskan banyak waktu kepada kegiatan online (Winter et al., 2014). Selanjutnya hubungan antara job stress dan cyberloafing ditemukan terdapat pengaruh yang positif dan signifikan. ...
Internet usage at the workplace has the potential for misuse with employees engaging in cyberloafing activities. Therefore, this research was conducted to examine the relationship between job boredom and work overload on cyberloafing with the mediation of rumination and work stress. This research uses quantitative methods and respondents were selected using a purposive sampling technique, namely workers belonging to the millennial generation and working using internet technology from various industrial sectors, totaling 311 respondents. The data testing technique used is SmartPLS 3.2.9 software. There are five hypotheses accepted out of eight hypotheses in total. Excessive workload has a negative and significant effect on cyberloafing. Work boredom has a positive and significant correlation with rumination. Meanwhile, workload has a negative and significant influence on work stress. Rumination has a positive but not significant relationship with cyberloafing. Job stress has a positive and significant effect on cyberloafing. Meanwhile, for the mediation results, it was found that work boredom had a negative and significant effect on cyberloafing if mediation was carried out with rumination. Excessive workload has a positive but not significant correlation with cyberloafing if mediated by work stress.
... Longitudinal studies of mortality and BMI and WC have been reviewed (32,33). High mortality and disability have been documented prospectively for individuals with frailty (34). ...
Introduction: Obesity is a known risk factor for cardiovascular disease (CVD) morbidity and mortality. A body shape index (ABSI) is a waist circumference (WC) measure of abdominal obesity independent of body mass index (BMI) that has been shown to predict mortality and numerous clinical outcomes.
Aims: To study the predictive value of ABSI in conjunction with BMI for all-cause mortality and coronary heart disease (CHD) hospitalization among adult participants.
Methods: Participants (n=2,225) were drawn from the First Israeli National Health and Nutrition Survey (1999-2001), constituting adults aged 25-64. Baseline anthropometrics, including weight, height, and WC, were measured and expressed as their allometric indices: BMI (weight/height ² ) and ABSI [WC/(BMI 2/3 *height 1/2 )]. Follow-up lasted through 2021 for mortality and 2022 for hospitalizations. Cox regressions assessed the adjusted risk of all-cause mortality and CHD hospitalization.
Results: The baseline mean [SD] age was 43 [11] years, and 50% were women. The correlation between BMI and WC was 0.78, and 0.02 for BMI and ABSI. Over a median follow-up of 21 years, 247 (11.1%) deaths occurred. The multivariable-adjusted hazard ratios (HRs) for mortality per 1 SD increase in BMI and ABSI were 1.11 (95% CI: 0.97; 1.27) and 1.55 (95% CI: 1.33; 1.79), respectively (Table). ABSI exhibited a significant association with mortality risk across all standard BMI categories; adjusted for demographics and classic CVD risk factors, the HRs (95% CIs) per 1 SD increase in ABSI were 1.38 (1.01; 1.88) for individuals with a BMI of 18.5-24.9, 1.70 (1.34; 2.16) for BMI 25.0-29.9, and 1.46 (1.13; 1.87) for BMI ≥30.0. Among CVD-free participants at baseline (n=2,146), 267 (12.4%) were hospitalized for CHD during follow-up. The latter had higher ABSI (0.082 vs. 0.078, P<.001) and BMI (28.1 vs. 26.7, P<.001) than individuals who remained free of CHD. An increase in the adjusted HR was seen for both ABSI [1.34 (95% CI: 1.15; 1.55)] and BMI [1.16 (95% CI: 1.01; 1.33)] (Table).
Conclusion: In a 20-year prospective study of a middle-aged cohort, baseline ABSI was a stronger predictor of mortality than BMI and predicted CHD hospitalization independently of BMI.
... A notable concern arises from the fact that the mean BMI of participants exceeded 29 kg/m 2 in both sexes, with approximately 40% of participants having a BMI > 30 kg/m 2 , indicating obesity according to the World Health Organisation (WHO) criteria (36). Although metaanalyses did not show a significant link between increased mortality and overweight in older adults, going beyond a BMI of 28 kg/m 2 put a considerable proportion of participants at risk (37). The high prevalence of obesity highlights an important health issue, supposedly originating mainly in imbalances in dietary intake and physical activity. ...
Background
Older adults living in nursing homes (NHs) are considered a vulnerable population in terms of nutrition. The aim of the present study was to explore the usual intake of energy, macronutrients, and specific food groups, along with offers in the NH menus on a nationally representative sample of Slovenian NH residents and compare dietary patterns with the established recommendations.
Methods
The study was conducted as part of a cross-sectional NutriCare study on 317 residents (65–101 years) from 20 Slovenian NHs in 9 health regions. Relatively independent residents were selected using quota sampling by sex and age. Data collection involved interviews and anthropometric measurements. Usual dietary intake was assessed by a multiple-source method from two 24-h dietary recalls and food frequency questionnaires. Adherence of dietary intake to the recommendations and dietary composition of NH menus were assessed. The Mini Nutritional Assessment (MNA) was used to explore nutritional status.
Results
Notable variability in energy and macronutrient intakes was observed with some participants showing intakes below and others above the recommended values. A high prevalence of BMI > 30 kg/m² was observed in 39% of participants, indicating potential discrepancies between total energy intake and expenditure. The usual intake of fat was 36% of total energy intake (TEI). The intake of foods of animal origin exceeded dietary guidelines. Intake of carbohydrates (46% TEI in men and 47% TEI in women) as well as dietary fibre (20 g/day for both sexes) was below recommendations. A scarce intake of fruits, vegetables, and cereals was observed. In total, 40% of men and 35% of women had usual daily protein intakes lower than 1 g/kg of body weight. The protein content of breakfast and dinner could be improved. NH residents consumed little food from outside NH. The usual nutrient and food group intakes of residents reflected the NH menu offers.
Conclusion
The study results on the usual intake of energy, macronutrients, specific food groups, and offers in the NH menus indicate the potential for optimisation. According to the World Health Organisation, the prevalence of BMI > 30 kg/m² is notable and warrants attention. Careful meal planning and regular monitoring of the nutritional status of NH residents should be considered.
... Using BMI as a disease risk predictor in the population of older adults does not take into account the senescenceassociated muscle loss and body composition shifts towards increased adiposity or stature decline which can both happen without major changes in BMI. Meta-analysis from Winter et al. [15] including 32 studies with an average follow-up of 12 years revealed that all-cause mortality risk associated with BMI in older adults follows a different trend than in their younger counterparts. All-cause mortality risk associated with BMI was the lowest within the range of BMI 24.0 and 30.9 kg/m 2 in adults aged 65 years and more. ...
Obesity is a complex health issue with growing prevalence worldwide. It is also becoming more prevalent in the population of older adults (i.e., 65 years of age and older), affecting frequency and severity as well as other comorbidities, quality of life and consequently, life expectancy. In this article we review currently available data on pharmacotherapy of obesity in the population of older adults and its role in obesity management. Even though there is growing evidence, in particular in the general population, of favourable efficacy and safety profiles of glucagon-like peptide-1 (GLP-1) receptor agonists liraglutide and semaglutide, and recently dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) agonist tirzepatide, concise guidelines for older adults are not available to this day. We further discuss specific approaches to frequently represented phenotype of obesity in older adults, in particular sarcopenic obesity and rationale when to treat and how. In older adults with obesity there is a need for more drug trials focusing not only on weight loss, but also on geriatric endpoints including muscle mass preservation, bone quality and favourable fat distribution changes to get enough data for evidence-based recommendation on obesity treatment in this growing sub-population.
... overweight (≥ 25), and obesity (≥ 30). While the BMI cut-off is widely used for adults above 20 years old, emerging studies suggest that the current classification may not be appropriate for older adults [37,38]. More specifically, a higher BMI may have a protective effect on comorbidity [39] and mortality [40]. ...
Background
Nutrition not only plays an important role in one’s physical health, but also mental health. The causal association between nutrition and mental health remains unclear. While a healthy dietary pattern may protect one against mental illness, it is also possible that poor mental health could lead to unhealthy eating habits or choices. Furthermore, emerging studies suggest that a higher body mass index (BMI) is associated with a lower risk of depressive symptoms in older adults, contrasting the effect observed in other populations. With an ageing population, this study aimed to investigate the long-term impact of a healthy dietary pattern, BMI, and other covariates on depressive symptoms in older adults.
Methods
We conducted a cohort study between 2014 and 2017, with each follow-up assessment being one year apart. A total of 2081 participants above 65 years old (M = 79.65, SD = 7.94) completed the baseline assessment in 2014, which included basic demographics, self-reported eating habits, depressive symptoms, and the measurement of height and weight. Distance to supermarkets and fast food was calculated based on participants’ residential addresses. Two growth models were performed to assess the trajectory of change in depressive symptoms over time.
Results
Older adults experienced a significant decrease in depressive symptoms over time (intercept = 2.68, p < .001; slope = -0.25, p < .001). At baseline, a higher diet quality (B = -0.95, p < .001), higher BMI (B = -0.09, p < .001), younger age (B = 0.40, p = .001), being a male (B = 0.76, p < .001), and having fewer chronic diseases (B = 0.39, p < .001) were associated with lower levels of depressive symptoms. Over time, a higher diet quality (B = 0.14, p = .05), higher BMI (B = 0.02, p = .04), and fewer chronic diseases (B = -0.08, p < .001) predicted lower levels of depressive symptoms over time.
Conclusions
A higher diet quality and higher BMI may serve as protective factors for depressive symptoms in older adults. Potential implications are being discussed.
... Age-related changes affecting nutrition likely underpin this pattern, including reductions in olfactory and taste functions, slowed gastrointestinal transit and absorption, and decreased intestinal microbiome diversity [32,33]. Common age-associated conditions like dental issues, gastrointestinal disorders, mobility limitations, dementia, depression and polypharmacy may additionally hinder adequate fiber consumption [34][35][36]. Recent nationally-representative nutrition surveys in the United States (US), Canada and Korea similarly demonstrate substantially lower fiber intakes among older versus younger adults [37]. ...
Objectives
This study aimed to quantify the global cardiovascular disease (CVD) burden attributable to diet low in fiber among adults aged 60 years and older using data from the Global Burden of Disease (GBD) Study 2019.
Methods
We extracted data on CVD mortality, disability-adjusted life-years (DALYs), and risk-factor exposures from the GBD 2019 study for people aged 60 and older. Age-period-cohort models were used to estimate the overall annual percentage change in mortality and DALY rate (net drift, % per year), mortality and DALY rate for each age group from 1990 to 2019 (local drift, % per year), longitudinal age-specific rate corrected for period bias (age effect), and mortality and Daly rate for each age group from 1990 to 2019 (local drift, % per year). And period/cohort relative risk (period/cohort effect).
Results
From 1990 to 2019, global age-standardized cardiovascular disease (CVD) mortality rates attributable to low dietary fiber intake decreased by 2.37% per year, while disability-adjusted life years (DALYs) fell by 2.48% annually. Decreases were observed across all sociodemographic index regions, with fastest declines in high and high-middle SDI areas. CVD mortality and DALY rates attributable to low fiber increased exponentially with age, peaking at 85–89 years, and were higher in men than women. Regarding period effects, mortality and DALY rates declined since 2000, reaching nadirs in 2015–2019. For birth cohort patterns, risks attributable to low fiber intake peaked among early 1900s births and subsequently fell, with more pronounced reductions over time in women.
Conclusions
Low dietary fiber intake is a leading contributor to the global cardiovascular disease burden, accounting for substantial mortality and disability specifically among older adults over recent decades.
... Height (Harpeden Wall Mounted Stadiometer), body mass (A&D HW-200KGL Calibrated Scales), and waist circumference (Cescorf Tape Measure) were measured following standard International Society for the Advancement of Kinanthropometry (ISAK) procedures. To calculate body mass index (BMI) the body mass relative to squared height was used [49]. Underweight (BMI < 23 kg/m 2 ), normal weight (BMI = 24-30 kg/m 2 ) and overweight (> 30 kg/m 2 ) were determined using standard BMI cut-offs for adults over the age of 65-years [50]. ...
Background
Osteoporosis poses a significant health and quality-of-life burden on older adults, particularly with associated fractures after a fall. A notable increase in pro-inflammatory cytokines associated with aging contributes to a decline in bone mineral density (BMD). Certain food components have been shown to influence an individual’s inflammatory state and may contribute to optimal bone health as a modifiable risk factor, particularly later in life. This study aims to explore the relationship between the dietary inflammatory index (DII) and dietary intake with BMD in community-dwelling older adults.
Methods
Heathy community-dwelling older adults aged 65–85 years. DII scores were calculated using 24-h dietary recalls, and lumbar spine (L1–L4) and femoral neck (ward’s triangle) BMD was assessed via dual-energy x-ray absorptiometry.
Results
A total of 94 participants were recruited (72.9 ± 4.9 years, 76.6% female) with 61.7% identified having an anti-inflammatory diet (average DII = − 0.50 ± 1.6), 88.3% were physically active, 47.8% were osteopenic and 27.7% osteoporotic. There was no significant difference between DII scores, nutrient or food group intake in groups stratified by BMD T-Score except for lean meats and alternatives food group (p = 0.027). Multiple regression analysis found no associations between DII and lumbar spine (unadjusted model β = 0.020, p = 0.155) or femoral neck BMD (unadjusted model β = − 0.001, p = 0.866).
Conclusion
Most of this cohort of functionally able community-dwelling older adults followed an anti-inflammatory diet. DII and dietary intake were not associated with BMD. This research underlines the complex interplay between modifiable and non-modifiable risk factors on the BMD of older, physically active adults.
... The findings from the moderated mediation model reveal the potential existence of three categories of BMI based on the cut-off criteria of Winter et al. (22). As illustrated in Figure 1, individuals with lower muscular strength in their lower body tend to exhibit higher BMI, particularly older individuals with an approximate value of 33 kg/m 2 . ...
The primary objective of this study was to analyze the moderating effect of body mass index (BMI) on the association between lower body strength, agility, and dynamic balance, considering the mediating influence of lower body flexibility and aerobic endurance in community-dwelling older adults. This study included a sample of 607 community-dwelling older adults (female = 443; male = 164) aged between 60 and 79 years (M = 69.24; SD = 5.12). Participants had a mean body mass index of 28.33kg/m2 (SD = 4.45). In the mediation-moderation model, positive associations were found between lower body strength and lower body flexibility, aerobic endurance, and agility and dynamic balance (p < 0.05). As for the moderation effects and interactions, BMI was found to have a significant interaction with lower body strength on agility and dynamic balance (β = -.04, [-.06, -.03]), representing an R2-change of 0.04 (p < .001). Conditional direct effects were estimated at BMI scores of 23.9 (β = -.09, [-.15, -.03]), 27.7 (β = -.19, [-.24, -.14]), and 32.7 (β = -.33, [-.40, -.26]) kg/m2. Older adults with high levels of muscular strength tended to have shorter timed up-and-go test times, regardless of BMI. Also, individuals with lower levels of lower body strength were found to have longer timed up-and-go test times, and this relationship became more pronounced with increasing BMI.
... weight and obesity are generally associated with excess mortality, some epidemiological studies in older adults suggest a U-shaped curve, with optimal longevity at a BMI in the overweight range (5). While many so-called "obesity paradoxes" remain controversial due to inconsistency across studies coupled with the correlative nature of the underlying evidence, these collective examples point to the importance of context even with a condition as tightly linked to disease as obesity. ...
Obesity is a known driver of endometrial cancer. In this issue of the JCI, Gómez-Banoy and colleagues investigated a cohort of patients with advanced endometrial cancer treated with immune checkpoint inhibitors targeting the interaction between programmed cell death receptor-1 (PD-1) and its ligand (PD-L1). Notably, a BMI in the overweight or obese range was paradoxically associated with improved progression-free and overall survival. A second paradox emerged from CT analyses of visceral adipose tissue, viewed as an unhealthy fat depot in most other contexts, the quantity of which was also associated with improved treatment outcomes. Though visceral adiposity may have value as a biomarker to inform personalized treatment strategies, of even greater impact would be if a therapeutic strategy emerges from the future identification of adipose-derived mediators of this putative anticancer immune-priming effect.
... In this study, BMI is used as an indicator of weight status. BMI has been criticised for not being a fully appropriate metric for evaluating the weight status of a given older patient, yet it has good predictive value at a population level [64] as long as the same cut-offs as for younger adults are not considered appropriate to apply [65]. Moreover, this study is based on self-reported data, which can be particularly problematic regarding height, weight, and food intake [66,67]. ...
Background
Eating is fundamental not only to survival and health, but also to how humans organise their social lives. Eating together with others is often seen as the healthy ideal, while eating alone is highlighted as a risk factor for negative health outcomes, especially among older adults. This paper, therefore, investigates the relationship between the frequency and subjective experience of eating alone and food-related outcomes among 70- to 75-year-olds in Sweden.
Methods
A survey was distributed to a nationally representative random sample of 1500 community-living in Sweden, aged 70–75 years. Two different constructs of eating alone (objective and subjective) were measured, along with the following food-related outcomes: a food index, intake of food groups, consumption of ready-made meals, number of main meals per day, and body mass index (BMI).
Results
In total, 695 respondents were included in the final sample. A quarter of the respondents were categorised as eating alone, of which a small proportion reported that doing so bothered them. There were no associations between eating alone and food index scores, BMI, or intake frequencies of fruits and berries, or fish and shellfish. However, people eating alone were less likely to report eating three meals per day (OR: 0.53, CI: 0.37–0.76, p = 0.006), less likely to report higher intake frequencies of vegetables and snacks, sugary foods, and sweet drinks (adjusted OR: 0.68, CI: 0.48–0.95, p = 0.023 resp. OR: 0.59, CI: 0.43–0.81, p = 0.001), and more likely to report higher intake frequencies of ready-made meals (adjusted OR: 3.71, CI: 2.02–6.84, p < 0.001) compared to those eating together with others. The subjective experience of eating alone did not have an impact on food-related outcomes.
Conclusion
Eating alone or with others played a role in participants’ food intake, and seemed to influence aspects of the organisation of everyday eating routines rather than overall dietary healthiness or weight status. Our findings add to the previous body of research on commensality, eating alone, and health among the older population, providing insights into the development of future health policies and research.
... Previously, a BMI of ≥25 was identified as a common factor contributing to metabolic abnormalities [20]. More recently, it has been shown that BMI values below 23 kg/m 2 and above 33 kg/m 2 are associated with an increased risk of mortality in the older population [51]; nonetheless, overweight and obesity are linked to better functional status [34]. Therefore, it is possible to have a BMI of more than 25 along with being well nourished. ...
Aging is commonly accompanied by increased cardiovascular risk and diet plays a crucial role in health condition. The aim of this study was to determine cardiovascular risk factors as predictors of nutritional risk in Mexican older adults. A cross-sectional study on Mexican patients aged ≥60 years with cardiovascular risk factors affiliated with a medical unit in Northeast Mexico was performed from July to December 2021. The nutritional risk evaluations were performed using the Mini Nutritional Assessment (MNA) questionnaire. After a multivariate analysis, the cardiovascular risk factors identified as independent predictors of risk of malnutrition were hypertriglyceridemia (adjusted OR (AOR): 1.8; 95% CI: 1.03–3.14; p = 0.04) and systolic hypertension I (AOR: 2.28; 95% CI: 1.04–5.02; p = 0.041); age over 80 years (AOR: 5.17; 95% CI: 1.83–14.65, p = 0.002) and elementary school education (AOR: 2.34; 95% CI: 1.20–4.55; p = 0.013) were also related. The cross-sectional design and single-center approach of this study limits the generalizability of the results; however, conducting timely evaluations of blood pressure, triglyceride levels, and risk of malnutrition using the MNA tool for patients aged ≥60 years could prevent illness and reduce mortality within this population group.
Prevalence rates of overweight and obesity in Germany are high. The weight-centred health paradigm assumes that all individuals with a BMI≥30 kg/m² or with a BMI≥25 kg/m² and comorbidities should be advised to lose weight. However, traditional weight loss programs have limited evidence regarding long-term weight loss and other beneficial outcomes. Therefore, alternative approaches to improve the treatment of individuals with obesity are needed. The aim of this article is to provide an overview of weight-neutral approaches for the treatment of obesity including a case study of a weight-neutral nutrition counselling. Weight-neutral approaches assume that individuals with a higher weight status can also achieve health and well-being. The most prominent weight-neutral approach is Health At Every Size (HAES). HAES is based on five principles (2013): Weight inclusivity, health enhancement, eating for well-being, respectful care and life-enhancing movement. Weight-neutral programs focus on different modules: Body acceptance, eating behaviour, nutrition behaviour, physical activity, and social support. A case study of a weight-neutral nutrition counselling is presented that targeted these modules. Exercises within these modules are for example the development of a biographical timeline in which the relationship between weight and self-esteem is reflected upon, introspection through journaling, and the separation of interoception and action. The effectiveness of weight-neutral programs has been demonstrated regarding various health parameters, including cardiovascular, anthropometric, and psychological parameters as well as physical activity. However, more studies of high methodological quality are needed, especially in Germany.
Background
Nutrition risk is common in Alzheimer's disease and is associated with symptoms of dementia, cognitive decline, institutionalization, and mortality. Family caregivers who increasingly manage nutrition needs of persons with dementia (PWD) experience high caregiver burden, low health literacy, and nutrition risk. Few interventions for informal caregivers have included nutrition.
Objective
To inform design of a future caregiver nutrition intervention.
Methods
This cross-sectional study used a convergent mixed methods approach to 1) assess nutrition status among PWD and caregiver dyads (measures in common included Mini Nutrition Assessment, skin carotenoid, and handgrip strength), and 2) interview caregivers to identify needs and barriers for nutrition intervention. We hypothesized caregiver nutrition literacy is associated with PWD nutrition risk. Data collected in nutrition assessment and interviews were analyzed separately then side-by-side for comparison.
Results
Of 50 dyads, 48% had at least one individual exhibiting nutrition risk, and nutrition status categories (χ 2 = 6.25, p = 0.012) between caregivers and PWD were related. Caregiver nutrition literacy was associated with 1) PWD factors including nutrition risk (rho = 0.244), body mass index (BMI) (rho = 0.421), handgrip strength (rho = 0.283), and skin carotenoid (rho = 0.351), and 2) Caregiver factors including nutrition risk (rho = 0.304), diet quality (rho = 0.304), and BMI (rho = 0.333). Interviews with 18 caregivers found caregivers prioritize PWD nutrition, provide more PWD nutrition care since diagnosis, experience social isolation, and would attend nutrition interventions if PWD are included.
Conclusions
Nutrition risk was more common among caregivers when PWD demonstrated nutrition risk. Factors present in individuals within the dyad were associated with partner nutrition risk. Future research should identify effective approaches for intervening on dyadic nutrition risk.
Background
Data on the prevalence of overweight and obesity in Southwestern China were limited. The aims of this study were to estimate the prevalence of overweight/obesity and their associated factors in this area.
Methods
A cross-sectional study was conducted from 2013 to 2014 in Chengdu and Chongqing, two megacities in Southwestern China. Data were obtained from questionnaires, physical examinations and lab tests. A total of 11,096 residents aged 35–79 years were included in the final analysis of this study.
Results
The prevalence of overweight and obesity among adults aged 35–79 years in Southwestern China were 29.7 and 4.4%, respectively. Multivariable logistic regression analysis suggested that women, non-smokers, ex-smokers, being hypertensive and diabetic were related to higher obesity prevalence, and that physically active adults and those aged 65–79 years were less likely to have obesity.
Conclusion
Obesity and overweight were prevalent in Southwestern China, especially among women, those with diabetes and/or hypertension, and those who have quitted smoking for more than 3 years.
This article will discuss the topic of malnutrition, with a focus on undernutrition rather than malnutrition causing obesity. It will use a case seen in clinical practice as an exemplar (table 1). In addition, this article will analyse and synthesise the relevant evidence relating to malnutrition in older adults and discuss the role of the advanced clinical practitioner (ACP) in the assessment and management of malnutrition to reduce the risk of refeeding syndrome.
This study introduces the concept of the "Goldilocks Day" – the optimal 24-hour time-use of intensity- or posture-specific composition specifically tailored for young (65–70 years) and old (> 70 years) older adults. We aimed (1) to optimal 24-hour time-use of compositions for each health outcome, and (2) identify the 'Goldilock Day' for all outcomes together. This approach, involving backwards pivot coordinates (bpcs), we provide a clearer interpretation of physical behavior data, offering practical insights for healthy aging. Data were collected from 309 older adults (65 + years) in Czechia, using accelerometers worn. Both intensity-specific (sedentary behavior - SB, light physical activity - LPA, moderate-to-vigorous physical activity - MVPA, and sleep) and posture-specific behaviors (lying, sitting, standing, moving, and walking) were assessed. Health outcomes included BMI, fall risk, fear of falling, physical fitness, usual gait speed, and lower extremity strength. Compositional regression models, based on the bpcs, were used to assess the relationships between time-use and these outcomes. In younger older adults, the time-use composition for optimal BMI included 7.5 hours of sleep, 12.0 hours of SB, 3.2 hours of LPA, and 1.4 hours of MVPA. Old older adults displayed slightly lower MVPA (1.0 hour) and increased SB (12.8 hours). Generally, higher MVPA and lower SB were associated with better physical fitness and reduced fear of falling. The optimal "Goldilocks Day" for both age groups highlighted the benefits of higher physical activity and reduced sedentary time, with significant implications for personalized health recommendations and improved health outcomes in Czech older adults.
Background
Obesity indices reflect not only fat mass but also muscle mass and nutritional status in older people. Therefore, they may not accurately reflect prognosis. This study aimed to investigate associations between a body shape index (ABSI), body mass index (BMI), and mortality in the general older population.
Methods
This nationwide observational longitudinal study included individuals aged between 65 and 74 years who underwent annual health checkups between 2008 and 2014. Exposures of interest were ABSI and BMI, and the primary outcome was all‐cause mortality. Association between the ABSI and BMI quartile (Q1–4) and mortality was assessed using Cox regression analysis. A restricted cubic spline was also used to investigate nonlinear associations. The missing values were imputed using multiple imputation by chained equations.
Results
Among 315,215 participants, 5074 died during a median follow‐up period of 42.5 (interquartile range: 26.2–59.3) months. Compared with ABSI Q1, ABSI Q3 and Q4 were associated with increased risk of mortality, with the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of 1.13 (1.05–1.22) and 1.23 (1.13–1.35), respectively. Compared with BMI Q3, BMI Q1 and Q2 were associated with an increased risk of mortality, with aHRs and 95% CIs of 1.51 (1.39–1.65) and 1.12 (1.03–1.22), respectively. The impacts of these indices were greater in male than in female. The heatmap of the aHR for mortality by continuous ABSI and BMI showed that higher ABSI was consistently associated with higher mortality risk regardless of BMI, and that the combination of low BMI and high ABSI was strongly associated with increased mortality risk.
Conclusions
High ABSI and low BMI are additively associated with the risk of all‐cause mortality in the general older population in Japan. Combination of ABSI and BMI is useful for evaluating mortality risk in older people.
Aging is a dynamic and progressive process characterized by the gradual accumulation of cellular damage. The continuous functional decline in the intrinsic capacity of living organisms to precisely regulate homeostasis leads to an increased susceptibility and vulnerability to diseases. Among the factors contributing to these changes, body composition—comprised of fat mass and lean mass deposits—plays a crucial role in the trajectory of a disability. Particularly, visceral and intermuscular fat deposits increase with aging and are associated with adverse health outcomes, having been linked to the pathogenesis of sarcopenia. Adipose tissue is involved in the secretion of bioactive factors that can ultimately mediate inter-organ pathology, including skeletal muscle pathology, through the induction of a pro-inflammatory profile such as a SASP, cellular senescence, and immunosenescence, among other events. Extensive research has shown that natural compounds have the ability to modulate the mechanisms associated with cellular senescence, in addition to exhibiting anti-inflammatory, antioxidant, and immunomodulatory potential, making them interesting strategies for promoting healthy aging. In this review, we will discuss how factors such as cellular senescence and the presence of a pro-inflammatory phenotype can negatively impact body composition and lead to the development of age-related diseases, as well as how the use of polyphenols can be a functional measure for restoring balance, maintaining tissue quality and composition, and promoting health.
This article will discuss the topic of malnutrition, with a focus on undernutrition. It will utilise a case study seen in clinical practice and analyse and synthesise the relevant evidence relating to malnutrition in older adults. It will also explore the role of the advanced practitioner in the assessment and management of malnutrition to reduce the risk of refeeding syndrome.
Purpose
Falls among inpatients represent a significant global health concern and are among the leading causes of accidental death. However, hospital falls are context- and population dependent. This study aimed to investigate the risk factors contributing to falls and the fall profiles among Vietnamese inpatients.
Methods
A nested case–control study was conducted at nine public hospitals in Ho Chi Minh City. For every fall identified through the medical fall incident reporting system, four controls (ie, nonfall patients) were also selected from medical records within the same department and timeframe. Medical records were extracted, which included detailed information about the falls.
Results
Among 101 fall cases and 404 nonfall controls, several risk factors for falls were found, including reduced strength and mobility (OR=3.08, 95% 1.30–7.30), nocturia (OR=9.08, 95% CI 4.04–20.45), having more than two diseases (OR=2.76, 95% CI 1.53–4.98), using walking aids (OR=23.26, 95% CI 10.20–53.03), using medical devices (OR=3.44, 95% CI 1.92–6.15) and using antiepileptics (OR=3.94, 95% CI 1.22–12.77). About 19.8% of the falls occurred within the first 24 hours from admission and the most common time of falls was from 0:00 am to 5:59 am (44.6%). The patient bed and bathroom were the most frequent locations for falls, accounting for 44.55% and 37.62% of the cases, respectively. More than 40% of the falls occurred when the patients were with their personal caregivers.
Conclusion
Although intervention programs can use these risk factors to target those who have a high risk of falling, to optimize resources, such programs should consider the fall patterns found in our study.
Background:
Body mass index (BMI) of patients with ischemic stroke (IS) has been associated with prognosis and disability in studies in the United States. Although the Asian population is leaner, the optimal BMI for stroke-related disability remains unknown.
Objectives:
To clarify the association between BMI and disability in patients with IS from a national database in Japan.
Methods:
The present study included 522,421 patients with IS identified in the JROAD-DPC database from April 2016 to March 2020. We used the WHO classification of BMI, which divides Asia-Pacific patients into five groups, to categorize BMI and the modified Rankin Scale (mRS) to assess stroke-related disability at admission and discharge. After multiple imputation for missing values, we conducted a multiple mixed-effect logistic regression analysis for poor mRS score (>2) in September 2023. In addition, we created a restricted cubic spline model between the odds ratio (OR) for poor mRS and BMI.
Results:
The mRS score worsened during hospitalization in 60.1% of the patients with IS, and 45.7% had a poor mRS score at discharge. Overweight patients had the lowest OR of having a poor mRS score (OR: 0.898, 95% confidence interval: 0.895-0.902). The spline curve for the OR for poor mRS score was U-shaped with a BMI of 24.7 kg/m2as the apex value.
Conclusion:
The present study revealed a U-shaped relationship between BMI and stroke-related disability, with overweight patients having the lowest OR for disability at discharge.
Purpose
This review discusses weight loss considerations in overweight and obese older adults.
Summary
Current US guidelines do not address weight loss in older adults. Waist circumference rather than body mass index (BMI) may be a more accurate assessment tool for obesity in older adults. Weight loss interventions are not recommended in overweight older adults due to the decreased mortality in this population (known as the “obesity paradox”). While weight loss in obese older adults may be beneficial, it is not without risks. The greatest risks include loss of muscle mass, decline in bone mineral density, and development of sarcopenic obesity. Weight loss interventions may be considered in older adults with a BMI of greater than 30 kg/m2 who have metabolic derangements, cardiovascular disease, and/or functional impairments after carefully weighing the risks against the benefits of weight loss and the impact of interventions on the patient’s quality of life. Medicare provides limited benefits for weight loss interventions. In older adults, there is no consensus on which lifestyle interventions are best for weight loss and there is a paucity of data on the use of weight loss medications. Careful consideration should be given before utilizing medications for weight loss in older adults given the enhanced adverse effect profiles, interactions, contraindications, and costs.
Conclusion
Weight loss in older adults should be approached differently from that in the general adult population. More data are needed on the efficacy and safety of weight loss medications in older adults.
Nesta coletânea de fôlego, os organizadores e autores oferecem uma poderosa ferramenta de trabalho aos pesquisadores e interessados na epidemiologia nutricional brasileira. Ampliando os horizontes tradicionais desse campo de estudo, o livro vai além de avaliação de dietas e da relação entre alimentação e doenças crônicas não transmissíveis. Os 38 capítulos desta segunda edição revista e ampliada contemplam métodos e análises que abrangem antigos e atuais problemas nutricionais brasileiros, com engajamento propositivo na solução de problemas. Simultaneamente, manual técnico da complexa área da avaliação nutricional e rigorosa enciclopédia nutricional brasileira, este compêndio de enfoque amplo e multidisciplinar reúne os principais investigadores na área de nutrição e saúde pública no Brasil e surge como leitura fundamental para os estudos de nutrição e saúde coletiva.
This epidemiological research investigated the relationship between body mass index (BMI) and lower limb function and community well-being among the older population (≥65 years old) in South Korea. Using the 2020 National Survey of Older Koreans (N = 10 097; M age = 73.6 ± 6.63; M BMI = 23.6 ± 2.61), the study identified underweight (2.3%), normal (72.8%), and obese (24.9%) groups. Findings revealed significant associations between BMI and lower limb function, with underweight individuals facing greater physical challenges ( P < .05–.01). Underweight participants were also found to live farther from key community locations, possibly reflecting social and environmental factors ( P < .01) and expressed higher dissatisfaction with community environments ( Ps < .05–.01). The study emphasizes the need for tailored community planning and health care strategies, focusing on the unique needs of the underweight older adults, considering South Korea’s rapidly increasing older population.
We have read your article titled "Association Between Body Mass Index and Cognitive Function Among Older Adults in India: Findings from a Cross-Sectional Study" with great interest. In this study, the authors hypothesized that older individuals with higher body mass index (BMI) have beter cognitive functions. However, we have noticed some major problems in the study's designand interpretation. The study categorized patients' BMIs using the World Health Organization's definition as 23 kg/m2, in MUST score>20 kg/m2, or in NRS-2002 >20.5 kg/m2). Additionally, in a large-scale meta-analysis, it was reported that the geriatric population had the lowest mortality rate between a BMI of 23-30 kg/m2.
Background: Guidelines for optimal weight in older persons are limited by uncertainty about the ideal body mass index (BMI) or the usefulness of alternative anthropometric measures.
Objective: We investigated the association of BMI (in kg/m²), waist circumference, and waist-hip ratio (WHR) with mortality and cause-specific mortality.
Design: Subjects aged ≥75 y (n = 14 833) from 53 family practices in the United Kingdom underwent a health assessment that included measurement of BMI and waist and hip circumferences; they also were followed up for mortality.
Results: During a median follow-up of 5.9 y, 6649 subjects died (46% of circulatory causes). In nonsmoking men and women (90% of the cohort), compared with the lowest quintile of BMI (<23 in men and <22.3 in women), adjusted hazard ratios (HRs) for mortality were <1 for all other quintiles of BMI (P for trend = 0.0003 and 0.0001 in men and women, respectively). Increasing WHR was associated with increasing HRs in men and women (P for trend = 0.008 and 0.0002, respectively). BMI was not associated with circulatory mortality in men (P for trend = 0.667) and was negatively associated in women (P for trend = 0.004). WHR was positively related to circulatory mortality in both men and women (P for trend = 0.001 and 0.005, respectively). Waist circumference was not associated with all-cause or circulatory mortality.
Conclusions: Current guidelines for BMI-based risk categories overestimate risks due to excess weight in persons aged ≥75 y. Increased mortality risk is more clearly indicated for relative abdominal obesity as measured by high WHR.
Context The prevalence of obesity and overweight increased in the United States
between 1978 and 1991. More recent reports have suggested continued increases
but are based on self-reported data.Objective To examine trends and prevalences of overweight (body mass index [BMI]
≥25) and obesity (BMI ≥30), using measured height and weight data.Design, Setting, and Participants Survey of 4115 adult men and women conducted in 1999 and 2000 as part
of the National Health and Nutrition Examination Survey (NHANES), a nationally
representative sample of the US population.Main Outcome Measure Age-adjusted prevalence of overweight, obesity, and extreme obesity
compared with prior surveys, and sex-, age-, and race/ethnicity–specific
estimates.Results The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared
with 22.9% in NHANES III (1988-1994; P<.001).
The prevalence of overweight also increased during this period from 55.9%
to 64.5% (P<.001). Extreme obesity (BMI ≥40)
also increased significantly in the population, from 2.9% to 4.7% (P = .002). Although not all changes were statistically significant,
increases occurred for both men and women in all age groups and for non-Hispanic
whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did
not differ significantly in the prevalence of obesity or overweight for men.
Among women, obesity and overweight prevalences were highest among non-Hispanic
black women. More than half of non-Hispanic black women aged 40 years or older
were obese and more than 80% were overweight.Conclusions The increases in the prevalences of obesity and overweight previously
observed continued in 1999-2000. The potential health benefits from reduction
in overweight and obesity are of considerable public health importance.
In this study, we analyzed age variation in the association between obesity status and US adult mortality risk. Previous studies have found that the association between obesity and mortality risk weakens with age. We argue that existing results were derived from biased estimates of the obesity-mortality relationship because models failed to account for confounding influences from respondents' ages at survey and/or cohort membership. We employed a series of Cox regression models in data from 19 cross-sectional, nationally representative waves of the US National Health Interview Survey (1986-2004), linked to the National Death Index through 2006, to examine age patterns in the obesity-mortality association between ages 25 and 100 years. Findings suggest that survey-based estimates of age patterns in the obesity-mortality relationship are significantly confounded by disparate cohort mortality and age-related survey selection bias. When these factors are accounted for in Cox survival models, the obesity-mortality relationship is estimated to grow stronger with age. © 2013 © The Author 2013. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: [email protected]
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Estimates of the relative mortality risks associated with normal weight, overweight, and obesity may help to inform decision making in the clinical setting.
To perform a systematic review of reported hazard ratios (HRs) of all-cause mortality for overweight and obesity relative to normal weight in the general population.
PubMed and EMBASE electronic databases were searched through September 30, 2012, without language restrictions.
Articles that reported HRs for all-cause mortality using standard body mass index (BMI) categories from prospective studies of general populations of adults were selected by consensus among multiple reviewers. Studies were excluded that used nonstandard categories or that were limited to adolescents or to those with specific medical conditions or to those undergoing specific procedures. PubMed searches yielded 7034 articles, of which 141 (2.0%) were eligible. An EMBASE search yielded 2 additional articles. After eliminating overlap, 97 studies were retained for analysis, providing a combined sample size of more than 2.88 million individuals and more than 270,000 deaths.
Data were extracted by 1 reviewer and then reviewed by 3 independent reviewers. We selected the most complex model available for the full sample and used a variety of sensitivity analyses to address issues of possible overadjustment (adjusted for factors in causal pathway) or underadjustment (not adjusted for at least age, sex, and smoking).
Random-effects summary all-cause mortality HRs for overweight (BMI of 25-<30), obesity (BMI of ≥30), grade 1 obesity (BMI of 30-<35), and grades 2 and 3 obesity (BMI of ≥35) were calculated relative to normal weight (BMI of 18.5-<25). The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity. These findings persisted when limited to studies with measured weight and height that were considered to be adequately adjusted. The HRs tended to be higher when weight and height were self-reported rather than measured.
Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality. The use of predefined standard BMI groupings can facilitate between-study comparisons.
Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
Two methods for point and interval estimation of relative risk for log-linear exposure-response relations in meta-analyses of published ordinal categorical exposure-response data have been proposed. The authors compared the results of a meta-analysis of published data using each of the 2 methods with the results that would be obtained if the primary data were available and investigated the circumstances under which the approximations required for valid use of each meta-analytic method break down. They then extended the methods to handle nonlinear exposure-response relations. In the present article, methods are illustrated using studies of the relation between alcohol consumption and colorectal and lung cancer risks from the ongoing Pooling Project of Prospective Studies of Diet and Cancer. In these examples, the differences between the results of a meta-analysis of summarized published data and the pooled analysis of the individual original data were small. However, incorrectly assuming no correlation between relative risk estimates for exposure categories from the same study gave biased confidence intervals for the trend and biased P values for the tests for nonlinearity and between-study heterogeneity when there was strong confounding by other model covariates. The authors illustrate the use of 2 publicly available user-friendly programs (Stata and SAS) to implement meta-analysis for dose-response data.
Objectives: To describe the relationship of body mass index and mortality in older adults, examining the influence of sex and cardiovascular morbidity. Methods: Sixteen-year cohort of a population sample of 1,008 people aged 65 and over. BMI mortality hazard ratios are estimated controlling for age, sex, education, physical activity, smoking, chronic conditions, and ADL (activities of daily living) disability. Results: At baseline the median BMI is 26.8 (Interquartile range: 24.2-29.7 Kg/m²). Findings show that during 16 years there were 672 deaths. The U-shaped curve of the mortality hazard by BMI is wide. The minimum mortality occur at BMI = 30.5 Kg/m². Findings show that men had lower mortality risk with increasing BMI and that cardiovascular disease was associated with high mortality in the low-BMI category. Discussion: Underweight is a risk factor for mortality among elderly people, whereas overweight and mild obesity are associated with the lowest mortality particularly among men and those with cardiovascular morbidity.
The impact of body mass index (BMI; kg/m(2)) and waist circumference (WC) on mortality in elderly individuals is controversial and previous research has largely focused on obesity.
With special attention to the lower BMI categories, associations between BMI and both total and cause-specific mortality were explored in 7604 men and 9107 women aged ≥ 65 years who participated in the Tromsø Study (1994-1995) or the North-Trøndelag Health Study (1995-1997). A Cox proportional hazards model adjusted for age, marital status, education and smoking was used to estimate HRs for mortality in different BMI categories using the BMI range of 25-27.5 as a reference. The impact of each 2.5 kg/m(2) difference in BMI on mortality in individuals with BMI < 25.0 and BMI ≥ 25.0 was also explored. Furthermore, the relations between WC and mortality were assessed.
We identified 7474 deaths during a mean follow-up of 9.3 years. The lowest mortality was found in the BMI range 25-29.9 and 25-32.4 in men and women, respectively. Mortality was increased in all BMI categories below 25 and was moderately increased in obese individuals. U-shaped relationships were also found between WC and total mortality. About 40% of the excess mortality in the lower BMI range in men was explained by mortality from respiratory diseases.
BMI below 25 in elderly men and women was associated with increased mortality. A modest increase in mortality was found with increasing BMI among obese men and women. Overweight individuals (BMI 25-29.9) had the lowest mortality.
A high body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) is associated with increased mortality from cardiovascular disease and certain cancers, but the precise relationship between BMI and all-cause mortality remains uncertain.
We used Cox regression to estimate hazard ratios and 95% confidence intervals for an association between BMI and all-cause mortality, adjusting for age, study, physical activity, alcohol consumption, education, and marital status in pooled data from 19 prospective studies encompassing 1.46 million white adults, 19 to 84 years of age (median, 58).
The median baseline BMI was 26.2. During a median follow-up period of 10 years (range, 5 to 28), 160,087 deaths were identified. Among healthy participants who never smoked, there was a J-shaped relationship between BMI and all-cause mortality. With a BMI of 22.5 to 24.9 as the reference category, hazard ratios among women were 1.47 (95 percent confidence interval [CI], 1.33 to 1.62) for a BMI of 15.0 to 18.4; 1.14 (95% CI, 1.07 to 1.22) for a BMI of 18.5 to 19.9; 1.00 (95% CI, 0.96 to 1.04) for a BMI of 20.0 to 22.4; 1.13 (95% CI, 1.09 to 1.17) for a BMI of 25.0 to 29.9; 1.44 (95% CI, 1.38 to 1.50) for a BMI of 30.0 to 34.9; 1.88 (95% CI, 1.77 to 2.00) for a BMI of 35.0 to 39.9; and 2.51 (95% CI, 2.30 to 2.73) for a BMI of 40.0 to 49.9. In general, the hazard ratios for the men were similar. Hazard ratios for a BMI below 20.0 were attenuated with longer-term follow-up.
In white adults, overweight and obesity (and possibly underweight) are associated with increased all-cause mortality. All-cause mortality is generally lowest with a BMI of 20.0 to 24.9.
Objective: To investigate the relationship between mortality and BMI in older people, taking into account other established mortality risk factors. Methods: A total of 3,646 French community dwellers aged 65 years and older from PAQUID cohort study were included. Cox proportional-hazards analysis was used to assess association between BMI and mortality. Results: Death occurred in 54.1% of the cohort more than 13 years: 68.99% of the underweight (BMI <19), 52.13% of the obese (BMI >" xbd="1204" xhg="1181" ybd="1711" yhg="1685"/>30), 51.66% of the overweight (BMI 25-30), and 51.79% of the reference participants (BMI 22-25) died.The relative risk of death as a function of BMI, adjusted for gender and age, formed a U-shaped pattern, with larger risks associated with lower BMI (<22.0) and for BMI of 25.0 to 30.0 and BMI ≥30. (BMI 22.0-24.9 was the reference.) After adjustment for demographic factors, smoking history, and comorbidity, increased mortality risk persisted in underweight older people, BMI <18.5 and BMI 18.5-22 (respectively, HR = 1.45, 95% CI 1.17-1.78; HR = 1.27, 95% CI 1.12-1.43) compared with reference. Overweight (BMI 25-29.9) and obesity (≥30) were not associated with increased mortality compared with the reference category (respectively, HR = 0.98, 95% IC 0.88-1.10; HR = 1.06, 95% IC 0.89-1.27). Similar relationships persisted for disabled participant. For nondisabled participant disability did not alter the associations for BMI of 25.0 and higher but for BMI less than 22.0, the risks become insignificantly different from those for the reference group. Discussion: BMI below 22 kg/ m² is a risk factor for 13-year mortality in older people, but our findings suggest that overweight and obesity may not be associated to mortality after adjustment for established mortality risk factors.
Low body mass index (BMI) and low cardiorespiratory fitness (CRF) are independently associated with increased mortality in the elderly. However, interactions among BMI, CRF, and mortality in older persons have not been adequately explored.
Hazard ratios (HRs) were calculated for predetermined strata of BMI and CRF. Independent and joint associations of CRF, BMI, and all-cause mortality were assessed by Cox proportional hazards analyses in a prospective cohort of 981 healthy men aged at least 65 years (mean age [+/-SD], 71 [+/-5] years; range, 65-88 years) referred for exercise testing during 1987-2003.
During a mean follow-up of 6.9 +/- 4.4 years, a total of 208 patients died. Multivariate relative risks (95% confidence interval [CI]) of mortality across BMI groups of <20.0, 20.0-25.0, 25.0-29.9, 30.0-34.9, and > or =35.0 were 2.51 (1.26-4.98), 1.0 (reference), 0.66 (0.48-0.90), 0.50 (0.31-0.78), and 0.44 (0.20-0.97), respectively, and across CRF groups of <5.0, 5.0-8.0, and >8.0 metabolic equivalents were 1.0 (reference), 0.56 (0.40-0.78), and 0.39 (0.26-0.58), respectively. In a separate analysis of within-strata CRF according to BMI grouping, the lowest mortality risk was observed in obese men with high fitness (HR [95% CI] 0.26 [0.10-0.69]; p = .007).
In this cohort of elderly male veterans, we observed independent and joint inverse relations of BMI and CRF to mortality. This warrants further investigation of fitness, fatness, and mortality interactions in older persons.
Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses.
Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews.
Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision.
In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias.
A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.
The US Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults set the body mass index (BMI; weight in kilograms divided by the square of height in meters) of 25 as the upper limit of ideal weight for all adults regardless of age. However, the prognostic importance of overweight and obesity in elderly persons (>/=65 years) is controversial. We sought to analyze the guidelines in the context of currently available evidence that is relevant to older adults.
We searched MEDLINE for all English-language studies of the association between BMI and all-cause or cardiovascular mortality or coronary heart disease events from January 1966 through October 1999. Additional pertinent articles were identified through bibliographies of the MEDLINE articles. We selected studies for detailed review if they reported on the association between BMI and mortality for nonhospitalized subjects who were 65 years or older and had been followed up for at least 3 years. We controlled for age, smoking, and baseline health status. Of the 444 screened articles, 13 were selected to assess the guidelines. We extracted information regarding publication year, study design, population, recruitment period, follow-up duration, number of subjects, sex, age range, inclusion and exclusion criteria, and statistical models, including variables and end points.
These data do not support the BMI range of 25 to 27 as a risk factor for all-cause and cardiovascular mortality among elderly persons. The results were not substantially different for men and women. Most studies showed a negative or no association between BMI and all-cause mortality. Three studies indicated overweight (BMI >/=27) as a significant prognostic factor for all-cause and cardiovascular mortality among 65- to 74-year-olds, and one study showed a significant positive association between overweight (BMI >/=28) and all-cause mortality among those 75 years or older. Higher BMI values were consistent with a smaller relative mortality risk in elderly persons compared with young and middle-aged populations.
Federal guideline standards for ideal weight (BMI 18.7 to <25) may be overly restrictive as they apply to the elderly. Studies do not support overweight, as opposed to obesity, as conferring an excess mortality risk. Future guidelines should consider the evidence for specific age groups when establishing standards for healthy weight.
To examine the relationship between body mass index (BMI) at age 70, weight change between age 70 and 75, and 15 y mortality.
Cohort study of 70-y-olds.
Geriatric Medicine Department, Göteborg University, Sweden.
A total of 2628 (1225 males and 1403 females) 70-y-olds examined in 1971--1981 in Gothenburg, Sweden.
The relative risks (RRs) for 15 y mortality were highest in the lowest BMI quintiles of males 1.20 (95% CI 0.96--1.51) and females 1.49 (95% CI 1.14--1.96). In non-smoking males, no significant differences were observed across the quintiles for 5, 10 and 15 y mortality. In non-smoking females, the highest RR (1.58, 95% CI 1.15--2.16) for 15 y mortality was in the lowest quintile. After exclusion of first 5 y death, no excess risks were found in males for following 5 and 10 y mortality across the quintiles. In females, a U-shaped relation was observed after such exclusions. BMI ranges with lowest 15 y mortality were 27--29 and 25--27 kg/m(2) in non-smoking males and females, respectively. A weight loss of > or = 10% between age 70 and 75 meant a significantly higher risk for subsequent 5 and 10 y mortality in both sexes relative to individuals with 'stable' weights.
Low BMI and weight loss are risk factors for mortality in the elderly and smoking habits did not significantly modify that relationship. The BMI ranges with lowest risks for 15 y mortality are relatively higher in elderly. Exclusion of early deaths from the analysis modified the weight-mortality relationship in elderly males but not in females.
This paper presents a command, glst, for trend estimation across different exposure levels for either single or multiple summarized case-control, incidence-rate, and cumulative incidence data. This approach is based on constructing an approximate covariance estimate for the log relative risks and estimating a corrected linear trend using generalized least squares. For trend analysis of multiple studies, glst can estimate fixed- and random-effects metaregression models. Copyright 2006 by StataCorp LP.
For the elderly, the association between waist circumference (WC) and mortality considering body mass index (BMI) remains unclear, and thereby also the evidence base for using these anthropometric measures in clinical practice. This meta-analysis examined the association between WC categories and (cause-specific) mortality within BMI categories. Furthermore, the association of continuous WC with lowest and increased mortality risks was examined.
Age- and smoking-adjusted relative risks (RRs) of mortality associated with WC-BMI categories and continuous WC (including WC and WC(2)) were calculated by the investigators and pooled by means of random-effects models.
During a 5-year-follow-up of 32 678 men and 25 931 women, we ascertained 3318 and 1480 deaths, respectively. A large WC (men: ≥102 cm, women: ≥88 cm) was associated with increased all-cause mortality RRs for those in the 'healthy' weight {1.7 [95% confidence interval (CI): 1.2-2.2], 1.7 (95% CI: 1.3-2.3)}, overweight [1.1(95% CI: 1.0-1.3), 1.4 (95%: 1.1-1.7)] and obese [1.1 (95% CI: 1.0-1.3), 1.6 (95% CI: 1.3-1.9)] BMI category compared with the 'healthy' weight (20-24.9 kg/m(2)) and a small WC (<94 cm, men; <80 cm, women) category. Underweight was associated with highest all-cause mortality RRs in men [2.2 (95% CI: 1.8-2.8)] and women [2.3 (95% CI: 1.8-3.1]. We found a J-shaped association for continuous WC with all-cause, cardiovascular (CVD) and cancer, and a U-shaped association with respiratory disease mortality (P < 0.05). An all-cause (CVD) mortality RR of 2.0 was associated with a WC of 132 cm (123 cm) in men and 116 cm (105 cm) in women.
Our results showed increased mortality risks for elderly people with an increased WC-even across BMI categories- and for those who were classified as 'underweight' using BMI. The results provide a solid basis for re-evaluation of WC cut-points in ageing populations.
A WHO expert consultation addressed the debate about interpretation of recommended body-mass index (BMI) cut-off points for determining overweight and obesity in Asian populations, and considered whether population-specific cut-off points for BMI are necessary. They reviewed scientific evidence that suggests that Asian populations have different associations between BMI, percentage of body fat, and health risks than do European populations. The consultation concluded that the proportion of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMIs lower than the existing WHO cut-off point for overweight (greater than or equal to25 kg/m(2)). However, available data do not necessarily indicate a clear BMI cut-off point for all Asians for overweight or obesity. The cut-off point for observed risk varies from 22 kg/m(2) to 25 kg/m(2) in different Asian populations; for high risk it varies from 26 kg/m(2) to 31 kg/m(2). No attempt was made, therefore, to redefine cut-off points for each population separately. The consultation also agreed that the WHO BMI cut-off points should be retained as international classifications. The consultation identified further potential public health action, points (23.0, 27.5, 32.5, and 37.5 kg/m(2)) along the continuum of BMI, and proposed methods by which countries could make decisions about the definitions of increased risk for their population.
The relation between relative weight and health differs between young and old. In older populations, weight change may cloud the association between a single relative weight and health outcomes. To determine whether weight or weight change is a more important determinant of mortality in a population of older adults, the authors analyzed data from the Systolic Hypertension in the Elderly Program (1984-1990), a randomized clinical trial testing the efficacy of antihypertensive drug treatment to reduce the risk of stroke in older adults (aged 60 years or more) with isolated systolic hypertension. After adjustment for covariates, an average annualized weight loss of at least 1.6 kg/year (odds ratio = 4.9), a weight loss between 1.6 and 0.7 kg/year (odds ratio = 1.7), a weight gain of more than 0.5 kg/year (odds ratio = 2.4), and a baseline body mass index of less than 23.6 (odds ratio = 1.4) all had a significant (p < 0.05) association with all-cause mortality compared with a referent group that was weight stable and of intermediate body mass index (23.6 to <28.0 kg/m 2 ) and weight change (-0.7 to <0.5 kg/year). The authors conclude that, in older adults, dynamic measures (e.g., annualized weight change) of weight change predict mortality better than do static weight measures (e.g., baseline body mass index). Even in those with high or low baseline body mass index, weight stability is associated with a lower mortality risk.
To examine how body mass index (BMI) and change in BMI are associated with mortality in old (70–79) and very old (≥80) individuals.
Pooled data from three multidisciplinary prospective population-based studies: OCTO-twin, Gender, and NONA.
Sweden.
Eight hundred eighty-two individuals aged 70 to 95.
BMI was calculated from measured height and weight as kg/m2. Information about survival status and time of death was obtained from the Swedish Civil Registration System.
Mortality hazard was 20% lower for the overweight group than the normal–underweight group (relative risk (RR) = 0.80, P = .011), and the mortality hazard for the obese group did not differ significantly from that of the normal–underweight group (RR = 0.93, P = .603), independent of age, education, and multimorbidity. Furthermore, mortality hazard was 65% higher for the BMI loss group than for the BMI stable group (RR = 1.65, P < .001) and 53% higher for the BMI gain group than for the BMI stable group (RR = 1.53, P = .001). Age moderated the BMI change differences. That is, the higher mortality risks associated with BMI loss and gain were less severe in very old age.
Old persons who were overweight had a lower mortality risk than old persons who were of normal weight, even after controlling for weight change and multimorbidity. Persons who increased or decreased in BMI had a greater mortality risk than those who had a stable BMI, particularly those aged 70 to 79. This study lends further support to the belief that the World Health Organization guidelines for BMI are overly restrictive in old age.
Objectives:
To identify predictors and consequences of nutritional risk, as determined by the Mini Nutritional Assessment (MNA), in older recipients of domiciliary care services living at home.
Design:
Baseline analysis of subject characteristics with low MNA scores (<24) and follow-up of the consequences of these low scores.
Setting:
South Australia.
Participants:
Two hundred fifty domiciliary care clients (aged 67-99, 173 women).
Measurements:
Baseline history and nutritional status were determined. Information about hospitalization was obtained at follow-up 12 months later.
Intervention:
Letters suggesting nutritional intervention were sent to general practitioners of subjects not well nourished.
Results:
At baseline, 56.8% were well nourished, 38.4% were at risk of malnutrition, and 4.8% were malnourished (43.2% not well nourished). Independent predictors of low MNA scores (<24) were living alone, and the physical and mental component scales of the 36-item Short Form Health Survey. Follow-up information was obtained for 240 subjects (96%). In the ensuing year not well-nourished subjects were more likely than well-nourished subjects to have been admitted to the hospital (risk ratio (RR) = 1.51, 95% confidence interval (CI) = 1.07-2.14), have two or more emergency hospital admissions (RR = 2.96, 95% CI = 1.15-7.59), spend more than 4 weeks in the hospital (RR = 3.22, 95% CI = 1.29-8.07), fall (RR = 1.65, 95% CI = 1.13-2.41), and report weight loss (RR = 2.63, 95% CI = 1.67-4.15).
Conclusion:
The MNA identified a large number of subjects with impaired nutrition who did significantly worse than well-nourished subjects during the following year. Studies are needed to determine whether nutritional or other interventions in people with low MNA scores can improve clinical outcomes.
Objective:
To determine the excess mortality associated with obesity (defined by body mass index (BMI)) in older people, with and without adjustment for other risk factors associated with mortality and for demographic factors.
Design:
Retrospective cohort analysis of the Longitudinal Study of Aging (LSOA).
Setting:
Nationally representative sample of community-dwelling older people.
Participants:
Seven thousand five hundred and twenty-seven participants age 70 and older in 1984.
Measurements:
We used Cox regression to calculate proportional hazards ratios for mortality over 96 months. We tested the hypothesis that increased BMI (top 15%) increased mortality rates in older people.
Results:
Death occurred in 38% of the cohort: 54% of the thin (lowest 10% of the population, BMI <19.4 kg/m(2)), 33% of the obese (highest 15%, BMI> 28.5 kg/m(2)), and 37% of the remaining participants (normal) died. Adjustment for demographic factors, health services utilization, and functional status still demonstrated reduced mortality in obese older people (hazard ratio 0.86, 95% confidence interval (CI) = 0.77-0.97) compared with normal. After adjustment, thin older people remained more likely to die (hazard ratio 1.46, 95% CI = 1.30-1.64) than normal older people. Sensitivity analyses for income, mortality during the first two years of follow-up, and medical comorbidities did not substantively alter the conclusions.
Conclusion:
Obesity may be protective compared with thinness or normal weight in older community-dwelling Americans.
OBJECTIVES: Older people are at risk of undernutrition because of a number of physiological conditions and lifestyle factors. The purpose of this study was to explore the predictive relationship of corrected arm muscle area (CAMA) with 8-year mortality in a representative sample of older Australians.
DESIGN: Prospective cohort study: The Australian Longitudinal Study of Ageing.
SETTING: Community.
PARTICIPANTS: One thousand three hundred ninety-six participants aged 70 and older.
MEASUREMENTS: Trained observers measured baseline weight, height, mid upper arm circumference, and triceps skinfold thickness using standard techniques. Body mass index (BMI) and CAMA were calculated. Baseline BMI and CAMA measurements were categorized according to cutoff values proposed by Garrow et al. and Friedman et al., respectively. Subsequent analyses were undertaken using Cox proportional hazards regression.
RESULTS: After adjustment for potential confounders (baseline age, gender, marital status, smoking, self-rated health, ability to conduct activities of daily living, comorbidity, cognition performance, and presence of depression), those older Australians with a low CAMA (≤21.4 cm2 for men and ≤21.6 cm2 for women) had an increased risk of mortality at 8-year follow-up (hazard ratio = 1.94, 95% confidence interval = 1.25–3.00, P = .003). There was no increased risk in 8-year mortality identified for those with a high or low BMI.
CONCLUSION: CAMA is a useful assessment of undernutrition in older adults that has better prognostic value than BMI in predicting death in older, community-living Australians.
Background
Physical performance may predict survival independently of other current predictors in non selected elderly subjects. We determined if poor balance and decreased gait speed may predict mortality after adjustment for both baseline and follow-up confounders in well-functioning elderly women.
Methods
A subgroup of participants in the Epidemiology of osteoporosis (EPIDOS) study (N = 1,300) was followed for 8 years. Participants were community-dwelling women aged 75 or older able to go outside home without assistance. The baseline examination included a questionnaire and a clinical and functional examination. Participants were contacted every year thereafter by mail.
Results
Poor balance, defined by the inability to stand in a tandem position or to complete ten foot taps in less than 4.6 seconds, and poor mobility, defined by a gait speed of less than 0.80 m/s or a stride length of less than 0.5 m were significant predictors of low 8-year survival, independently of other predictors of death at baseline (educational level, social network, number of drugs, fear of falling, visual acuity, perceived health, IADL score, physical activity, and comorbidities) and during follow-up (falls, IADL score, the need to be accompanied to go outside, weight loss, hospitalization, and the report of new comorbidities).
Conclusion
The current study shows that poor balance and mobility are significant predictors of 8-year mortality independently of baseline and intermediate events in pre-disabled women aged 75 years and older, suggesting that they may reflect a certain failure to respond adequately in the face of present and future medical and non-medical events.
A WHO expert consultation addressed the debate about interpretation of recommended body-mass index (BMI) cut-off points for determining overweight and obesity in Asian populations, and considered whether population-specific cut-off points for BMI are necessary. They reviewed scientific evidence that suggests that Asian populations have different associations between BMI, percentage of body fat, and health risks than do European populations. The consultation concluded that the proportion of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMIs lower than the existing WHO cut-off point for overweight (⩾25 kg/m2). However, available data do not necessarily indicate a clear BMI cut-off point for all Asians for overweight or obesity. The cut-off point for observed risk varies from 22kg/m2 to 25kg/m2 in different Asian populations; for high risk it varies from 26kg/m2 to 31kg/m2. No attempt was made, therefore, to redefine cut-off points for each population separately. The consultation also agreed that the WHO BMI cut-off points should be retained as international classifications. The consultation identified further potential public health action points (23·0, 27·5, 32·5, and 37·5 kg/m2) along the continuum of BMI, and proposed methods by which countries could make decisions about the definitions of increased risk for their population.
To assess the association between Body Mass Index (BMI) and cause-specific mortality in older adults and to assess which BMI was associated with lowest mortality.
Prospective study.
European towns.
1,980 older adults, aged 70-75 years from the SENECA (Survey in Europe on Nutrition and the Elderly: a concerted action) study.
BMI, examined in 1988/1989, and mortality rates and causes of death during 10 years of follow-up.
Cox proportional hazards model including both BMI and BMI², accounting for sex, smoking status, educational level and age at baseline showed that BMI was associated with all-cause mortality (p<0.01), cardiovascular mortality (p<0.01) and mortality from other causes (p<0.01), but not with cancer or respiratory mortality (p>0.3). The lowest all-cause mortality risk was found at 27.1 (95%CI 24.1, 29.3) kg/m², and this risk was increased with statistical significance when higher than 31.4 kg/m² and lower than 21.1 kg/m². The lowest cardiovascular mortality risk was found at 25.6 (95%CI 17.1, 28.4) kg/m², and was increased with statistical significance when higher than 30.9 kg/m².
In this study, BMI was associated with all-cause mortality risk in older people. This risk was mostly driven by an increased cardiovascular mortality risk, as no association was found for mortality risk from cancer or respiratory disease. Our results indicate that the WHO cut-off point of 25 kg/m² for overweight might be too low in old age, but more studies are needed to define specific cut-off points.
Elderly subjects are at risk for undernutrition. Restrictive diets may increase this risk. The aim was to evaluate the impact of restrictive diets on undernutrition and its risk in free-living elderly.
Ambulatory patients over age 75 and under a restrictive diet (low salt, low cholesterol, diabetic) were included prospectively, along with age- and gender-matched controls. Weight and height were measured, and the short-form of the Mini Nutritional Assessment was scored. Groups were compared to determine variables associated with a low MNA-SF(®).
95 patients in the diet group (62 F, 33 M, 80 ± 4 y) and 95 controls (57 F, 38 M, 82 ± 5 y) were included. Restrictive diets (low salt n = 33, diabetic n = 19, low cholesterol n = 15, combination n = 27) had been followed since 11.0 ± 5.9 years. Using the cut-off of 12 for MNA-SF(®), 44 patients in the diet group were at risk vs. 22 among controls (P < 0.001). In multivariate analysis, a restrictive diet increased the probability of having an MNA-SF(®) < 12 (OR = 3.6, (95%)CI = 1.8-7.2, P < .001).
Restrictive diets in patients over 75 increase the risk of undernutrition. On an individual level, these diets may need reassessment. Society guidelines should promote specific recommendations for the elderly.
We examined the relation between measures of body size and mortality in a predominantly White cohort of 8029 women aged 65 years and older who were participating in the Study of Osteoporotic Fractures.
Body composition measures (fat and lean mass and percentage body fat) were calculated by bioelectrical impedance analysis. Anthropometric measures were body mass index (BMI; kg/m2) and waist circumference.
During 8 years of follow-up, there were 945 deaths. Mortality was lowest among women in the middle of the distribution of each body size measure. For BMI, the lowest mortality rates were in the range 24.6 to 29.8 kg/m2. The U-shaped relations were seen throughout the age ranges included in this study and were not attributable to smoking or measures of preexisting illness. Body composition measures were not better predictors of mortality than BMI or waist girth.
Our results do not support applying the National Institutes of Health categorization of BMI from 25 to 29.9 kg/m2 as overweight in older women, because women with BMIs in this range had the lowest mortality.
The adverse effect of obesity on health outcomes may be lower in older and African American adults than in the general U.S. population.
To examine and compare the relationship between obesity and all-cause mortality and functional decline among older U.S. adults.
Longitudinal cohort study.
Secondary analysis of data from the 1994 to 2000 Medicare Current Beneficiary Surveys, linked to Medicare enrollment files through 22 April 2008.
20,975 community-dwelling participants in the 1994 to 2000 Medicare Current Beneficiary Surveys who were aged 65 years or older.
All-cause mortality through 22 April 2008; new or worsening disability in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) in 2 years.
37% of the study sample were overweight (body mass index [BMI] of 25 to <30 kg/m(2)), 18% were obese (BMI ≥30 kg/m(2)), 48% died during the 14-year follow-up, and 27% had ADL and 43% had IADL disability at baseline. Among those without severe disability at baseline, 17% developed new or worsening ADL disability and 26% developed new or worsening IADL disability within 2 years. After adjustment, adults with a BMI of 35 kg/m(2) or greater were the only group above the normal BMI range who had a higher risk for mortality (hazard ratio, 1.49 [95% CI, 1.20 to 1.85] in men and 1.21 [CI, 1.06 to 1.39] in women, compared with the reference group [BMI of 22.0 to 24.9 kg/m(2)]; P for BMI-sex interaction = 0.003). In contrast, both overweight and obesity were associated with new or progressive ADL and IADL disability in a dose-dependent manner, particularly for white men and women. Significant interactions were detected between BMI and sex but not between BMI and race for any outcome, although risk estimates for ADL disability seemed attenuated in African American relative to white respondents.
This was an observational study, baseline data were self-reported, and the study had limited power to detect differences between white and African American respondents.
Among older U.S. adults, obesity was not associated with mortality, except for those with at least moderately severe obesity. However, lower levels of obesity were associated with new or worsening disability within 2 years. Efforts to prevent disability in older adults should target those who are overweight or obese.
National Institute of Diabetes and Digestive and Kidney Diseases.
To investigate the independent association between undernutrition and death in older adults in a community-dwelling setting.
This retrospective study was based on the Health, Well-being and Ageing survey conducted in 2000 that included 1170 older adults (≥60 y) from São Paulo, Brazil. Death occurrences were considered through March, 2007. The variables analyzed were undernutrition (Mini-Nutritional Assessment), gender, income, muscle strength, hip fracture, smoking habits, cancer, depression, diabetes, coronary heart disease, chronic lung disease, cerebral vascular disease, and hypertension. A hierarchical multivariate analysis by logistic regression was performed according to age groups (60-74 and ≥75 y).
Undernutrition frequency was higher in adults ≥75 y old (2.6% versus 2.4%). The frequency of death in undernourished subjects was higher in the 60- to 74-y-old group (7.6%) than in those ≥75 y old (3.9%). Undernutrition was the strongest independent risk factor for death (P < 0.05) in the 60- to 74-y-old group (odds ratio 6.05, 95% confidence interval 5.76-6.35) and in the ≥75-y-old group (odds ratio 2.76, 95% confidence interval 2.51-3.04). All other variables were also associated with death, except for hip fracture and cerebral vascular disease, in the two age groups and hypertension in the 60- to 74-y-old group; however, the effect of these variables was less.
Undernutrition represented the strongest risk factor for death in Brazilian community-dwelling older adults 60 to 74 y old and showed a stronger association than for adults ≥75 y old.
To examine in an older population all-cause and cause-specific mortality associated with underweight (body mass index (BMI)<18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), and obesity (BMI> or =30.0).
Cohort study.
The Health in Men Study and the Australian Longitudinal Study of Women's Health.
Adults aged 70 to 75, 4,677 men and 4,563 women recruited in 1996 and followed for up to 10 years.
Relative risk of all-cause mortality and cause-specific (cardiovascular disease, cancer, and chronic respiratory disease) mortality.
Mortality risk was lowest for overweight participants. The risk of death for overweight participants was 13% less than for normal-weight participants (hazard ratio (HR)=0.87, 95% CI=0.78-0.94). The risk of death was similar for obese and normal-weight participants (HR=0.98, 95% CI=0.85-1.11). Being sedentary doubled the mortality risk for women across all levels of BMI (HR=2.08, 95% CI=1.79-2.41) but resulted in only a 28% greater risk for men (HR=1.28 (95% CI=1.14-1.44).
These results lend further credence to claims that the BMI thresholds for overweight and obese are overly restrictive for older people. Overweight older people are not at greater mortality risk than those who are normal weight. Being sedentary was associated with a greater risk of mortality in women than in men.
Later life weight change and mortality amongst elders.
Nested case-control study.
Six countries from the European Investigation into Cancer and nutrition-Elderly, Network on Ageing and Health.
A total of 1712 deceased (cases) and 4942 alive (controls) were selected from 34,239 participants, > or = 60 years at enrolment (1992-2000) who were followed-up until March 2007. Annual weight change was estimated as the weight difference from recruitment to the most distant from-date-of-death re-assessment, divided by the respective time.
Mortality in relation to weight change was examined using conditional logistic regression.
Weight loss > 1 kg year(-1) was associated with statistically significant increased death risk (OR = 1.65; 95% CI: 1.41-1.92) compared to minimal weight change (+/-1 kg year(-1)). Weight gain > 1 kg year(-1) was also associated with increased risk of death (OR = 1.15; 95% CI: 0.98-1.37), but this was evident and statistically significant only amongst overweight/obese (OR = 1.55; 95% CI: 1.17-2.05). In analyses by time interval since weight re-assessment, the association of mortality with weight loss was stronger for the interval proximal (< 1 year) to death (OR = 3.10; 95% CI: 2.03-4.72). The association of mortality with weight gain was stronger at the interval of more than 3 years and statistically significant only amongst overweight/obese (OR = 1.58; 95% CI: 1.07-2.33). Similar patterns were observed regarding death from circulatory diseases and cancer.
In elderly, stable body weight is a predictor of lower subsequent mortality. Weight loss is associated with increased mortality, particularly short-term, probably reflecting underlying nosology. Weight gain, especially amongst overweight/obese elders, is also associated with increased mortality, particularly longer term.
To examine the association between body mass index (BMI) and mortality in older people.
A longitudinal cohort study of an age-homogenous, representative sample born in 1920/21.
Community-based home assessments.
West Jerusalem residents born in 1920/21 examined at baseline in 1990 (n=447), with additional recruitment waves in 1998 (n=870) and 2005 (n=1,086).
Comprehensive assessment of health variables including BMI (m/kg(2)) at ages 70, 78, and 85. The primary outcome of mortality was collected from age 70 to 88 (1990-2008). Adjusted Cox proportional hazards analysis was used to calculate hazard ratios (HRs) for mortality according to unit increase in BMI.
A unit increase in BMI in women resulted in HRs of 0.94, (95% confidence interval (CI)=0.89-0.99) at age 70, 0.95 (95% CI=0.91-0.98) at age 78, and 0.91 (95% CI=0.86-0.98) at age 85. Similarly, in men, HRs were 0.99 (95% CI=0.95-1.05) at age 70, 0.94 (95% CI=0.91-0.98) at age 78, and 0.91 (95% CI=0.86-0.98) at age 85. A time-dependent analysis of 450 subjects followed for 18 years confirmed the above findings; a unit increase in BMI resulted in HRs of 0.93 (95% CI=0.87-0.99) in women and 0.93(95% CI=0.88-0.98) in men. Eliminating the first third of follow-up mortality to account for possibility of reverse causality did not change the results.
Higher BMI was associated with lower mortality from age 70 to 88.
To identify associations between malnutrition falls risk and hospital admission among older people presenting to ED.
A prospective convenience sample of patients, aged 60 years or more, presenting to an Australian tertiary teaching hospital ED were included in this cross-sectional study. Malnutrition Screening Tool and Subjective Global Assessment tool were administered to 126 non-consecutive participants. Participants were categorized as non-fallers, frail mechanical or active mechanical fallers. Self-reported falls in past 6 months and hospital admission were documented.
Participant age and sex (median age 74, interquartile range 65-82 years; male 59%, 74/126, 95% CI 50-67%) were representative of older people presenting to the ED. Malnutrition prevalence was 15% (19/126, 95% CI 9-21%). There was an increased risk of being assessed as malnourished when a frail mechanical faller relative to: a non-faller (relative risk [RR]: 1.5, 95% CI 1.0-2.3, P= 0.001), an active mechanical faller (RR: 3.1, 95% CI 1.0-10.9, Fisher's Exact test P= 0.02) or a non-faller and active mechanical faller combined (RR: 1.5, 95% CI 1.0-2.1, P= 0.001). Malnourished participants had an increased risk of self-reported falls over 6 months (RR: 1.5, 95% CI 1.0-2.5, P= 0.03). There was over five times the risk of hospital admission if malnourished than if well-nourished (RR: 5.3, 95% CI 1.4-20.0, Fisher's exact test P= 0.001). The Malnutrition Screening Tool captured 84% (16/19, 95% CI 78-92%) of participants assessed as malnourished by Subjective Global Assessment.
Older people presenting to ED should be nutritionally screened. Malnutrition prevalence of 15% was documented and was associated with an increased risk of frail mechanical falls and hospital admission. The Malnutrition Screening Tool was a simple and practical screen for ED.
The Bergen Clinical Blood Pressure Study in Norway was used to examine the relationship between body mass index (BMI (kg/m(2))) and total mortality in different age segments. Of 6,811 invited subjects, 5,653 (84%) participated in the study (1965-1971) and 4,520 (66%) died during 182,798 person-years of follow-up (1965-2007). Mean age at baseline was 47.5 years; range 22-75 years. BMI (kg/m(2)) was calculated from standardized measurements of body height and weight and divided into four groups (<22.0, 22.0-24.9, 25.0-27.9, > or =28.0). The 20 years cumulative risk of death related to baseline BMI was U-shaped in the elderly (aged 65-75 years), whereas the pattern was more linear in the youngest age group (20-44 years). In contrast to the younger age groups, the highest mortality in the elderly was in the lower BMI range (<22.0 kg/m(2)) (adjusted Cox proportional Hazard Ratio 1.39, 95% Confidence Interval 1.10, 1.75) compared to the BMI reference group (22.0-24.9 kg/m(2)). This pattern persisted after 72 months of early follow-up exclusion and it was robust to adjustments for a wide range of possible confounders including gender, history of cardiovascular disease, respiratory disease or hypertension, smoking habits, physical activity, socioeconomic status, physical appearance and other anthropometric measures. The study shows that a low BMI is an appreciable independent risk factor of total mortality in the elderly, and not a result of subclinical disease or confounding factors such as current or previous smoking. Awareness of this issue ought to be emphasized in advice, care and treatment of elderly subjects.
The association between BMI and all-cause mortality may vary with gender, age, and ethnic groups. However, few prospective cohort studies have reported the relationship in older Asian populations. We evaluated the association between BMI and all-cause mortality in a cohort comprised 26,747 Japanese subjects aged 65-79 years at baseline (1988-1990). The study participants were followed for an average of 11.2 years. Proportional-hazards regression models were used to estimate mortality hazard ratios (HRs) and 95% confidence intervals. Until 2003, 9,256 deaths occurred. The underweight group was associated with a statistically higher risk of all-cause mortality compared with the mid-normal-range group (BMI: 20.0-22.9); resulting in a 1.78-fold (95% confidence interval: 1.45-2.20) and 2.55-fold (2.13-3.05) increase in mortality risk among severest thin men and women (BMI: <16.0), respectively. Even within the normal-range group, the lower normal-range group (BMI: 18.5-19.9) showed a statistically elevated risk. In contrast, being neither overweight (BMI: 25.0-29.9) nor obese (BMI: > or =30.0) elevated the risk among men; however among women, HR was slightly elevated in the obese group but not in the overweight group compared with the mid-normal-range group. Among Japanese older adults, a low BMI was associated with increased risk of all-cause mortality, even among those with a lower normal BMI range. The wide range of BMI between 20.0 and 29.9 in both older men and women showed the lowest all-cause mortality risk.
Multivariate meta-analysis is increasingly used in medical statistics. In the univariate setting, the non-iterative method proposed by DerSimonian and Laird is a simple and now standard way of performing random effects meta-analyses. We propose a natural and easily implemented multivariate extension of this procedure which is accessible to applied researchers and provides a much less computationally intensive alternative to existing methods. In a simulation study, the proposed procedure performs similarly in almost all ways to the more established iterative restricted maximum likelihood approach. The method is applied to some real data sets and an extension to multivariate meta-regression is described.
To estimate the associations of weight dynamics with physical functioning and mortality in older adults.
Longitudinal cohort study using prospectively collected data on weight, physical function, and health status in four U.S. Communities in the Cardiovascular Health Study. Included were 3,278 participants (2,013 women and 541 African Americans), aged 65 or older at enrollment, who had at least five weight measurements. Weight was measured at annual clinic visits between 1992 and 1999, and summary measures of mean weight, coefficient of variation, average annual weight change, and episodes of loss and gain (cycling) were calculated. Participants were followed from 1999 to 2006 for activities of daily living (ADL) difficulty, incident mobility limitations, and mortality.
Higher mean weight, weight variability, and weight cycling increased the risk of new onset of ADL difficulties and mobility limitations. After adjustment for risk factors, the hazard ratio (95% confidence interval) for weight cycling for incident ADL impairment was 1.28 (1.12, 1.47), similar to that for several comorbidities in our model, including cancer and diabetes. Lower weight, weight loss, higher variability, and weight cycling were all risk factors for mortality, after adjustment for demographic risk factors, height, self-report health status, and comorbidities.
Variations in weight are important indicators of future physical limitations and mortality in the elderly and may reflect difficulties in maintaining homeostasis throughout older ages. Monitoring the weight of an older person for fluctuations or episodes of both loss and gain is an important aspect of geriatric care.
The main associations of body-mass index (BMI) with overall and cause-specific mortality can best be assessed by long-term prospective follow-up of large numbers of people. The Prospective Studies Collaboration aimed to investigate these associations by sharing data from many studies.
Collaborative analyses were undertaken of baseline BMI versus mortality in 57 prospective studies with 894 576 participants, mostly in western Europe and North America (61% [n=541 452] male, mean recruitment age 46 [SD 11] years, median recruitment year 1979 [IQR 1975-85], mean BMI 25 [SD 4] kg/m(2)). The analyses were adjusted for age, sex, smoking status, and study. To limit reverse causality, the first 5 years of follow-up were excluded, leaving 66 552 deaths of known cause during a mean of 8 (SD 6) further years of follow-up (mean age at death 67 [SD 10] years): 30 416 vascular; 2070 diabetic, renal or hepatic; 22 592 neoplastic; 3770 respiratory; 7704 other.
In both sexes, mortality was lowest at about 22.5-25 kg/m(2). Above this range, positive associations were recorded for several specific causes and inverse associations for none, the absolute excess risks for higher BMI and smoking were roughly additive, and each 5 kg/m(2) higher BMI was on average associated with about 30% higher overall mortality (hazard ratio per 5 kg/m(2) [HR] 1.29 [95% CI 1.27-1.32]): 40% for vascular mortality (HR 1.41 [1.37-1.45]); 60-120% for diabetic, renal, and hepatic mortality (HRs 2.16 [1.89-2.46], 1.59 [1.27-1.99], and 1.82 [1.59-2.09], respectively); 10% for neoplastic mortality (HR 1.10 [1.06-1.15]); and 20% for respiratory and for all other mortality (HRs 1.20 [1.07-1.34] and 1.20 [1.16-1.25], respectively). Below the range 22.5-25 kg/m(2), BMI was associated inversely with overall mortality, mainly because of strong inverse associations with respiratory disease and lung cancer. These inverse associations were much stronger for smokers than for non-smokers, despite cigarette consumption per smoker varying little with BMI.
Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well add extra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22.5-25 kg/m(2). The progressive excess mortality above this range is due mainly to vascular disease and is probably largely causal. At 30-35 kg/m(2), median survival is reduced by 2-4 years; at 40-45 kg/m(2), it is reduced by 8-10 years (which is comparable with the effects of smoking). The definite excess mortality below 22.5 kg/m(2) is due mainly to smoking-related diseases, and is not fully explained.
Results of studies comparing overall obesity and abdominal adiposity or body fat distribution with risk of mortality have varied considerably. We compared the relative importance and joint association of overall obesity and body fat distribution in predicting risk of mortality. Participants included 5,799 men and 6,429 women aged 30-102 years enrolled in the third National Health and Nutrition Examination Survey who completed a baseline health examination during 1988-1994. During a 12-year follow-up (102,172 person-years), 1,188 men and 925 women died. In multivariable-adjusted analyses, waist-to-thigh ratio (WTR) in both sexes (Ptrend<0.01 for both) and waist-to-hip ratio (WHR) in women (Ptrend 0.001) were positively associated with mortality in middle-aged adults (30-64 years), while BMI and waist circumference (WC) exhibited U- or J-shaped associations. Risk of mortality increased with a higher WHR and WTR among normal weight (BMI 18.5-24.9 kg/m2) and obese (BMI>or=30.0 kg/m2) adults. In older adults (65-102 years), a higher BMI in both sexes (Ptrend<0.05) and WC in men (Ptrend 0.001) were associated with increased survival, while remaining measures of body fat distribution exhibited either no association or an inverse relation with mortality. In conclusion, ratio measures of body fat distribution are strongly and positively associated with mortality and offer additional prognostic information beyond BMI and WC in middle-aged adults. A higher BMI in both sexes and WC in men were associated with increased survival in older adults, while a higher WHR or WTR either decreased or did not influence risk of death.
The primary purpose of this study was to determine whether current and midlife obesity status provide independent information on mortality risk in elderly persons. Analyses were based on 3,238 participants from the original Framingham Heart Study (FHS) cohort who lived to at least 70 years of age and who had BMI measures from when they were in their 50s. Within this group of 70-year olds, obesity based on current BMI was associated with a 21% increased risk of mortality (P = 0.019) whereas obesity in 70-year olds based on BMI measures obtained at around 50 years of age was associated with a 55% increased risk of mortality (P < 0.0001). Compared to 70-year olds who were nonobese at both 50 and 70 years of age, mortality risk was increased by 47% (P < 0.001) in those who were obese at both 50 and 70 years of age, increased by 56% (P < 0.001) in those who were obese at 50 years of age and nonobese at 70 years of age, and not significantly different (P > 0.9) in those who were nonobese at 50 years of age and obese at 70 years of age. In summary, in this cohort of elderly adults, midlife and current BMI had independent effects on mortality risk. Specifically, although mortality risk was increased in obese older adults who were already obese at midlife, this was not the case for newly obese older adults. Conversely, nonobese older adults who were obese at midlife had an increased mortality risk. These observations imply that it is imperative to consider an elderly adult's BMI in context of their BMI at midlife.
To determine whether body weight is a risk factor for mortality among older persons, we analyzed body mass index (weight [kilogram]/height [square meter]) data for 4710 white, National Health and Nutrition Examination Survey respondents who were aged 55 to 74 years during 1971 through 1975, in relation to their survival over an average of 8.7 years of follow-up. In a multivariate analysis that controlled for elevated blood pressure, smoking, and poverty, we found no additional risk associated with weight among women and a statistically significant, but moderate, additional risk (relative risk, 1.1 to 1.2) among men in the upper decile (body mass index, greater than or equal to 30 kg/m2). In contrast, low weight (body mass index, less than 22 kg/m2) was associated with increased mortality (relative risk, 1.3 to 1.6) except for women aged 55 to 64 years. We conclude that the accepted definition of overweight (body mass index, greater than or equal to 27.8 kg/m2 [men] or greater than or equal to 27.3 kg/m2 [women]) lacks specificity and may be inappropriate for older persons who do not have weight-related medical conditions. The low-weight mortality association, consistently demonstrated, deserves serious scrutiny.
Multtiple regression models are increasingly being applied to clinical studies. Such models are powerful analytic tools that
yields valid statistical inferences and make reliable predictions if various assumptions are satisfied. Two types of assumptions
made by regression models concern the distribution of the response variable and the nature or shape of the relationship between
the predictors and the response. This paper addresses the latter assumption by applying a direct and flexible approach, cubic
spline functions, to two widely used models: the logistic regression model for binary responses and the Cox proportional hazards
regression model for survival time data. [J Natl Cancer Inst 1988;80:1198–1202]
Despite the increase in body fat and obesity that occurs with aging, there is a linear decrease in food intake over the life span. This conundrum is explained by decreased physical activity and altered metabolism with aging. Thus, older persons fail to adequately regulate food intake and develop a physiologic anorexia of aging. This physiologic anorexia depends not only on decreased hedonic qualities of feeding with aging (an area that remains controversial) but also on altered hormonal and neurotransmitter regulation of food intake. Findings in older animals and humans have provided clues to the causes of the anorexia of aging. An increase in circulating concentrations of the satiating hormone, cholecystokinin, occurs with aging in humans. In addition, animal studies suggest a decrease in the opioid (dynorphin) feeding drive and possibly in neuropeptide Y and nitric oxide. The physiologic anorexia of aging puts older persons at high risk for developing protein-energy malnutrition when they develop either psychologic or physical disease processes. Despite its high prevalence, however, protein-energy malnutrition in older persons is rarely recognized and even more rarely treated appropriately. Screening tools for the early detection of protein-energy malnutrition in older persons have been developed. Multiple treatable causes of pathologic anorexia have been identified. There is increasing awareness of the importance of depression as a cause of severe weight loss in older persons. Approaches to the management of anorexia and weight loss in older persons are reviewed. Although many drugs exist that can enhance appetite, none of these are ideal for use in older persons currently.
Body-mass index (the weight in kilograms divided by the square of the height in meters) is known to be associated with overall mortality. We investigated the effects of age, race, sex, smoking status, and history of disease on the relation between body-mass index and mortality.
In a prospective study of more than 1 million adults in the United States (457,785 men and 588,369 women), 201,622 deaths occurred during 14 years of follow-up. We examined the relation between body-mass index and the risk of death from all causes in four subgroups categorized according to smoking status and history of disease. In healthy people who had never smoked, we further examined whether the relation varied according to race, cause of death, or age. The relative risk was used to assess the relation between mortality and body-mass index.
The association between body-mass index and the risk of death was substantially modified by smoking status and the presence of disease. In healthy people who had never smoked, the nadir of the curve for body-mass index and mortality was found at a body-mass index of 23.5 to 24.9 in men and 22.0 to 23.4 in women. Among subjects with the highest body-mass indexes, white men and women had a relative risk of death of 2.58 and 2.00, respectively, as compared with those with a body-mass index of 23.5 to 24.9. Black men and women with the highest body-mass indexes had much lower risks of death (1.35 and 1.21), which did not differ significantly from 1.00. A high body-mass index was most predictive of death from cardiovascular disease, especially in men (relative risk, 2.90; 95 percent confidence interval, 2.37 to 3.56). Heavier men and women in all age groups had an increased risk of death.
The risk of death from all causes, cardiovascular disease, cancer, or other diseases increases throughout the range of moderate and severe overweight for both men and women in all age groups. The risk associated with a high body-mass index is greater for whites than for blacks.
In developed countries, there is a general increase in body weight and body mass index (BMI) with age, until approximately 60 years of age, when body weight and BMI begin to decline. The proportion of intra-abdominal fat, which is related to increased morbidity and mortality, progressively increases with age. There is also a progressive decline in energy intake and daily total energy expenditure (165 kcal/decade in men and 103 kcal/decade in women in developed countries), which is primarily due to a decrease in physical activity, and to a lesser extent, a decrease in basal metabolic rate. The decrease in physical activity is more pronounced in those with chronic disabilities and diseases. The BMI-mortality curves have been reported to move upward (greater overall mortality), become flatter (less effect of BMI on mortality), and in some cases shift to the right (minimum mortality occurs at a higher BMI), for a variety of possible reasons. Weight loss in the elderly has been reported to increase, decrease, or not alter mortality, but the studies are confounded by numerous methodological problems. It has been argued that there may be little benefit in encouraging weight loss in extreme old age (short life expectancy), especially when there are no obesity-related complications or biochemical risk factors and when strong resistance and distress arise from changes in lifelong habits of eating and exercise. In contrast, weight loss in the elderly can reduce morbidity from arthritis, diabetes and other conditions, reduce cardiovascular risk factors, and improve well-being. BMI also predicts morbidity in those without disease. Furthermore, increased physical activity in the elderly, which is an important component of weight management, can produce beneficial effects on muscle strength, endurance, and well-being.
The extent of heterogeneity in a meta-analysis partly determines the difficulty in drawing overall conclusions. This extent may be measured by estimating a between-study variance, but interpretation is then specific to a particular treatment effect metric. A test for the existence of heterogeneity exists, but depends on the number of studies in the meta-analysis. We develop measures of the impact of heterogeneity on a meta-analysis, from mathematical criteria, that are independent of the number of studies and the treatment effect metric. We derive and propose three suitable statistics: H is the square root of the chi2 heterogeneity statistic divided by its degrees of freedom; R is the ratio of the standard error of the underlying mean from a random effects meta-analysis to the standard error of a fixed effect meta-analytic estimate, and I2 is a transformation of (H) that describes the proportion of total variation in study estimates that is due to heterogeneity. We discuss interpretation, interval estimates and other properties of these measures and examine them in five example data sets showing different amounts of heterogeneity. We conclude that H and I2, which can usually be calculated for published meta-analyses, are particularly useful summaries of the impact of heterogeneity. One or both should be presented in published meta-analyses in preference to the test for heterogeneity.