84 Menopause International Vol. 13 No. 2 June 2007
Home care needs of extremely obese
elderly European women
L W Sørbye,* M Schroll,
P V Jónnson,
and R Bernabei
for the AdHOC Project Research Group
* Diakonhjemmet University College, Oslo, Norway;
Bispebjerg Hospital, København, Denmark;
STAKES/CHESS, Helsinki, Finland;
Landspitali University Hospital, Reykjavík, Iceland; ** Department of
Social and Clinical Pharmacy, Faculty of Pharmacy, Hradec Králové, Czech Republic;
Vårdutveckling, Stockholm, Sweden;
Centro Medicina Invecchiamento, Università Cattolica del Sacro Cuore,
Correspondence: Liv Wergeland Sørbye, RN MA, Diakonhjemmet University College, Postboks 184, 0319 Oslo, Norway.
Objective. To examine the health and needs of extremely obese women aged over 65 years receiving home
care in Europe.
Study design. A cross-sectional assessment study based on the Aged in Home Care (AdHOC) project
recruited 2974 women aged 65 or over who were receiving home care at 11 sites in European countries.
Extreme obesity was defined as ‘Obesity of such a degree as to interfere with normal activities, including
Main outcome measures: Resident Assessment Instrument for Home Care (RAI-HC version 2.0); Activity
of Daily Living Scale; Instrumental Activity of Daily Living Scale; the Minimum Data Set Cognitive
Performance Scale; and a health profile.
Results: One hundred and twenty women (4.0%) were extremely obese. They were younger than their
thinner counterparts, with a median age of 78.3 versus 83.3 years, and they more often had multiple
health complaints and needed more help with mobility outside the home. The extremely obese had
received home care longer than the non-extremely obese (median 28.7 versus 36.6 months). Extremely
obese women also needed more help with personal care than the other group and, due to lower age, they
were less cognitively impaired.
Conclusions: Extreme obesity is a problem that increasingly affects home care of elderly women.
Keywords: Ageing, extreme obesity, female health, home care, Resident Assessment Instrument
Menopause International 2007; 13: 84–87
Average life span has increased continuously in the
Over the last few decades, there
has been an unprecedented increase in the prevalence of
obesity, especially in economically developed countries.
Of 93,290 female US veterans aged 18 and over, 37.4%
were classified as obese,
defined as a body mass index
(BMI) of 30 kg/m
or more. Obesity is associated with
an increased risk of health problems such as diabetes,
hypertension, dyslipidaemia, breathlessness, sleep
apnoea, gall bladder disease, coronary heart disease
or heart failure and osteoarthritis.
It is becoming an
increasingly recognized health issue in the elderly and is
associated with more requirements for care.
The aim of this study was to examine the health and
needs of extremely obese women aged over 65 years
receiving home care in 11 European countries.
A cross-sectional study was undertaken using the
population recruited for the European Aged in Home
Care (AdHOC) project (all aged 65 years and over). The
participants lived in urban settings and were already
receiving home care services at the start of the study:
1036 men and 2974 women from 11 European countries
were involved (Figure 1). The total refusal rate was 13%.
Participants were assessed using the Resident Assess-
ment Instrument for Home Care (RAI-HC), version
The assessors observed and talked with the
clients; additional information was gathered from
written documentation, other team members or next
of kin. ‘Extreme obesity’ was defined as ‘Obesity of
such a degree as to interfere with normal activities,
This corresponds to the
World Health Organization’s classes 2 (BMI 35–39.9 )
Menopause International Vol. 13 No. 2 June 2007 85
L W Sørbye et al. Extremely obese elderly women
and 3 (BMI q 40).
Physical and cognitive function
were assessed using the Activity of Daily Living (ADL)
and the Instrumental Activity of Daily Living (IADL)
and the Minimum Data Set (MDS) Cognitive
Associations between extreme obesity and the follow-
ing conditions were analysed: hypertension, congestive
heart failure, diabetes, chronic obstructive pulmonary
disease (COPD), Alzheimer’s disease and other
dementias, oedema, urinary incontinence, renal failure,
falls (at least one fall during the last 90 days) and pain.
Medication use was also examined.
Local legislation for ethical approval and data col-
lection in each country was followed and informed
consent was obtained.
Descriptive statistics were retrieved from the database
from July 2004. Analyses were performed using SPSS
software, version 13. The factors associated with the
extreme obesity were analysed. Conditions significantly
associated with extreme obesity (P<0.05) were entered
into a forward logistic regression model, with grade of
obesity (extreme versus non-extreme) as the dependent
variable. Results from both the cross-tabulations and the
regression model are reported as odds ratios (ORs) with
95% confidence intervals (CIs).
One hundred and twenty women (4.0%) and 22 men
(2.1%) were extremely obese (further analysis was
confined to women). Extremely obese women receiving
home care were younger than the non-extremely obese:
median age 78.3 (range 64.3–94.9) years versus 83.3
(range 64.4–104.5) years and had received home care for
longer (Table 1). Extremely obese women needed more
help with personal care than the other group but they
were less cognitively impaired.
Table 2 presents the frequency of clinical condi-
tions. The OR indicates the risk for each. The extremely
obese group had significantly more shortness of breath
and oedema, urinary incontinence and required more
specialist skin care. Due to diabetes they needed more
dietary consultations; five of them were treated with
insulin injections (data not shown). They required
more help when moving outside the house. They also
reported multiple heath complaints.
All the conditions listed in Table 2 were entered
into a logistic regression. In the final model, extreme
obesity was significantly associated at the 5% level with:
increased need of care related to diabetes (OR 1.81,
95% CI 1.20–2.72), shortness of breath (OR 2.26, 95%
CI 1.52–3.37), oedema (OR 1.56, 95% CI 1.04–2.32),
multiple health complaints (OR 1.73, 95% CI 1.05–2.84)
and urinary incontinence (OR 2.16, 95% CI 1.45–3.22).
The extremely obese were also more likely to need assist-
ance for locomotion outside the home (use of frame
outside home, OR 1.73, 95% CI 1.10–2.71; help for
moving outside the home, OR 1.56, 95% CI 1.03–2.37).
This study examined the characteristics and special
needs of extremely obese elderly European women and
the challenges they pose for home care services. As far as
we know, this is the first cross-national study of extreme
obesity in older European women receiving home care.
Extreme obesity here is a clinical term without any
specific linkage to BMI, making this study difficult to
compare with other studies. Another limitation is the
relatively small number of EO clients in the sample; the
analysis may therefore have been hampered by lack of
We found that 4.0% of women were extremely obese;
they were five years younger than non-obese women
receiving home care, more often had multiple health
Table 1 Sociodemographic, functional and clinical
(n = 2854)
(n = 120)
(range): years 83.3
Number (%) living alone 1945 (68%) 70 (58%)
of home care
at assessment (range): months
Median ADL score (range) 1.0 (0–8) 2.0 (0–8)
Median IADL score (range) 5.0 (0–7) 4.0 (0–7)
Median CPS score (range) 0.0 (0–6) 0.0 (0–6)
Median number of medications
6.0 (0–9) 6.0 (0–9)
One extremely obese and four non-obese women were 64 years old.
n =2588 and 113.
ADL, Activities of Daily Living (range 0–8); IADL, Instrumental Activity
of Daily Living (0–7); CPS, Cognitive Performance Scale (range 0–6); for
all three scales a higher number indicates greater impairment.
Figure 1 European Aged in Home Care project (AdHOC)
sites in 11 European countries. The present study examined
women aged 65 years or more who met the criterion for
extreme obesity. The n values are for sample sizes for the
larger project. The EO values are the sample prevalence
rates for extreme obesity.
n = 259
EO = 2.7%
n = 338
EO = 0.3%
n = 152
EO = 9.9%
n = 274
EO = 6.6%
n = 371
EO = 5.1%
n = 215
EO = 3.3%
n = 153
EO = 10.5%
n = 301
EO = 2.3%
n = 278
EO = 0.7%
n = 179
EO = 1.1%
n = 454
EO = 5.7%
86 Menopause International Vol. 13 No. 2 June 2007
L W Sørbye et al. Extremely obese elderly women
complaints and needed more help with mobility outside
the home. As this is a cross-sectional study, we cannot
comment on any cause and effect relationships. For
example, it is not clear whether the multiple health
complaints were the cause or a consequence of obesity
in this group.
The prevalence of extreme obesity in our population,
and that it was more common in women, concurs with
the findings of other studies. For example, Friedmann et
al. found in a US sample of people with a mean (SD) age
of 71.7 (5.7) years that the prevalence of extreme obesity
was 4% in women and 1.4% in men.
Scores for Activity of Daily Living were approximately
the same in both extremely obese and non-extremely
obese subjects. These results could correspond to the
U-shaped BMI–mortality curve reported by Waaler
for older people: a high BMI was associated with lower
relative mortality risk than in younger people. Elia
has given different explanations for this U-curve; one
possibility is that individuals who had been prone to the
complications of obesity may have already died, while
those who remain are more resistant to the effects of
obesity. Zamboni et al.
have documented this ‘survival
effect’. Must et al.
found that the disease burden associ-
ated with extreme obesity was lower for people aged 55
years or more than for those aged 25–54 years.
That extremely obese women are younger and have
been receiving home care for longer than their thin-
ner counterparts has economic implications. This is of
special concern as populations are ageing and obesity
may not necessarily be associated with increased mortal-
ity, as found in a US cohort.
Extreme obesity in elderly women is a problem of the
21st century that governments will have to address until
the obesity epidemic has been halted and reversed.
Table 2 Clinical characteristics of the 120 extremely obese women and 2854 non-extremely obese elderly women receiving
Clinical characteristics Non-extremely
obese: n (%)
obese: n (%)
Odds ratio (95% CI)
65–85 years versus 85 years or more 1218 (42.7) 17 (14.2) 4.51 (2.69–7.57) 0.001
Conditions and clinical symptoms
Not demented versus demented 2486 (87.0) 113 (94.0) 2.42 (1.12–5.23) 0.001
Diabetes versus no diabetes 476 (16.7) 42 (35.0) 2.69 (1.82–3.96) 0.01
Congestive heart failure versus no heart failure 664 (23.3) 41 (34.2) 1.71 (1.16–2.52) 0.001
Shortness of breath versus no shortness of breath 576 (20.2) 51 (42.5) 2.92 (2.01–4.25) 0.001
Oedema versus no oedema 695 (24.4) 50 (41.7) 2.21 (1.53–3.22) 0.01
Pain interrupting daily activity versus no pain 1095 (38.6) 60 (50.4) 1.62 (1.12–2.34) 0.001
q1/week versus continent
1328 (46.5) 79 (65.8) 2.21 (1.51–3.25) 0.000
Use of pads versus no use of pads 1223 (42.9) 69 (57.5) 1.80 (1.25–2.61) 0.002
Skin problems versus no skin problems 752 (26.3) 47 (39.2) 1.80 (1.24–2.62) 0.002
Mental, cognitive and social functioning
Any psychiatric diagnosis versus no such diagnosis 246 (8.6) 17 (14.2) 1.75 (1.03–2.97) 0.04
Multiple health complaints versus no complaints 270 (9.5) 23 (19.2) 2.27 (1.42–3.64) 0.001
Use of frame outside home versus no use 438 (15.3) 29 (24.2) 1.75 (1.14–2.70) 0.009
Help for moving out of house versus no use of help 583 (20.4) 37 (30.8) 1.74 (1.17–2.58) 0.006
Skin care versus no skin care 327 (11.5) 22 (18.39 1.74 (1.07–2.79) 0.02
Special diet versus no special diet 145 (5.1) 15 (12.5) 2.67 (1.52–4.70) 0.001
Includes use of different types of catheter.
Acknowledgements: We are grateful to interRAI, a collabora-
tive network of researchers in over 20 countries committed
to improving health care for people who are elderly, frail, or
disabled. For statistical advice we are grateful to the following
members of the AdHOC group: Iain Carpenter, UK; Dinnus
Frijters, The Netherlands; Jean Claude Henrard, France; Vjenka
Garms-Homolová, Germany; and Sigrunn Holbek Sørbye,
Norway. We are grateful for funding from the European
Commission Fifth Framework Program, contract number
Competing interests: None declared.
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