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Keywords:

  • elderly;
  • mortality;
  • body mass index;
  • basal metabolic rate;
  • energy expenditure

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

In developed countries, there is a general increase in body weight and body mass index (BMI) with age, until ∼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.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

The elderly continue to represent one of the fastest growing segments of the population in developed countries. Those >65 years of age account for ∼15% of the population in western European countries and the United States, and the proportion is expected to grow to 19% to 26% by 2025 (1).

Obesity is also increasing rapidly and is now recognized as an important global public health problem. Therefore, it is perhaps surprising that more attention has not been given to the problem of obesity in the elderly, especially because it seems that obesity has quantitatively different effects on morbidity and mortality in older individuals compared with younger individuals. To understand these complex interrelationships, it is necessary to first consider the changes in weight, body mass index (BMI), and body composition that occur with increasing age.

Effect of Age on Body Weight, BMI, and Body Composition

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

In England the BMI gradually rises during most of adult life, peaks at ∼60 years, and then declines (2). Similar patterns have been observed in a variety of other developed countries (e.g., Finland) (3). This pattern has also been confirmed by a large number of longitudinal studies in adults. After 65 years of age, the rate of weight loss occurs at an average rate of 0 to 0.65 kg/yr (summary of various studies) (4), although there is substantial variation between individuals. Loss of muscle mass (and to a lesser extent other lean tissues) begins from 30 to 40 years of age and continues into advanced old age (5). In contrast, body fat increases through most of adulthood. Because fat replaces fat free mass with increasing age, older subjects tend to have a greater proportion of fat than younger individuals with the same BMI (6), especially men (7). They also have an increase in the proportion of visceral and abdominal fat (7) (8) (9), even when the total amount of fat is the same (9). An increase in intra-abdominal fat is associated with greater mortality in both younger and older adults, even when it is independent of overall adiposity (e.g., lean elderly subjects with increased intra-abdominal fat have increased mortality) (10). However, the effect of BMI (an index of total body fat) on mortality seems to differ quantitatively between older and younger subjects.

Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

The effect of BMI on mortality has been reported to vary in different age groups in several ways. Although some of these are controversial in cause, interpretation, and significance, others are not.

  • 1
    . There is an expected progressive upward shift in the BMI–mortality curves with increasing age (mortality in general increases with age) (11) (12) (13) (14), with no abrupt change in mortality.
  • 2
    . Several studies have reported an attenuation of the U- or J-shaped BMI–mortality curve in older subjects, implying that obesity may have less of an effect on mortality in older individuals than in younger individuals (3) (13) (15) (16) (17).
  • 3
    . Some studies have reported a shift to the right in the mortality–BMI curve, implying that minimum mortality occurs at a higher BMI in older subjects than in younger subjects (11) (12) (14) (15) (16), but only some of these studies controlled for the effects of confounding variables, such as smoking (11), or studied groups (16) or subgroups of subjects who did not smoke (12). It was suggested by the National Research Council (18) in 1989 and by the Department of Agriculture (19) in 1990 that the desirable BMI range in older individuals is higher than in younger adults. The 1995 report from the Department of Agriculture (Dietary Guidelines for Americans) (20) did not include age-specific BMI ranges, presumably because it reconsidered the situation and believed that at that time there was insufficiently strong evidence to support such recommendations for Americans.

The less pronounced U-shaped mortality–BMI curves in older subjects, which in some cases have become virtually flat (little effect of BMI on mortality), not only have major implications for the definition of obesity in older subjects, but also for the desirability of losing weight in those with a high BMI. The answers to views on these issues depend on the explanations for the differences in age-specific BMI–mortality curves. Some of these are listed below:

  • 1
    . Limited lifespan: because elderly individuals have a relatively short lifespan, even when not obese, it may be more difficult to demonstrate the effects of obesity on mortality.
  • 2
    . Selective survival: individuals who are prone to the complications of obesity may have already died, leaving behind those who are more resistant to the effects of obesity.
  • 3
    . Different cohorts: BMI–mortality curves for different age groups have been established using individuals that have grown up at different times and have been exposed to different lifestyles and risk factors, e.g., infections, which were a much more common cause of death before the introduction of antibiotics. One recent study in Europe found that the BMI–all-cause-mortality curve flattened little when the same cohort of individuals, who had already been followed for 15 years, was followed for another 15 years (starting age: 40 to 59 years) (21). In contrast, a study in the United States suggested a marked change in the BMI–mortality (coronary heart disease) curve when subjects (initial age: 40 to 55 years) were followed first for 14 years and then for another 7 years (22). Substantial changes have also been reported in the same cohorts of middle-aged and elderly Seventh Day Adventists (16).
  • 4
    . Confounding variables: possible flattening and/or shift to the right of the mortality–BMI curve reported by some workers might be due to inadequate consideration of confounding variables, such as smoking (23). However, some studies have accounted for the effect of smoking (11) or independently analyzed mortality data of groups (12) or subgroups (12) of nonsmokers and have continued to observe a flattening and/or a shift to the right of the BMI–mortality curves. Some of these workers (11) (13) have also attempted to account for the effects of preexisting illness by excluding such individuals at the outset of their studies and by analyzing mortality after the early deaths were excluded [only 1 or 2 years (12) (13) in these studies]. Another confounding variable is race. Most of our concepts about BMI–mortality relationships have been based on studies of American and European white individuals, which may not apply to other races. For example, a study of Pima Indians aged 25 to 74 years suggests that BMI has little or no effect on mortality (flat curve) until the BMI reaches a value of >40 kg/m2 (24). Similarly, although mortality is greater in black than in white American women, the effect of BMI was less pronounced for black women within the same educational group (25).
  • 5
    . Excess fat may have less effect on mortality in older people than in younger people. The reduced lipolytic activity of intra-abdominal omental fat in response to noradrenaline may be relevant, because fatty acids released from lipolysis are considered to be part of the mechanism by which excess intra-abdominal fat leads to increased morbidity (26).

Effect of Changes in Weight on Mortality (Longitudinal Studies)

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

There have been at least 30 studies addressing the effect of weight change on mortality in middle to older age groups (27), but the overall effects are unclear. Weight loss has been reported to decrease, increase, and to have no effect on mortality. Weight gain has been reported to increase or have no effect on mortality. Some studies even report that weight loss and/or fluctuation in men originally aged 40 to 56 years affect mortality during the first 15 years of follow-up, but not between 16 and 25 years of follow-up. The following can account for at least some of the above discrepancies:

  • 1
    . The time-period over which weight change was measured varied from a few years to over 20 years.
  • 2
    . Weight change was calculated in different ways: as the difference between two study examinations; as the difference between current weight and recalled weight at 18 or 25 years of age; as the difference between current weight and highest weight ever achieved; and as trend of a series of measurements over a period. Most of these methods do not distinguish between changes in weight that have occurred recently and those that have occurred over a more prolonged period.
  • 3
    . Although the predictive value of weight loss in obese compared with lean individuals may differ, this distinction has often not been made.
  • 4
    . It is generally unknown whether the weight changes were intentional (e.g., for obesity-related disorders) or unintentional due to underlying disease. Only a few epidemiological studies (28) (29) (30) have attempted to distinguish between the two, although they have not been entirely successful (e.g., they have frequently inadequately assessed the extent to which the weight loss is transient). In addition, the studies have generally relied heavily on reported weight changes (sometimes over several decades). These studies have reported that unintentional weight loss is associated with increased mortality, whereas intentional weight loss has not generally been found to have an effect on all-cause or cardiovascular mortality. However, one study reported that intentional weight loss in women 40 to 64 years of age weight loss over 12 to 13 years was generally associated with decreased mortality, especially when the weight loss was for obesity-related complications (equivocal results in women without obesity-related complications). Furthermore, it is well-known that weight loss beneficially affects cardiovascular risk factors. Controlled trials are needed to obtain additional information about morbidity and mortality in relation to particular risk factors (e.g., fat distribution) and multiple outcome measures, including bone loss and risk of fractures (which have been linked to a low BMI), and both cardiovascular and noncardiovascular risks, which do not parallel each other, at least in cross-sectional studies (11). Changing lifelong habits of nutrition and exercise in elderly subjects with short life expectancies may be difficult to introduce and cause distress and anxiety. Such issues should also be considered before establishing rational clinical and public health policies that aim to improve mortality and morbidity and well-being. In contrast, there is considerable evidence that healthy active aging is related to the beneficial physical and psychological effects of regular physical activity (31). Elderly subjects undertaking increased physical activity can regain fitness (32) and prevent themselves from falling beneath functionally important thresholds (33) (34), such as rising from a chair or undertaking everyday household tasks.

Effect of BMI on Morbidity

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

Various studies have shown that BMI and fat mass are positively related to disability (35) (36) (37), e.g., limitation in activities of daily living (35), walking upstairs, walking on flat surfaces (36); pulmonary disease; diabetes; and arthritis (38). Visser et al. (36) reported that in individuals over 65 years of age, body fat, measured by bioelectrical impedance, was not only related to mobility-related problems, but it also predicted the development of problems in those without the disabilities during the baseline period. Others have confirmed such a prediction (39). There is a large body of clinical experience that clearly indicates that weight loss produces benefits in individuals with diabetes, arthritis, respiratory disease, hiatus hernia, and other conditions. In contrast, development of osteoporosis of the femoral neck has been reported to occur more rapidly in lean individuals, who are more likely to sustain a fracture of the femoral neck than more obese individuals (40). Cause and effect between a number of variables, including physical activity and other diseases/disabilities, need to be studied in more detail.

Energy Intake and Expenditure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References

If changes in BMI are to be achieved, they will generally involve a change in intake (or absorption) or expenditure. Most measurements of energy expenditure have been undertaken in the resting state; however, Elia et al. (41) reported measurements of total energy expenditure (TEE) in free-living conditions in 560 healthy subjects (259 men and 301 women, from teenagers to those over 80 years of age). There was a decrease in daily TEE by 165 kcal/decade in men and 103 kcal/decade in women. This was partly due to decreased basal metabolic rate (BMR), but was primarily due to decreased physical activity. In healthy elderly subjects, the physical activity level (TEE/BMR) was 1.63 ± 0.20 in men and 1.60 ± 0.22 in women. There was no relationship between physical activity level (or physical activity energy expenditure) and BMI (or the percentage of fat). The incidence of chronic diseases and disabilities rises steeply after 65 years (e.g., locomotion and ability to undertake domestic tasks) (41). In general, such conditions decrease TEE in both lean and obese subjects, primarily because of decreased physical activity. Energy intake is also lower in the elderly (41). Furthermore, the compensation to increased or decreased dietary intake is impaired, compared with younger individuals, e.g., during 10 days of ad lib intake after 3 weeks over- or underfeeding (42). Older individuals also seem to experience less frequent hunger during dietary restriction (43) and sense hypoglycemia less readily (44) than do younger individuals. It is uncertain whether obesity affects these compensatory mechanisms.

In developed countries, the incidence of individuals with a BMI > 30 kg/m2 generally increases up to the age of ∼60 years and decreases thereafter. Energy turnover (intake, TEE, and components of TEE, such as BMR) progressively decrease with age; generally to a greater extent in those with chronic diseases. Although the effects of BMI on mortality may be less in older compared with younger individuals, a high BMI generally increases morbidity. Controlled exercise in the elderly is recommended, especially in those who are inactive but capable of substantially increasing their activity levels. Apart from its effects on obesity, increased physical activity has been found to increase muscle bulk, strength (45), and endurance (46); improve balance; and reduce the number of falls in elderly subjects (47), as well as producing a variety of psychological benefits, such as less depression and positive effects on body image and self-esteem (48). It may also prevent deterioration below functionally important thresholds necessary for activities of daily living (33). Additional research on genetic and other determinants of morbidity and mortality is required to identify obese and non-obese elderly individuals most likely to benefit from lifestyle changes.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Effect of Age on Body Weight, BMI, and Body Composition
  5. Effect of Age on the Relationship between BMI and Mortality (Cross-Sectional Studies)
  6. Effect of Changes in Weight on Mortality (Longitudinal Studies)
  7. Effect of BMI on Morbidity
  8. Energy Intake and Expenditure
  9. Acknowledgments
  10. References
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