Volume 63, Issue 1, Pages 7-12 (20 May 2009)

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Obesity: What is an elderly population growing into?

Received 17 January 2009; received in revised form 18 February 2009; accepted 23 February 2009. published online 20 March 2009.

Abstract

Objectives

Obesity is currently a major public health concern; however, there is little data available on the prevalence and impact of obesity within the elderly population. This review examines the prevalence and health effects of obesity among individuals aged ≥50.

Methods

PubMed (1996–2008) and PsychInfo (2002–2008) search engines were used to retrieve qualified peer-reviewed articles focusing on obesity or a health condition correlated with obesity using BMI or other weight index as a defining variable; and studies limited to the elderly (age 60+) or pre-elderly (50+).

Results

Worldwide, the elderly population is increasingly becoming obese regardless of socio-economic status. Among elderly persons, obesity increases the risks for a variety of morbidity conditions including cancers, diabetes, hypertension, stroke, heart disease, metabolic syndrome, obstructive sleep apnea syndrome, osteoarthritis, depression, disability, and lower scores on quality of life measures. In some reports, obesity has been linked to Alzheimer's disease and other forms of cognitive decline. Obesity significantly increases healthcare costs and nursing homes are currently ill equipped to address the needs of the rising number of obese residents.

Conclusions

Obesity is increasing in the elderly population worldwide and is expected to continue to rise. Obesity is associated with disease and disability in addition to escalating healthcare costs, and hospitals and nursing homes are ill equipped to serve the obese elderly. It is imperative that research efforts and funding be devoted to studying the effects and the reduction of obesity in the elderly population.

Keywords: Obesity, Elderly, Morbidity, Mortality

Article Outline

• Abstract

• 1. Introduction

• 2. Materials and methods

• 3. Results

• 3.1. Prevalence

• 3.2. Morbidities

• 3.2.1. Obesity and chronic health problems

• 3.2.2. Obesity and activities of daily living

• 3.2.3. Obesity and quality of life

• 3.3. Mortality

• 3.4. Future projections

• 4. Discussion

• References

• Copyright

1. Introduction

Obesity is increasingly becoming an important public health concern among all age groups in most of the developed world [1]. In the United States, about one-third of Americans are currently classified as obese [2], [3]. Being overweight or obese is associated with elevated risks for an array of chronic disease and disabilities including diabetes, heart disease, high blood pressure, stroke, cancers, gall bladder disease, obstructive sleep apnea syndrome, and metabolic syndrome [4], [5], more problems with activities of daily living (ADLs) and lower scores on self-reported quality of life data [6]. The diseases associated with obesity usually appear during the second half of life [7] which places disease burden on the elderly. While the impact of excess adiposity has been the focus of a number of studies in the early phase of life and adulthood, similar data on the consequences of obesity in the elderly population are relatively limited [8], [9], [10] and inconclusive [4], [11].

Since the elderly are more vulnerable to the current obesity epidemic, and because they also experience higher levels of morbidity than other population sub-groups [8], it becomes both timely and pertinent to address the issue. Accordingly, we present in this review paper a synthesis of the epidemiology and consequences of the growing obesity epidemic in the elderly population in terms of morbidity and mortality. Based on the study findings, we provide recommendations regarding critical domains for future obesity research in this at risk population.

2. Materials and methods

We included in the review studies published in peer-reviewed journals that met the following inclusion and exclusion criteria:

(a)published study results focusing on obesity, or a health condition correlated with obesity using BMI or other weight index as a defining variable;

(b)studies limited to human subjects, defined as elderly (age 60+) or pre-elderly (50+);

(c)studies published after 1996;

(d)studies either published in or translated to English.

Search engines used to retrieve qualified articles include PubMed (1996–2008) and PsychInfo (2002–2008). Databases including EbscoHost, Wiley Interscience, ScienceDirect, and Ovid were used for article viewing. A search strategy was developed using health terms associated with obesity in the elderly. Search terms included “obesity in elderly populations,” “osteoporosis and obesity,” “diabetes and obesity in the elderly,” “sexuality in the obese elderly,” “obesity and mental health in the elderly,” “obesity and dementia,” “Alzheimer's disease and obesity,” “depression and obesity in the elderly,” and “obesity and the aging process.” The authors scanned titles and abstracts and reviewed potentially relevant articles. The authors also viewed articles generated by PubMed's “Related Articles” tool and employed cross-referencing of bibliographies from selected articles to obtain copies of articles that were not readily available. In total, the authors screened approximately 225 articles for this review; 69 were retained based on inclusion/exclusion criteria, relevance, and the manner in which age ranges and weight measurements were reported. For the prevalence portion of this paper, countries were grouped by income level according to the World Bank Country Classification Table [12].

3. Results

3.1. Prevalence

Zamboni et al. report that the prevalence of obesity in older adults is growing in industrialized countries, though the prevalence of obesity in this age group appears to be higher in the United States when compared with Europe [4]. Fig. 1 contains information about obesity prevalence in twenty-three countries. This figure was created by averaging all stratified data presented in cited papers for age ≥50 [13], [14], [15], [16], [17], [18], [19], [20]. These countries can be further stratified by income levels as classified by the World Bank [12]. To aid in interpretation, the countries in this figure are labeled either as “High” (meaning they are classified by the World Bank as “High Income Economies”) or as “Other” (which means the World Bank has classified the country as “Upper Middle” or “Lower Middle” income economies). In our figure, “High” countries include the United States, Saudi Arabia, Barbados, Austria, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, and Switzerland. Countries classified as “Other” are India, China, Albania, Iran, Brazil, Turkey, Mexico, Chile, and Cuba.

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Fig. 1. Worldwide prevalence of obesities across selected countries grouped in quartiles.

In our study, the countries with the lowest obesity prevalence are “High” regions, and the country with the highest obesity prevalence (Turkey) is an “Other” region. European countries were constrained to the middle quartiles of our graph, with the exception of Albania and Spain which were in the upper quartile. Readers should note that obesity prevalence within a single country can vary due to study locations (i.e. rural versus urban setting) and different socio-economic status [16] with rural areas typically having lower prevalence of obesity than urban areas. As a country changes from a lower economy to a higher economy and industrialization increases, it is believed that the prevalence of obesity increases [21], [18]. This relationship has been described as a U-shape with BMI increasing rapidly in relation to national income before flattening and eventually declining [22]. Durazo-Arvizu et al. suggested that the rate of change is fastest on the “ascending limb,” or the move from low to middle income status [23].

In studies reporting gender as a variable, obesity was found to be more prevalent among women than men. The only countries in our study reporting a higher prevalence among men when compared to women were Denmark and Switzerland [11].

3.2. Morbidities

3.2.1. Obesity and chronic health problems

In the pre-elderly and elderly, obesity is associated with the onset or amplification of several chronic conditions [24]. Table 1 summarizes some newer findings related to chronic health concerns associated with obesity in the elderly. There are also more established findings regarding chronic health concerns associated with obesity in this population. One morbidity thought to be caused by obesity is the metabolic syndrome, a cluster of metabolic abnormalities that includes glucose intolerance, insulin resistance, central obesity, dyslipidaemia, and hypertension [25]. The metabolic syndrome has been increasing worldwide over the past two decades [25] in tandem with the obesity epidemic, and is associated with development of Type II diabetes mellitus as well as cardiovascular disease [26].

Table 1.

Highlights of findings for the association between obesity and chronic disease/pain in the elderly.


Study title	Study site	Sample size	Findings
Relationship of obesity with osteoporosis [66]	China and United States	4489 Caucasian subjects	In both Chinese and Caucasians, there was a positive correlation between bone mass and BMI. The higher the BMI the lower the likelihood for osteoporosis.
		Mean age: women 65.04; men 62.25
			Higher weight is noted as a protective factor against osteoporosis, although this may be due to higher lean (muscle) mass instead of fat mass.
		1988 Chinese subjects
		Mean age: women 27.26; men 27.16	After controlling for the mechanical loading effects of total body weight, There is an inverse relationship between bone mass and fat mass.
		*Note the difference in mean ages

Chronic pain and obesity in elderly people: results from the Einstein Aging Study [67]	United States	840 subjects ages 70 and older	When compared to normal-weight individuals, obese individuals were twice as likely to have chronic pain and severely obese individuals (BMI>35) were more than four times as likely to have chronic pain. Subjects with higher BMI categories had more painful body locations, higher pain frequency, and more severe pain.
	United States	840 subjects ages 70 and older	The most common locations for chronic pain were the legs and feet, followed by the back, neck and shoulders.

Obesity and osteoarthritis in knee, hip and/or hand: an epidemiological study in the general population with 10 years follow-up [68]	Norway	1854 subjects age 24–76	Obesity was significantly associated with knee osteoarthritis 10 years later, and this relationship was dose-dependent. Obesity was significantly associated with hand osteoarthritis. There was no significant association between obesity and hip osteoarthritis.

Late-life body mass index and dementia incidence: nine-year follow-up data from the Kungsholmen Project [69]	Sweden	1255 subjects age 75 and older	After full adjustment for covariate factors, overweight subjects had a lower risk of developing dementia than normal-weight subjects. The results were similar when Alzheimer's disease was separated from all dementias; overweight subjects had a lower risk of developing Alzheimer's disease over nine-year follow-up.
			When BMI changes over the first 3 years of the follow-up period were controlled for, subjects with a >10% decrease in BMI had a 50% greater risk of developing dementia in the following 6 years.
			Authors suggest a protective effect of obesity in old age.

An 18-year follow-up of overweight and risk of Alzheimer disease [44]	Sweden	392 subjects age 70–88	During 18-year follow-up, 93 participants were diagnosed with dementia. Women who developed dementia between ages 79–88 had a higher BMI at age 70 years than those who did not develop dementia. There were no BMI differences between those who were diagnosed between age 79-88 years and those who were not at age 70 years.
			Dementia risk was associated with an “overweight” BMI, and the BMI among those who developed Alzheimer's disease was 3.6 higher (on average) than those who did not.
			For every 1.0 increase in BMI at age 70, Alzheimer's disease risk increased by 36%.

Obesity is also a strong risk factor for adult-onset diabetes. In one prospective cohort study comprising 31,702 women ages 55–69 years who were free of diabetes and heart disease at baseline, a follow-up 12 years later showed that women in the highest quintiles of BMI and waist–hip ratio had a pronounced risk for diabetes (RR=29.0) when compared to women in the lowest quintiles [27]. In this same study, those at the highest quintiles of BMI and waist–hip ratio also had an elevated risk for hypertension (RR=3.0), echoing findings of another study from eleven European countries that reported higher odds ratios for high blood pressure, high cholesterol, and diabetes among overweight and obese men and women ages ≥50 as compared to normal-weight persons [28].

In the general population, overweight and obesity increase the risk of hospitalization and death from cardiovascular disease and type 2 diabetes after adjustment for other risk factors [29]. In particular, middle-age obesity increases the risk of hospitalization and death from cardiovascular disease (CHD), and diabetes after age 65 [30]. In one cross-sectional study involving 73,003 adults within the age range of 50–76, the adjusted risk for history of congestive heart failure was 5.6 as high among obese women and 3.9 as high among men [31]. Studies have also linked obesity to the onset of stroke [32] and a positive relationship between higher BMI and cerebrovascular events including stroke-related death has also been observed [33].

In U.S. adults aged 50 and older, the proportion of all cancer-related deaths attributable to overweight and obesity may be as high as 20% in women and 14% in men [34]. Colorectal cancer is the second leading cause of cancer death in the United States [24] and the third most common cancer worldwide [35]. In the general population, obesity has been consistently associated with increased colorectal cancer risks in both men and women [36]. In the general population, obesity has also been associated with higher risks of rectal cancer in men [36] and higher risks of kidney, endometrial, and female gallbladder cancers. However, studies examining the association between obesity and cancers of the prostate and pancreas have produced mixed results [37], [34].

Ascending BMI values have been identified as contributing to the development of breast cancer, although this relationship may only be evident in post-menopausal women. In a case–control study of 232 post-menopausal women, those with BMIs classified as “obese” had three times the risk of breast cancer as compared to non-obese women after controlling for other characteristics [38]. However, an inverse relationship between BMI of 31 or more and risk of breast cancer has been repeatedly observed in pre-menopausal women [39]. In a systematic review, Harvie et al. suggested that the increased risk for breast cancer in post-menopausal women may be due to central (waist) obesity rather than general obesity [40].

Results of studies on the association between adiposity and Alzheimer's disease show conflicting findings, perhaps due to differences in study subject characteristics. In a review, Luchsinger stated that studies conducted on middle age individuals find a relationship between elevated BMI and increased dementia, but results are conflicting in investigations done among older subjects [41]. In a systematic review of the literature on conditions related to cognitive decline, van der Berg et al. reported that obesity was related to a worsening of cognitive performance in intellectual domains that include cognitive flexibility, perception and construction, memory, and processing speed [42]. The relationship between obesity and cognitive performance is strengthened by hypertension, a common health concern in the obese [43]. Diabetes (another obesity-associated morbid condition) has also been found to be a risk factor for dementia and cognitive impairment [41]. For every 1.0 increase in BMI at age 70, Alzheimer's disease risk increases by 36% [44].

Obesity is a risk factor for obstructive sleep apnea (OSA), which is already more prevalent among the elderly population than any other age group [45]. The prevalence of OSA is expected to increase further as obesity rates rise [45].

3.2.2. Obesity and activities of daily living

Previous research has suggested a positive relationship between overall obesity or BMI and a heightened risk for functional disabilities in the elderly [46], [47] and obesity has been found to be one of the predictors for earlier onset of severe disability [48]. Obese men and women are more likely than normal-weight persons to report difficulties in activities of daily living (ADLs) including bathing, dressing, eating, walking across a room and getting in or out of bed [28], [49]. In a prospective cohort study of elderly Spanish individuals, waist circumference was predictive of disability 2 years later. Men in the highest waist circumference quintile had more than twice the risk of mobility restriction and about five times the risk of agility disability than those in the lowest waist circumference quintile after adjustment for potential confounders [10]. The association did not, however, demonstrate gender differences in risk estimates [10] although other investigators have reported that the link between obesity and ADL may be weaker in men than women [8], [28].

3.2.3. Obesity and quality of life

Quality of life is defined as “the individual's perceptions of their position in life in the context of the cultural and value systems in which they live and in relation to their goals, expectations, standards, and concerns” [50]. In a study of 18,584 individuals from 11 European countries, obese men and women were less likely than normal-weight men or women to report “very good” or “good” subjective health scores [28]. Another study on women ages 50–74 found that obesity did not affect global self-rated quality of life, but did influence sexual and “psychical” domains, the latter including emotional components such as anger [51].

There have been inconsistent reports on the association between obesity and depression. One cross-sectional study of 4641 U.S. women ages 40–65 reported a strong and consistent relationship between obesity and depression [52] while in another cross-sectional study of 2604 Chinese older adults (male and female, mean age=67.8 years), subjects with a higher BMI had more chronic medical problems but a relatively lower prevalence of symptoms classified as “depressive” when compared with subjects with a lower BMI [53]. This study used a cutoff score to indicate depression on the Chinese version of the Geriatric Depression Scale, which has been validated for use in Chinese subjects. However, the cutoff score is not equivalent to a clinical diagnosis of Major Depressive Disorder [53]. Cultural background may influence the relationship between obesity and depression, a point of interest noted in a study of 4162 men and women aged ≥65 in which authors found a “significant but not dramatic comorbidity” between depression and obesity in non-African-American participants, but not in African-American participants. However, the study had insufficient sample size to draw conclusions about characteristics of these relationships [54].

3.3. Mortality

There is some evidence that high BMI is associated with elevated mortality in the general population [55]. Indeed, the rising wave of obesity in the general population is expected to reduce overall life expectancy if the trend continues [55].

Nonetheless, the results of studies that examined the impact of excess adiposity on mortality remain inconclusive, and estimates appear to vary based on the type of adiposity measurement used. When high waist circumference was used as the measurement of excess weight rather than high BMI, higher mortality rates in those with high than those with low waist circumference was observed [56]. Consistent with this finding, another study indicates that high waist circumference suggests a higher mortality risk than low waist circumference after adjustment for high BMI risk [57]. However, high BMI should still be considered, as it has been associated with increased mortality risks in general. A prospective cohort study (N=61,317) of subjects ages 50–71 years old found an increased risk of death in the highest and lowest BMI categories upon initial measurement; when analyses were restricted to healthy never-smokers, the risk of death increased two to three times in obese individuals [58] which is a strong indicator that obesity was responsible for the elevated risk.

In contrast, Lang et al. used BMI as their unit of measurement and reported that excess body weight is not associated with greater mortality risk [49]. Grabowski and Ellis [59] conducted a retrospective cohort analysis, N=7527 participants age 70 and older, and used Cox regression to calculate proportional hazards ratios for mortality over 96 months. They reported reduced mortality in obese subjects when compared to normal-weight subjects, and found that subjects with a BMI of less than 19.4 were more likely to die than normal-weight subjects. These associations were still true after adjustment for demographic factors, utilization of health services, and functional status [59]. The authors speculate that the overweight and obese elderly persons in this study have survived to their age despite their risk factors, and therefore may represent “hardier stock” than other older persons [59].

3.4. Future projections

In the United States, it is expected that the prevalence of obesity in adults aged 60 and older will increase to 37.4% of the population in 2010 and that the prevalence of normal weight will decrease [6]. An Australian study tried to project future utilization of medical services for obesity-related conditions in the general population based on growing obesity rates. The study projected increases in medical interventions for all of these health problems and concluded that “the consequences of obesity have serious implications for the healthcare system” [60]. A similar situation also exists in the United States, where from age 70 onward, the publicly financed health system Medicare (for the elderly) spends 35% more on an obese person than someone of normal weight; therefore, growth in obesity is likely to entail significant financial costs for the entire Medicare system [61]. Lakdawalla et al. comment that the disability costs of obesity may even be a bigger contributor to obesity's welfare costs than healthcare spending [61].

Another great concern that could negatively impact the quality of care to the elderly is that nursing homes may not be prepared to manage the current growth in obesity rates if persistent. A most recent comprehensive analysis on obesity in nursing homes found a limited number of studies on the prevalence, significance, complications and solutions to the obesity epidemic [9]. The study reported that the percentage of newly obese nursing home residents in the United States is increasing, that obesity increases the relative risk of nursing home admission, and that nursing homes may not be equipped to deliver optimal care to obese nursing home residents [9]. Obviously, these are great challenges that accompany the current obesity epidemic in the elderly.

4. Discussion

One interesting finding in this study is the distribution of obesity in elderly populations from country to country. The countries classified as “Other Economies” tend to have lower rates of obesity compared to the “High Income Economies” (with the exception of Turkey and Albania, whose prevalence rates were among the highest). The Middle Eastern countries of Turkey, Iran, and Saudi Arabia have some of the highest prevalence rates of obesity in the elderly population, which may be explained in Saudi Arabia by a cultural view of excess weight as a desirable sign of beauty and affluence [14], [20]. Many studies note that as modernization and/or urbanization takes place in an area, obesity rate increases [20], [62], [18].

Some of the chronic health problems experienced by the elderly may be exacerbated by obesity in middle age. For example, osteoarthritis may be the result of obesity in middle age [63], and newer research suggests that midlife obesity is associated with an increased risk of Alzheimer's disease and dementia in later years [43], [64]. Thus, it may be a pertinent health goal to reduce excess weight before middle age to avoid complications subsequently during the elderly years.

An important observation that is noteworthy in interpreting study findings is in how obesity is defined in these studies (i.e. BMI or waist circumference). There is speculation that BMI and waist circumference measure different aspects of health and that waist circumference may be a better proxy of abdominal fat mass than BMI [65], but there is a dearth of research assessing waist circumference and mortality in the elderly [56]. Because of body composition changes, aging may modify both the numerator of a BMI measurement (weight) as well as the denominator (height), so that elevated waist circumference alone or together with BMI may be an optimal definition of obesity in the elderly population [4]. Future research may explore the patterns of mortality and morbidity phenotypes associated with waist circumference and BMI as a combined health marker in the elderly population.

In summary, obesity is increasing in the elderly population worldwide and is expected to continue to rise. Obesity is associated with disease and disability in addition to escalating healthcare costs, and hospitals and nursing homes are ill equipped to serve the obese elderly. Given these findings, it is imperative that research efforts and funding be devoted to studying the effects and the reduction of obesity in the elderly population.

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a Department of Obstetrics and Gynecology, University of South Florida, USA

b Department of Epidemiology and Biostatistics, University of South Florida, USA

c Department of Community and Family Health, University of South Florida, USA

Corresponding author at: Center for Research and Evaluation, Lawton and Rhea Chiles Center for Healthy Mothers and Babies, University of South Florida, 3111 E. Fletcher Avenue, Tampa, FL 33613, USA. Tel.: +1 813 974 1073; fax: +1 813 974 8889.

PII: S0378-5122(09)00070-X

doi:10.1016/j.maturitas.2009.02.010

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