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Body mass index in elderly people--do the reference ranges matter?

INTRODUCTION

Among numerous factors influencing both Polish and the global health situation, the process of demographic and epidemiological transition of society, understood as an ageing of society, remains one of the most significant. Demographic predictions indicate that by 2025 approximately 21% of the Polish population and 29% of the total European population will be over 65 years old [1, 2].

Evidence suggests that the risk of finding oneself at the extremes of the body mass index (either underweight or obese), increases along with age [3]. Changes in weight and body composition that occur as we are getting older, have important implications for the health status and functional efficiency of the elderly population [4-6].

The most obvious changes associated with ageing concern body composition [4]. Ageing is typically associated with a reduction in total and lean body mass. It is generally known that weight increases until approximately 60 years of age and decreases progressively thereafter. Muscle mass declines with age and is gradually replaced by a fat mass. Furthermore, fat location changes over time, with fat mass tending to increase around the abdomen as we age, which can often lead to serious metabolic consequences [3, 5-8].

Loss of height is also integrally connected with the ageing process. It is caused by a thinning of the vertebrae, compression of the vertebral discs, development of kyphosis or the effects of osteoporosis. Loss of height occurs in both men and women, although it may develop more rapidly in elderly women due to osteoporosis. It is estimated that loss of height begins at around 30 years of age, leading to a loss of approximately 1cm per decade until the age of 70, with a loss of 0.5cm per year thereafter [9].

The changes in body composition associated with ageing may result in BMI increase of 1.5-2.5 kg/[m.sup.2] in both men and women, even when body weight remains constant [3, 10, 11].

All changes in body composition should draw our attention to the nutritional status of elderly people, especially that they are often affected by comorbidities.

Many different methods have been used to diagnose malnutrition in the elderly, but BMI (Body Mass Index) is the most frequently used method, both in Poland and globally. Moreover, BMI calculations are included in such screening tools as the MNA[R] (Mini Nutritional Assessment), the MUST (Malnutrition Universal Screening Tool) and the NRS 2002 (Nutritional Risk Screening 2002) and is generally accepted as an indicator of an optimal weight [12, 13]. BMI has been also shown to be a longitudinal predictor of quality of life in the elderly with chronic diseases like hypertension and diabetes [14].

BMI, sometimes also referred to the Quetelet index, is a weight-for-height index. It is calculated by dividing the subject's weight (kg) by the square of their height (m). Currently, the BMI criteria proposed by WHO are the most widely used (Table 1.).

However, there is an ongoing debate about whether use of the BMI index is appropriate for monitoring the nutritional status of older subjects [15]. Some experts claims that current BMI thresholds for overweight/obesity may be overly restrictive for elderly people, believing that BMI is of limited usefulness in the elderly population as this method does not allow us to distinguish between a lean body mass and a fat mass [16-18]. Instead, experts have proposed using age-related BMI criteria developed in 1989 by the Committee on Diet and Health in the USA (Table 1). The age related BMI criteria has been used by several international researchers [19, 20].

The objective of the study was to analyse the nutritional status of over 65 year olds using different BMI cut-offs and verify if the BMI cut-off values for the elderly are justified.

MATERIALS AND METHODS

The research was conducted between November 2008 and July 2010. Studied institutions were comprised of one hospital and five care institutions located within the Bielsko, county in the south of Poland. The research proposal was accepted by the Ethical Committee of the Regional Medical Chamber in Bielsko-Biala (research approved 25th January 2008).

All patients, aged 65 and above, were hospitalised in the selected institutions and were eligible for inclusion in the study. A total of 308 elderly patients were tested. Participation was voluntary and all subjects were informed that they could leave the study at any stage of research. The following exclusion criteria were implemented:

* patients less than 65 years of age;

* patients with severe cognitive impairment;

* lack of informed consent;

* active phase of neoplastic disease on course of chemo- or radiotherapy treatment;

* physical condition hindering anthropometric examination (such as immobile patients, contraindication to lifting or amputation of both lower extremities).

Fig.1 shows a flow chart for patients considered for inclusion selection.

[FIGURE 1 OMITTED]

The study employed a questionnaire method and was conducted by means of direct interview. During the interview categorising notes were taken. Clinical data were obtained from careful review of the participants' medical charts. All anthropometric measurements were recorded by a single individual. The body weight was obtained by weighing all patients in a state of fasting; using the same calibrated electronic wheelchair scale (SECA-EC, type approval D 05-09-024). In patients with amputated limbs (upper or lower), weight was calculated by adding the weight of the missing limbs to the current body weight, in accordance with the Nestle Nutrition Institute guidelines (Table 2) [13].

The participants' heights were calculated using the patients age and knee height (KH) (measured in centimeters), in accordance with Chumlea's formula:

For men:

Height (cm) = 64.2 - 0.04 x age + 1.83 x KH For women:

Height (cm) = 84.9 - 0.24 x age + 1.83 x KH

KH is a surrogate measurement used to estimate the height of elderly and non-ambulatory patients [21-23].

KH was measured using a knee caliper with the knee bent at a 90 degree angle to the ankle. BMI was calculated using the formula: Wt (kg)/Ht([m.sup.2])

The participants' nutritional status was assessed using a criteria proposed by the WHO and the Committee on Diet and Health (Table 1).

The results were recorded on Excel Microsoft Office 2007 database prepared for the needs of this study and statistical analysis was conducted by the Statistica PL 9.0 program; license granted to the University of Bielsko-Biala. The study population was described using numbers and percentages of subjects. Quantitative features were presented with the arithmetic mean and standard deviation. In the assessment of differences between the groups, the Mann-Whitney non-parametric U test was used for independent variables.

RESULTS

The majority of studied population were women (73.76%), and the average age of participants was 77.59 [+ or -] 7.35 years (65-100 years of age). Almost half of the participants had completed only primary level education (47.52%), 4.95% of participants received no formal education.

The majority of the study population were professionally active prior to reaching retirement age, and of those study participants previously working 62.38% had performed manual work, 22.77% clerical work and 6.43% had worked in agriculture. Hospital patients were admitted for an average of 3.16 [+ or -] 2.48 days (1-8 days) and people staying in care institutions were resident for an average of 66.17[+ or -]55.64 months (0.5-216 months). Due to different units of time being (hospital stays were measured in days, whereas care institution stays were measured in months) the average length of stay for the total population had not been specified.

A significant majority of studied population suffered from multiple diseases (86.63% of subjects were diagnosed with 2-8 concurrent diseases) and the average number of chronic diseases was 3.24 [+ or -] 1.57 (0-8). The two study subgroups had similar compositions in terms of the gender, age and educational status of the subjects, former professional activity and number of chronic diseases (p-value >0.05). Table 3 shows demographics of study participants.

The average BMI value of the subjects was 27.76 [+ or -] 5.34kg/[m.sup.2] (15-48kg/[m.sup.2]). Comparison of study participants' BMI in accordance with different BMI criteria is shown in Table 4. Having analysed the BMI results in accordance with the criteria proposed by the WHO, it was found that only a quarter of the studied group fell within the "normal" BMI range, whereas a significant majority (71.29%) exceeded this range to varying degrees: 36.14% of subjects were found to be overweight; I[degrees] obesity was confirmed in 25.74% of the population, II[degrees] obesity in 8.42% of subjects and obesity was confirmed in 2 subjects (0.99%). Only a small percentage of participants were found to have below average BMIs (3.96%). The place of residence at the time of examination did not significantly influence the results.

Analysis of BMI results in accordance with the criteria for elderly people proposed by the Committee on Diet and Health revealed 38.61% of participants to have a desirable BMI. Almost exactly the same percentage (39.11%) were found to be overweight or obese, whilst as many as 22.28% of the study participants were found to have BMI results below the norm for elderly people. Using these criteria, the place of residence significantly influenced results (p=0.007). Almost twice as many residents of care institutions were diagnosed as undernourished compared with hospitalised patients, whereas patients on medical wards were twice as likely as care institution residents to exceed the desirable BMI thresholds for elderly people.

By far the most frequent diseases diagnosed in the subjects were those related to the cardiovascular system, regardless of which BMI category the study participants were found to belong to. The single-most common disease among the study population was hypertension. The second most common type of diseases were those of the metabolic & endocrine systems, of which the most frequently diabetes was diagnosed. Using the BMI criteria for elderly people, diseases of the metabolic and endocrine system were significantly more common in participants with higher or lower than average BMIs (p=0.490).

Musculoskeletal disease was the third most commonly diagnosed type of disease in all groups, except for those study participants, who were classified, according to the WHO criteria, as being undernourished; these participants were found to be more likely to suffer from gastrointestinal disease (Table 5).

DISCUSSION

From a population health perspective, malnutrition in the elderly is an important health issue, which requires attention. Undernutrition and overweight/obesity are both global problems that have serious negative health consequences [21-23].

Despite the widespread use of BMI, there is evidence that practitioners lack confidence in its efficacy. Cook at al. state that among dieticians working with older subjects who participated in the study, only 26% are totally happy with its use, while 69% continue to use BMI with elderly patients but feel that the reference ranges are not applicable for this demographic. Indeed, 5% continue to use this method because there is "nothing better" or because it is required by departmental policy [24].

Studies regarding the nutritional status of elderly people are confounded by numerous methodological problems. Significant amongst these problems is the fact that most data regarding desirable BMI thresholds originates from studies on children and young adults [3]. The BMI thresholds identified by the WHO as defining obesity were chosen because of increased all-cause mortality rates in subjects with a BMI greater than 25 kg/m2 [5]. However, in the elderly the relationship between BMI and mortality is not the same.

It is clear, that the risk of being overweight or obese increases with advancing age. Obesity often leads to functional disability, depression and poor quality of life [25-27]. According to Polish epidemiological studies, all of which followed the BMI criteria recommended by the WHO, 27.9% of the Polish population were estimated to be overweight, with a further 17.4% estimated to be obese [28-31]. In their study of the rural population of eastern Poland, Panasiuk et al diagnosed underweight in 2.8%, overweight in 37.6% and obesity in 33.8% of participants aged 60 and above [29]. All studies conducted in Poland in years 1983-2005 reviewed by Jarosz and Rychlik used WHO criteria as well [32]. They estimated the level of overweight as between 41-45.5% of elderly men and 28.7-35.5% of elderly women, while the level of obesity was recorded as between 20.8-37.2% of elderly study participants. In the present study, only 24.75% of study participants fell within the "normal" BMI range according to WHO standards, and excess body weight seemed to be a significant problem in the study population. The findings were different when the BMI criteria for elderly people were used. Following these guidelines, about 40% of the studied population proved to be well-nourished, but the percentage of undernourished people rose significantly to 22.28%.

Obesity in over 65 year olds has different effects on morbidity and mortality compared with the effects on younger subjects [33]. Review of the international literature with regards to the relationship between BMI and mortality in the elderly suggests that the BMI range with the lowest risk for mortality is between 23.5-27kg/[m.sup.2] [10, 14, 34, 35]. These findings may suggest that overweight in elderly people is not associated with a higher all-cause mortality risk, the opposite of which is true when it comes to obesity.

On the other hand, underweight, not only obesity, can also be responsible for frailty and higher mortality in the elderly [36, 37]. Kimyagarov et al. observed that low BMI was associated with a 45% increase in the mortality rates of elderly people, while high BMI was associated with a 11% decrease in mortality compared with the normal BMI group [38]. In Poland, Jozwiak et al. analyzed the relationship between BMI and mortality in a study of 1219 older hospitalized subjects and reported that increased BMI reduced the risk of mortality by 22% for each decimal of BMI [39]. Jozwiak et al. found, in common with previous studies, that the highest mortality rate was amongst the subjects with a BMI of less than 25 kg/[m.sup.2], whilst the lowest was among those who were overweight or moderately obese. As tolerance of undernutrition is much poorer in old age and the range of homeostasis is scarce, weight loss should be considered as an alarm signal rather than weight gain. These findings also suggest that the recommended BMI range for the elderly should be adjusted, favoring higher values in order to detect inadequate nutritional status earlier.

With regards to morbidity, the incidence of chronic disease in the present study population tended to rise with increasing BMI value, regardless of the criteria used. The most frequently diagnosed diseases in the subjects were those related to obesity, such as diseases of the cardiovascular, metabolic & endocrine systems. The incidence of cardiovascular disease was, in fact, higher amongst those subjects with a below average BMI (classified according to the Committee on Diet and Health criteria) than it was amongst the subjects with an above average BMI. This phenomenon is quite difficult to understand but it could be explained by several factors that were not investigated in this study, such as smoking habits, functional condition or cognitive status. Beck and Damkjsr stated in their study that participants with a BMI of greater than 29 kg/[m.sup.2] had a higher quality of life, despite increased incidence of obesity-related diseases [40]. Thus, perhaps the quality of life of the elderly population is of greater importance than a single measurement such as body mass index.

This study has several limitations. Firstly, obtained data are limited to elderly people hospitalized in selected medical and care institutions. The inclusion of community-dwelling seniors could strengthen the research. Secondly, there is relatively little data regarding studies which used BMI criteria specific for elderly. The widely access to the international data could make the findings more meaningful for clinical practice.

CONCLUSIONS

In spite of the fact that BMI is not an ideal method for assessing nutritional status in the elderly and that there is still much controversy regarding the correct parameters to use, this method is far more effective than any alternative. Our study showed that BMI range proposed by the Committee on Diet and Health were more effective in detecting of undernutrition in elderly people. Since the BMI of less than 25 kg/[m.sup.2] can be responsible for frailty and higher mortality in the elderly, using of specific criteria for this population can be recommended. However, more studies in this research area are needed. In the interest of being as thorough as possible, future research into the nutritional status of the elderly should always take into account the subjects' age, weight change history, history of chronic diseases, anthropometric measurements and test results, rather than just BMI measurement alone.

Conflicts of interest

We declare that we have no conflicts of interest.

REFERENCES

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Babiarczyk B., Turbiarz A.*

Faculty of Health Sciences, University of Bielsko-Biala, Poland

* Corresponding author:

Faculty of Health Sciences, 6 Konopnickiej str.

43-300 Bielsko-Biala, Poland

Tel: +48 33 827 91 97

E-mail: aturbiarz@ath.bielsko.pl (Turbiarz Agnieszka)

Received: 13.03.2012

Accepted: 19.05.2012
Table 1. Selected BMI criteria.

Source       Age          Criteria                Classification

Committee    19-24y       19-24 kg/[m.sup.2]      Desirable BMI
on Diet      25-34 y      20-25 kg/[m.sup.2]
and Health   35-44 y      21-26 kg/[m.sup.2]
(1989)       45-54 y      22-27 kg/[m.sup.2]
             55-65 y      23-28 kg/[m.sup.2]
             >65 y        24-29 kg/[m.sup.2]

Ferro-Luzzi  unspecified  <16 kg/[m.sup.2]        Chronic energy
                                                    deficiency-class 3
                          16-16.9 kg/[m.sup.2]    Chronic energy
                                                    deficiency-class 2
                          17-18.4 kg/[m.sup.2]    Chronic energy
                                                    deficiency-class 1
                          18.5-24.9 kg/[m.sup.2]  Normal weight
                          25-29.9 kg/[m.sup.2]    Obese-class 1
                          30-39.9 kg/[m.sup.2]    Obese-class 2
                          >40 kg/[m.sup.2]        Obese-class 3

WHO (1997)   unspecified  <16 kg/[m.sup.2]        Undernutrition-
                                                    class 3
                          16-16.9 kg/[m.sup.2]    Undernutrition-
                                                    class 2
                          17-18.4 kg/[m.sup.2]    Undernutrition-
                                                    class 1
                          18.5-24.9 kg/[m.sup.2]  Normal weight
                          25-29.9 kg/[m.sup.2]    Preobese/overweight
                          30-34.9 kg/[m.sup.2]    Obese-class 1
                          35-39.9 kg/[m.sup.2]    Obese-class 2
                          >40 kg/[m.sup.2]        Obese-class 3

MNA[R]       unspecified  <19 kg/[m.sup.2]        Undernutrition
                          19-24.9 kg/[m.sup.2]    Normal weight
                          25-29.9 kg/[m.sup.2]    Overweight
                          >30 kg/[m.sup.2]        Obese

Table 2. Percent of body weight contributed by specific body parts
[13]

BODY PART                 PERCENTAGE

Trunk w/o limbs               50
Hand                          0.7
Forearm with hand             2.3
Forearm without hand          1.6
Upper arm                     2.7
Entire arm                    5.0
Foot                          1.5
Lower leg with foot           5.9
Lower leg without foot        4.4
Thigh                        10.1
Entire leg                   16.0

Table 3. Demographics of study participants.

Variable                      Total sample        Medical ward (MW)
                                 n=202                  n=104


Gender
Female                        149 (73.76)              78 (75)
Male                           53 (26.24)              26 (25)

Age (Mean [+ or -] SD)    77.59 [+ or -] 7.35    75.83 [+ or -] 6.03

Education
None                           10 (4.95)               2 (1.92)
Primary school                 96 (47.52)             53 (50.96)
Vocational school              21 (10.40)             11 (10.58)
College                        56 (27.72)             30 (28.85)
High school                    19 (9.41)               8 (7.69)

Former professional
activity
Manual work                   126 (62.38)             68 (65.38)
Clerical work                  46 (22.77)             18 (17.31)
Farmer                         13 (6.43)               6 (5.77)
Non-working                    17 (8.42)              12 (11.54)

Length of the stay in
institutions * (Mean              --              3.16 [+ or -] 2.48
[+ or -] SD)

Number of chronic          3.24 [+ or -] 1.57     3.46 [+ or -] 1.58
diseases (Mean
[+ or -] SD)

Variable                   Care institutions
                                  (CI)
                                  n=98
Gender
Female                         71 (72.45)
Male                           27 (27.55)

Age (Mean [+ or -] SD)    79.47 [+ or -] 8.15

Education
None                            8 (8.16)
Primary school                 43 (43.88)
Vocational school              10 (10.20)
College                        26 (26.53)
High school                    11 (11.23)

Former professional
activity
Manual work                    58 (59.19)
Clerical work                  28 (28.57)
Farmer                          7 (7.14)
Non-working                     5 (5.10)

Length of the stay in
institutions * (Mean      66.17 [+ or -] 55.64
[+ or -] SD)

Number of chronic          3.01 [+ or -] 1.54
diseases (Mean
[+ or -] SD)

* MW in days; CI in months; MW-CI: p=non significant

Table 4. Comparison of study participants' BMI in accordance with
different BMI criteria.

BMI range              WHO        Committee on Diet and
                    criteria       Health criteria (a)

Above the norm
Total sample       144 (71.29)          78 (38.61)
MW                 80 (76.92)           53 (50.96)
CI                 64 (65.31)           25 (25.51)

Normal
Total sample       50 (24.75)           79 (39.11)
MW                 19 (18.27)           34 (32.69)
CI                 31 (31.63)           45 (45.92)

Below the norm
Total sample        8 (3.96)            45 (22.28)
MW                  5 (4.81)            17 (16.35)
CI                  3 (3.06)            28 (28.57)

MW: medical ward, n=104; CI: care institutions, n=98; Below the norm:
WHO <18.5 kg/[m.sup.2], Committee on Diet and Health <24 kg/[m.sup.2];
Normal: WHO 18.5-24.9 kg/[m.sup.2], Committee on Diet and
Health 24-29 kg/[m.sup.2]; Above the norm: WHO >25 kg/[m.sup.2],
Committee on Diet and Health >29 kg/[m.sup.2]; a Mann-Whitney test;
MW-CI: p=0.007

Table 5. Number of participants with chronic diseases in accordance
with different BMI criteria.

                                  BMI range by WHO

Diseases                  Above the           Normal (N=50)
                        norm (N=144)

                            n(%)                  n(%)

Number of chronic    3.29 [+ or -] 1.61    3.20 [+ or -] 1.43
  diseases
cardiovascular           116 (80.56)           41 (82.00)
respiratory              27 (18.75)             7 (14.00)
gastrointestinal         42 (29.17)            10 (20.00)
renal & urinary          16 (11.11)             2 (4.00)
metabolic &              45 (31.25)            17 (34.00)
  endocrine
musculoskeletal          45 (31.25)            20 (40.00)
sensorineural            30 (20.83)             13(26.00)
hematology                7 (4.86)              3 (6.00)
cancer                    5 (3.47)              4 (8.00)

                                              BMI range by
                                            Committee on Diet
                      BMI range by WHO         and Health

Diseases                  Below the             Above the
                         norm (N=8)            norm (N=78)

                            n(%)                  n(%)

Number of chronic    2.63 [+ or -] 1.69    3.29 [+ or -] 1.51
  diseases
cardiovascular            5 (62.50)            64 (82.05)
respiratory               2 (25.00)            15 (19.23)
gastrointestinal          3 (37.50)            21 (26.92)
renal & urinary               0                 8 (10.26)
metabolic &               2 (25.00)            35 (44.87)
  endocrine
musculoskeletal           1 (12.50)            27 (34.62)
sensorineural             1 (12.50)            15 (19.23)
hematology                2 (25.00)             1 (1.28)
cancer                    1 (12.50)             4 (5.13)

                     BMI range by Committee on Diet and Health

Diseases                Normal (N=79)           Below the
                                               norm (N=45)

                            n(%)                  n(%)

Number of chronic    3.24 [+ or -] 1.71    3.16 [+ or -] 1.43
  diseases
cardiovascular           60 (75.95)            38 (84.44)
respiratory              14 (17.73)             7 (15.56)
gastrointestinal         23 (29.11)            11 (24.44)
renal & urinary           8 (10.13)             2 (4.44)
metabolic &              14 (17.72)            15 (33,33)
  endocrine
musculoskeletal          24 (30.38)            15 (33.33)
sensorineural            17 (21.52)            12 (26.67)
hematology                8 (10.13)             3 (6.67)
cancer                    1 (1.27)              5 (11.11)

Below the norm: WHO <18.5 kg/m2, Committee on Diet and Health
<24 kg/[m.sup.2]; Normal: WHO 18.5-24.9 kg/[m.sup.2], Committee on
Diet and Health 24-29 kg/[m.sup.2]; Above the norm: WHO >25 kg/
[m.sup.2], Committee on Diet and Health >29 kg/[m.sup.2]; a Mann-
Whitney test; p=0.0490
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Author:Babiarczyk, B.; Turbiarz, A.
Publication:Progress in Health Sciences
Article Type:Report
Geographic Code:4EXPO
Date:Jun 1, 2012
Words:5102
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