The Journal of Nutrition, Health & Aging© Volume 16, Number 4, 2012
OBESITY IN MENORCA ELDERS
Body mass index, life-style, and healthy status in free living elderly people in menorca island A. FerrA, M. del MAr BiBiloni, M.e. ZApAtA, J. pich, A. pons, J.A. tur
research Group on community nutrition and oxidative stress, university of Balearic islands, e-07122 palma de Mallorca, spain. corresponding author: dr. Josep A. tur, research Group on community nutrition and oxidative stress, universitat de les illes Balears, Guillem colom Bldg, campus, e-07122 palma de Mallorca, spain. phone: 34-971-173146, Fax: 34-971-173184, e-mail:
[email protected]
abstract: Objectives: to assess the BMi, life-style, and healthy status, and explore relationships between these parameters, among Menorca’s free living elderly people. Methods: A cross-sectional survey carried out in Menorca island in 2009. A random sample (n=450) of the elderly population (≥65 years) was interviewed. Anthropometric measurements and a general questionnaire incorporating questions related to socio-demographic and life-style factors and health status were used. Results: Approximately five per cent of elders were underweight and 60% overweight or obese. underweight were positively and overweight and obesity negatively affected by age. the prevalence of central obesity, according to the Wc cut-off points, was 66.8% in men and 85.1% in women. low education, socioeconomic status and physical activity were risk factors for malnutrition and overweight/obesity. A possible cognitive impairment was found among elderly persons with BMi<22 kg/m2. A J-shaped association between BMi and hypertension, hypercholesterolemia, heart failure and other cV diseases, a u-shaped relation between BMi and diabetes mellitus, arthritis, and chronic bronchitis, and an inverted J-shape between BMi and gastric ulcer, osteoporosis & bone fractures, cancer, and prostatitis (in men) were found. Conclusions: Both low and high BMi are associated with a wide range of prevalent conditions and diseases in Menorca elderly men and women. Key words: Body Mass index, elderly, lifestyle, disease, Menorca.
introduction
elderly population is rapidly growing worldwide, and usually they suffer chronic illnesses and health problems. socio-economic, demographic and life-style factors as well as individual attitudes influence the risk of disease among old people. healthy disorders may be related to body mass index (BMi), mainly well documented in overweighed and obese people (1). Most of associations established between BMi and several illnesses have been focused on the detrimental effect of obesity (2, 3). however, scarce population-based studies have been developed on elderly people. lately, a single centre population-based study (4) showed that both low and high BMi are associated with a wide range of prevalent conditions and diseases in elderly people, demonstrating that nutritional assessment is an important part of the medical evaluation of elderly patients. several authors pointed out that nutritional disorders, poor dietary habits, physical inactivity, as well as health, economic, and social status are contributing factors to obesity (5, 6). it would be desirable to assess if these results may be also obtained from other populations. Menorca is the northern island of the Balearic islands archipelago. similarly to the other islands, Menorca was consecutively conquered by several civilizations that gave peculiar trends to the Menorca’s inhabitants, but also particular habits (enclosing food habits) and life style (7, 8). lately, two immigrations arrived to Menorca island in the 1960’s (mainly from other spanish regions) and in the 2000’s (mainly from latin America, Maghreb, and eastern europe) (9). nobody can doubt that these last human movements introduced new food
Received August 6, 2010 Accepted for publication January 28, 2011
and life-style habits among the islanders. till now, there are no previous research for the assessment of BMi, life-style, and healthy status of Menorca elderly people. the aim of this work was to assess the BMi, life-style, and healthy status, and explore relationships between these parameters, among Menorca’s free living elderly people. methods
Study design the study is a population based cross-sectional nutritional survey carried out in Menorca island in 2009. selection of participants, recruitment and approval the target population consisted of all inhabitants living in Menorca island aged ≥65 years. the sample population was derived from residents aged ≥65 years registered in Menorca island. the theoretical sample size was set at 450 individuals in order to provide a specific relative precision of 5% (type i error=0.05; type ii error=0.10), taking into account an anticipated 70% participation rate. the sampling technique included stratification according to municipality size, age, and sex of inhabitants, and random selection within subgroups, with Menorca island municipalities being the primary sampling units, and individuals within these municipalities comprising the final sample units. the interviews were performed at the interviewer’s home. the final sample size was 402 individuals (89% participation). the reason to not participate was the subject declined to be interviewed. this study was conducted according to the guidelines laid down in the declaration of helsinki and all procedures involving human subjects/patients were approved by the Balearic islands ethics committee.
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Written informed consent was obtained from all subjects. the sample was divided in male and female, and within them divided again into three age groups: 64-74 yr, 75-84yr, and 85 yr and above.
Anthropometric measurements height was determined using a mobile anthropometer (Kawe 44444; Kirchner & Wilhelm Gmbh, Asperg, Germany) to the nearest millimetre, with the subject’s head in the Frankfurt plane. the tibiale laterale-base height (cm) was also measured, with the subject stand with feet together on the floor with the right leg facing the observer, the end pointer placed flush on the floor and the housing pointer extended vertically upward to the marked tibiale laterale landmark. Body weight was determined to the nearest 100g using a digital scale (tefal charm, sc 2504; rumilly, France). the subjects were weighed without shoes in light clothing. triceps and subscapular skinfold thickness were measured using a holtain skinfold caliper (tanner/Whitehouse, crymych, uK), and the mean of three measurements (right arm) was used, and used to calculate BF as described previously (10). Waist circumference (Wc, measured at the navel in men, and midway between the bottom of the ribs and the top of the hip bone in women), hip circumference (hc, measured at the tip of the hip bone in men, and at the widest point between the hips and the buttocks in women), mid-upper-arm circumference (mid-acromiale-radiale distance of the right arm parallel to the long axis of the humerus when the subject was standing erect and the relaxed arm was hanging by the sides), and mid-thigh circumference (mid-trochanterion-tibiale laterale distance of the right thigh perpendicular to the long axis of the femur when the subject was standing erect, legs slightly parted, weight equally distributed on both feet) were measured to the nearest 0.1 cm, using a non-stretchable measuring tape (KaWe, 43972; Kirchner & Wilhelm Gmbh, Asperg, Germany). humerus biepicondylar breadth (distance between medial and lateral epicondyles of the humerus when the arm is raised forward to the horizontal and the forearm is flexed to a right angle at the elbow) and femur bi-epicondylar breadth (distance between medial and lateral epicondyles of the femur when the subject is seated and the leg is flexed at the knee to form a right angle with the thigh) were measured to the nearest 0.1 cm by means of a small bone caliper (Mitutoyo corp., Japan). Blood pressure (Bp) and heart pulse were measured using automated machines (omron no. rX3 plus, omron healthcare europe B.V., hoofddorp, the netherlands). Anthropometric measurements were performed by a welltrained observer in order to avoid the inter-observer coefficients of variation. BMi was calculated as weight divided by the square of height (kg/m2). Waist-hip ratio (Whr) cut-off limits for men and women described elsewhere (11, 12) were also considered. According to the anthropometric reference parameters for the spanish elderly (13) and the espen (european society of parenteral and enteral nutrition) guidelines for nutrition screening in the elderly (14,15), the
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prevalence of underweight BMi<22.0 kg/m2, normal weight 22.0≤BMi<27.0 kg/m 2, overweight 27.0≤BMi<30.0 kg/m 2, obesity BMi≥30.0 kg/m2, were calculated. the prevalence of central obesity was calculated based on Wc, using the following cut-off points (16): >102 cm in men and >88 cm in women.
General questionnaire A questionnaire incorporating the following questions were used: gender, age, region of origin (born in the Balearic islands, east of spain as representative of the spanish Mediterranean coast, other parts of spain and other countries), marital status (married/full time relationship, single, widowed), educational level (low, <6 years at school; medium, 6-12 years of education; high, >12 years of education), economic status (low and high), kind of household (alone, with partner/partner and children, with other persons), smoking (current smokers, occasionally smokers, no smokers), alcohol consumption (everyday, occasionally/sometimes, never), and physical activity (home activities: preparing food, cooking, doing the housework; leisure sedentary: reading, watching tV or listening to the radio, playing cards or chess, and knitting or sewing; and non-sedentary activities: walking, dancing, gardening, cycling). A wide range of diseases and symptoms was also recorded. this instrument was used in accordance to the methodology described by the spanish society of epidemiology (17).
Health status participants were asked for their detailed medical history regarding present and past illnesses. evaluation of global cognitive abilities was assessed by means of Folstein’s Mini Mental state examination (MMse), which has been validated for elderly people (6, 18), including spanish elderly population (19). it has been used as a research tool to screen for cognitive disorders in epidemiological studies and follow cognitive changes in clinical trials. in spite of MMse has limited specificity with respect to individual clinical syndromes, it represents a brief, standardized method by which to grade cognitive mental status. A cut off score of 23 out of 30 shows possible cognitive impairment. intellectual impairment/mental status was assessed by means of pfeiffer’s short portable Mental state Questionnaire (spMsQ) (20), translated and validated to the spanish population (21). it is a reliable instrument to detect the presence of intellectual impairment and to determine its degree (intact mental functioning, borderline/mild, moderate, and severe organic impairment, according to a 10-based score of 0-2, 3-4, 5-7, and 8-10 error, respectively). the Geriatric depression scale (Gds) was used to screen for any elements of depression (6, 22). the spanish version was used (23). A cut off value of ≥5 suggested possible depression. Statistics Analyses were performed with spss version 17.0 (spss inc, chicago illinois. usA). significant differences in
The Journal of Nutrition, Health & Aging© Volume 16, Number 4, 2012
OBESITY IN MENORCA ELDERS
percentages were calculated by means of χ2 test. differences between means were tested using AnoVA. odds ratios and 95% confidence intervals (cis) adjusted for sex and age for the different dichotomized socioeconomic factors, life-style, mental and health status according to the four different BMi categories were calculated using logistic regression. the normal weight category (22.0≤BMi<27.0 kg/m2) was chosen as the reference category. Multiple logistic regression analyses adjusted for sex and age were also used to simultaneously examine the effect of socioeconomic factors, life-style, mental and health status on the prevalence of central obesity (Wc>cutoff limits). results
table 1 provides a descriptive analysis of the characteristics of the sample, by gender and age. the mean age (sd) of the total sample was 75.8 yr (7.0) in men and 74.5 yr (7.0) in women. distribution of age between the two sexes was not different. Most of Menorca’s elderly people were born in the Balearic islands (mainly in Menorca) and approximately 10% of them were born in other spanish regions. the younger subjects, the higher the proportion of foreigners. the proportion of individuals born in other countries was negligible. there were no differences between the two sexes. eighty per cent of the men were married, but just 62% of the women, 9.6% of men reported that they were single or had never married (8.8% women) and 9-6% were widowed (29.3% women). the marital status was significantly different between gender and age groups. the level of education was higher in men than in women. the level of education was higher in the 64-74 age group than the other male age groups, but it was higher in ≥85 age group than in the other female age groups. the economic level was better in men than in women, and the older subjects, the lower economic level. eighty-two per cent of the men live with partner/partner and children, but just sixty-two per cent of the women, 11.8% of men reported to live alone (28.4% women) and 5.9% with other persons (9.3% women). the kind of household was significantly different between gender and age groups. Most (≥90%) of the participants were no smokers. there were no differences between gender and age groups. Fifty-two per cent of the men consumed alcohol (mainly wine) everyday, mainly on meals. the alcohol consumption was significantly different between gender, the men tended to consume more alcohol than women. the older subjects showed the lower alcohol consumption. Men devoted more time than women to leisure nonsedentary activities, but there were no differences between sexes in time devoted to leisure sedentary activities. however, women tended to perform more time devoted to home activities than men. Age negatively affected the time devoted to home and leisure non-sedentary activities, and positively to leisure sedentary activities.
table 1 socioeconomic and demographic characteristics of the sample
men
all (n=187)
65-74 yrs 75-84 yrs (n=92) (n=68)
≥85 yrs (n=27)
Age (years, sd)*** region of origin* Balearic islands east of spain other spanish region other countries Marital status*** Married/full time relationship single Widowed educational status* low (<6 years) Medium (6-12 years) high (>12 years) economic level* low high Kind of household* Alone With partner/partner and children With other persons smoking habits smokers occasionally smokers no smokers Alcohol consumption** everyday occasionally/sometimes never leisure sedentary activities (h, sd)*** leisure non-sedentary activities (h, sd)*** home activities (h, sd)***
75.8 (7.0) 69.7 (2.8)† 79.6 (2.9)# 86.9 (2.8)‡
Age (years, sd)*** region of origin* Balearic islands east of spain other spanish region other countries Marital status*** Married/full time relationship single Widowed educational status* low (<6 years) Medium (6-12 years) high (>12 years) economic level low high Kind of household*** Alone With partner/partner and children With other persons smoking habits smokers occasionally smokers no smokers Alcohol consumption* everyday occasionally/sometimes never leisure sedentary activities (h, sd)*** leisure non-sedentary activities (h, sd)*** home activities (h, sd)***
74.5 (7.0) 68.6 (2.8)† 79.1 (2.8)# 86.8 (2.3)‡
Women
85.6% 3.2% 10.7% 0.5%
81.5% 3.3% 14.1% 1.1%
88.2% 2.9% 8.8% 0.0%
92.6% 3.7% 3.7% 0.0%
65.2% 29.4% 5.3%
60.9% 33.7% 5.4%
69.1% 25.0% 5.9%
70.4% 25.9% 3.7%
11.8% 82.4% 5.9%
12.0% 84.8% 3.3%
13.2% 76.5% 10.3%
7.4% 88.9% 3.7%
80.7% 9.6% 9.6%
49.7% 50.3%
4.8% 2.1% 93.0%
85.9% 9.8% 4.3%
42.4% 57.6%
5.4% 2.2% 92.4%
72.1% 10.3% 17.6%
58.8% 41.2%
5.9% 2.9% 91.2%
51.9% 58.7% 50.0% 2.2% 1.5% 1.6% 46.5% 39.1% 48.5% 6.5 (2.7) 6.1 (2.7) 6.4 (2.5)# 4.1 (2.7) 4.7 (2.8)† 3.7 (2.3) 2.2 (1.3) 2.4 (1.3) 2.2 (1.4)# all (n=215)
65-74 yrs 75-84 yrs (n=110) (n=83)
85.2% 7.4% 7.4%
51.9% 48.1%
0.0% 0.0% 100.0%
33.3% 0.0% 66.7% 7.9 (2.8)‡ 2.9 (2.7)‡ 1.3 (1.1)‡ ≥85 yrs (n=22)
89.8% 3.3% 6.5% 0.3%
88.2% 1.8% 9.1% 0.9%
91.6% 3.6% 4.8% 0.0%
90.9% 9.1% 0.0% 0.0%
72.1% 22.3% 5.6%
74.5% 21.8% 3.6%
71.1% 21.7% 7.2%
63.6% 27.3% 9.1%
28.4% 62.3% 9.3%
18.2% 79.1% 2.7%
41.0% 45.8% 13.3%
31.8% 40.9% 27.3%
61.9% 8.8% 29.3%
73.5% 26.5%
1.9% 0.0% 98.1%
79.1% 4.5% 16.4%
75.5% 24.5%
1.8% 0.0% 98.2%
44.6% 10.8% 44.6%
71.1% 28.9%
2.4% 0.0% 97.6%
26.0% 29.1% 22.9% 1.8% 0.0% 1.0% 73.0% 69.1% 77.1% 6.0 (2.6) 5.6 (2.4) 6.1 (2.6)# 2.5 (1.9) 2.8 (1.9) 2.4 (1.8) 4.8 (2.0) 5.3 (2.0)† 4.4 (1.8)#
40.9% 22.7% 36.4%
72.7% 27.3%
0.0% 0.0% 100.0%
22.7% 0.0% 77.3% 7.8 (2.7)‡ 1.8 (2.3)‡ 3.5 (2.2)‡
*p<0.05, **p<0.01, ***p<0.001 percentages compared with χ2 test; mean (sd) compared with AnoVA (age groups): †65-74 vs. 75-84, ‡65-74 vs. >85, #75-84 vs. >85 (p<0.05).
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men
table 2 Anthropometric characteristics of the sample all (n=187)
65-74 yrs (n=92)
75-84 yrs (n=68)
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and negatively the dBp in both, men and women.
≥85 yrs (n=27)
table 3 health status characteristics
Body weight (kg)** 79.7 (13.6) 82.8 (13.3)† Body fat (%) 31.1 (7.1) 30.7 (5.6) height (cm) 168.2 (5.9) 169.1 (5.7) tibiale laterale-base height (cm) 49.9 (4.2) 50.2 (4.7) thigh circumference (cm) 44.1 (4.2) 44.8 (4.0) Arm circumference (cm) 30.7 (3.4) 31.2 (3.2) humerus bi-epicondylar breadth (cm) 31.7 (6.6) 30.8 (6.0) Femur bi-epicondylar breadth (cm) 54.5 (9.2) 54.0 (9.2) systolic blood pressure (mmhg)* 143.9 (18.7) 141.9 (19.5)† diastolic blood pressure (mmhg)* 81.2 (9.2) 82.1 (9.5)† heart pulse (units/min) 70.8 (10.5) 72.2 (10.4) 2 28.1 (4.2) 28.9 (3.9) BMi (kg/m ) 1.1 prevalence of underweight (%)* 4.3 prevalence of overweight (%)* 27.8 31.5 prevalence of obesity (%)* 31.6 35.9 Waist circumference, Wc (cm) 106.8 (10.4) 107.6 (10.4) Wc>cut-off limits (%)* 66.8 73.9 hip circumference (cm) 108.3 (8.9) 108.3 (8.4) Waist-to-hip ratio (Whr) 0.99 (0.05) 0.99 (0.06) Whr>cut-off limits (%)* 39.9 45.6
77.4 (12.8) 75.0 (14.3)‡ 31.5 (7.1) 31.2 (11.0) 167.6 (6.2) 166.6 (5.4) 49.6 (4.0) 49.4 (2.9) 43.7 (4.5) 42.8 (4.0) 30.4 (3.1) 30.2 (4.5) 32.7 (7.1) 32.4 (6.9) 54.7 (9.0) 55.6 (10.0) 145.4 (18.5)147.5 (16.1)‡ 80.6 (9.0) 79.8 (8.9)‡ 68.8 (10.5) 71.1 (10.4) 27.5 (3.9) 27.1 (5.4) 5.9 11.1 26.5 18.5 29.4 22.2 105.6 (9.6) 107.1 (12.3) 60.3 59.3 108.0 (8.3) 108.8 (12.0) 0.98 (0.05) 0.98 (0.04) 31.1 40.7
men
Body weight (kg)* 69.1 (12.2) Body fat (%) 38.7 (5.9) height (cm)** 156.2 (6.3) tibiale laterale-base height (cm)* 46.7 (3.8) thigh circumference (cm) 44.5 (6.2) Arm circumference (cm)* 30.5 (3.8) humerus bi-epicondylar breadth (cm) 30.2 (6.4) Femur bi-epicondylar breadth (cm) 53.3 (8.6) systolic blood pressure (mmhg)* 142.6 (18.6) diastolic blood pressure (mmhg)* 81.6 (8.5) heart pulse (units/min) 73.5 (11.1) 28.3 (4.6) BMi (kg/m2) prevalence of underweight (%)* 6.5 prevalence of overweight (%)* 28.4 prevalence of obesity (%)* 32.1 Waist circumference, Wc (cm) 98.2 (10.3) Wc>cut-off limits (%)* 85.1 hip circumference (cm) 108.6 (9.6) Waist-to-hip ratio (Whr) 0.90 (0.05) Whr>cut-off limits (%) 58.8
68.8 (12.4) 62.3 (12.0)‡ 39.0 (5.6) 36.8 (6.8) 155.1 (6.4) 153.9 (6.6)‡ 46.4 (3.5) 44.8 (4.5)‡ 44.4 (5.4) 41.7 (5.1)‡ 30.5 (4.0) 28.4 (3.2)‡ 31.3 (6.7) 29.3 (7.2) 54.4 (9.2) 53.5 (9.3) 141.7 (17.8)#152.5 (18.2)‡ 79.8 (8.4) 79.6 (9.1)‡ 73.9 (11.1) 71.5 (10).7 28.5 (4.6) 26.5 (6.0) 6.0 13.6 30.1 22.7 32.5 13.6 99.2 ± 10.4 95.3 (10.8) 90.4 77.3 109.0 ± 9.6 105.8 (9.6) 0.91 ± 0.06 0.90 (0.07) 59.1 58.2
possible cognitive impairment (MMse)* 37.7% Mental status (spMsQ) Borderline/mild organic impairment 15.8% Moderate organic impairment 7.4% possible depression (Gds) 14.9% chronic diseases hypertension 45.1% hypercholesterolemia 22.8% Arthritis 14.4% diabetes mellitus 10.2% Gastric ulcer** 10.2% osteoporosis & bone fractures 9.3% cancer** 5.6% chronic bronchitis 4.2% heart failure*** 1.4% other cV diseases*** 2.8% Mean number of prescribed drugs (sd)*** 2.7 (1.6)
Women
all (n=215)
65-74 yrs (n=110)
70.7 (11.7) 38.9 (6.0) 157.5 ( 5.8)† 47.2 (3.7) 45.1 (6.9) 30.8 (3.6) 29.6 (5.9) 52.5 (8.1) 141.3 (18.7)† 83.3 (8.1)† 73.6 (11.2) 28.5 (4.3) 5.5 28.5 35.5 98.0 (10.1) 82.7 108.8 (9.5) 0.90 (0.05) 59.2
75-84 yrs (n=83)
≥85 yrs (n=22)
*p<0.05, **p<0.01, ***p<0.001 percentages compared with χ2 test; mean (sd) compared with AnoVA (age groups): †65-74 vs. 75-84, ‡65-74 vs. >85, #75-84 vs. >85 (p<0.05).
table 2 shows the anthropometric characteristics of the sample. Mean weight (sd) was 79.7 (13.6) kg in men and 69.1 (12.2) kg in women. these measurements were significantly different between age groups: the older subjects, the lower weight. Mean body fat represented 31.1% (7.1) in men and 38.7% (5.9) in women. there were no differences between the age groups. Mean height was 168.2 (5.9) cm in men and 156.2 (6.3) cm in women, and mean tibiale laterale-base height was 49.9 (4.2) cm in men and 46.7 (3.8) cm in women. differences between age groups were observed just in women. Age positively affected the percentage of men with Whr over the cut-off limits, but not in women. Arm and thigh circumference, and humerus and femur bi-epicondylar breadth were no different between gender and age groups. Men and women showed no different systolic (spB) and diastolic blood pressure (dBp), and heart pulse values. Age affected positively the spB
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all (n=187)
possible cognitive impairment (MMse)* 30.5% Mental status (spMsQ) Borderline/mild organic impairment 11.2% Moderate organic impairment 1.6% possible depression (Gds) 3.7% chronic diseases hypertension 44.4% cancer** 25.7% prostatitis* 24.6% diabetes Mellitus 15.0% hypercholesterolemia 12.8% 9.1% heart failure Arthritis 8.0% chronic bronchitis 8.0% Gastric ulcer** 8.0% other cV diseases*** 3.2% Mean number of prescribed drugs (sd)*** 2.7 (1.6) Women
all (n=215)
65-74 yrs (n=92)
75-84 yrs (n=68)
≥85 yrs (n=27)
12.0% 1.1% 5.4%
11.8% 1.5% 2.9%
7.4% 3.7% 0.0%
29.3%
44.6% 18.5% 18.5% 16.3% 14.1% 8.7% 8.7% 7.6% 4.3% 1.1% 2.2 (1.5)†
26.5%
47.1% 29.4% 27.9% 14.7% 14.7% 10.3% 10.3% 8.8% 8.8% 4.4% 3.1 (1.5)
37.0% 40.7% 37.0% 11.1% 13.7% 7.4% 10.0% 7.4% 18.5% 7.4% 3.1 (1.6)‡
38.6%
54.5%
65-74 yrs (n=110)
75-84 yrs (n=83)
13.6% 7.3% 16.4%
19.3% 6.0% 12.0%
33.6%
43.6% 21.8% 12.7% 9.1% 9.1% 11.8% 7.3% 3.6% 0.0% 1.8% 2.2 (1.5)†
44.4%
50.6% 30.1% 16.9% 10.8% 13.3% 6.0% 4.8% 4.8% 1.2% 1.2% 3.1 (1.5)
≥85 yrs (n=22) 13.6% 13.6% 18.2%
31.8% 20.0% 13.6% 13.6% 4.5% 9.1% 0.0% 4.5% 9.1% 13.6% 3.1 (1.6)‡
*p<0.05, **p<0.01, ***p<0.001 percentages compared with χ2 test; mean (sd) compared with AnoVA (age groups): †65-74 vs. 75-84, ‡65-74 vs. >85, #75-84 vs. >85 (p<0.05).
Mean BMi (sd) was 28.1 (4.2) in men and 28.3 (4.6) in women, without statistically differences between age groups. however, analyzing in terms of BMi value, 4.3% of men and 6.5% of women were underweight, 27.8% of men and 28.4% of women showed overweight, and 31.6% of men and 32.1% of women were obese. Age positively affected underweight, but negatively overweight and obesity in both, men and women. More than half of women and approximately a third of men showed Whr higher than cut-off limits. the prevalence of central obesity, according to the Wc cut-off points, was 66.8% in men and 85.1% in women. Among men, the highest percentage was seen in those 65 to 74 years of age (73.9%) and the lowest (59.3%) in those ≥85 years of age. Among women, the highest prevalence was seen in those 75 to 84 years of age (90.4%). the health status of the sample is shown on table 3. possible cognitive impairment was detected in a third of the sample. the prevalence of cognitive impairment was higher in
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table 4 Adjusteda odds ratios (95% confidence intervals) for associations between socioeconomic factors, life-style, mental and health conditions and Body Mass index (BMi) in elderly men and women socioeconomic factorsc living alone low education low economy life-stylec current smoking Alcohol consumption (everyday) low physical activity Mental status possible cognitive impairment (MMse) organic impairment (spMsQ) possible depression (Gds) health status hypertension hypercholesterolemia diabetes Mellitus Arthritis Gastric ulcer osteoporosis & bone fractures cancer chronic bronchitis heart failure other cV diseases prostatitisd
<22.0
22.0-26.9
0.67 (0.29-1.54) 0.80 (0.42-1.54) 1.31 (0.67-2.53)
1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
3.74 (2.66-4.29) 0.62 (0.30-1.28) 1.80 (0.91-2.54)
1.32 (0.69-2.52) 1.90 (0.93-2.42) 1.30 (0.69-1.83)
0.26 (0.11-0.64) 0.74 (0.47-1.17) 2.76 (1.01-5.53) 1.21 (0.47-3.12) 1.80 (0.82-3.95) 1.61 (0.13-2.79) 1.77 (0.77-2.06) 6.72 (2.46-8.42) 0.56 (0.12-1.52) 0.91 (0.30-1.79) 1.44 (0.49-2.23)
Bmi (kg/m2)
1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
27.0-29.9
≥30.0
pb
0.86 (0.55-1.33) 1.59 (1.08-2.34) 0.92 (0.64-1.33)
0.82 (0.53-1.25) 1.53 (1.06-2.21) 1.55 (1.38-1.79)
0.303 0.024 0.001
0.86 (0.31-1.66) 0.90 (0.62-1.31) 1.61 (0.43-1.87)
1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.09 (0.76-1.57) 1.02 (0.52-2.74) 0.79 (0.44-1.42)
1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.) 1.00 (ref.)
1.42 (1.00-2.04) 1.09 (0.70-1.70) 2.17 (1.11-4.15) 1.13 (0.79-2.24) 0.48 (0.26-0.88) 1.07 (0.87-1.82) 0.60 (0.35-1.01) 1.27 (0.52-3.12) 1.09 (0.80-1.37) 1.07 (0.16-2.28) 0.50 (0.27-0.94)
0.88 (0.49-1.33) 1.12 (0.79-1.61) 1.97 (0.92-2.83)
0.048 0.198 0.007
2.22 (1.57-3-14) 1.18 (0.54-2.56) 4.27 (2.32-7.71) 1.93 (1.21-3.05) 0.25 (0.12-0.52) 1.18 (0.58-2.42) 0.71 (0.43-1.16) 2.34 (1.70-4.10) 1.40 (0.86-2.86) 1.45 (0.23-2.87) 0.75 (0.43-1.31)
<0.001 0.002 <0.001 0.005 <0.001 0.021 0.05 <0.001 0.001 0.048 0.032
0.69 (0.48-1.00) 1.05 (0.46-2.40) 0.69 (0.38-1.23)
0.05 0.165 0.304
a. Adjusted for sex and age; b. p-value for overall testing of BMi for each variable; c. A measurement below the median value was defined as low; d. Analysis displayed just in men.
older subjects, and higher in women than in men. eleven per cent of men and fifteen per cent of women showed borderline/mild mental impairment, and 1.6% of men and 7.4% of women showed moderate mental impairment. no severe impairment has been observed in the studied population. the age negatively affected the prevalence of mild mental impairment, but positively the prevalence of moderate mental impairment in both men and women. possible depression affected 3.7% of men and 14.9% of women. Age negatively affected the prevalence of depression in men, but positively in women. the most common diseases were hypertension, cancer, prostatitis, diabetes, hypercholesterolemia, and heart failure in men, and hypertension, hypercholesterolemia, arthritis, diabetes, gastric ulcer, and osteoporosis & bone fractures in women. A high percentage of the sample (89%) was taking drugs. the mean number of drugs (sd) were 2.7 (1.6) in men and women, and the older subjects, the higher number of taken drugs. table 4 shows the adjusted associations between BMi and the prevalence of some socioeconomic factors, life-style, mental and health status. the test for interaction by sex was for all variables non-significant. low education was associated with overweight and obesity (in a J-shaped relation). low economy and physical activity were related to underweight, overweight, and obesity (in a u-shaped relation). current smoking was inversely related to BMi (in an inverted J-shaped
relation). hypertension, hypercholesterolemia, heart failure, and other cV diseases were associated only with the higher BMi categories (in a J-shape relation). diabetes mellitus, arthritis, and chronic bronchitis were associated with underweight and overweight/obesity (in a u-shaped relation). the cognitive impairment, gastric ulcer, osteoporosis & bone fractures, cancer, and prostatitis (in men) were inversely related to BMi (in an inverted J-shape relation). other associations showed no statistical significance. overweighed persons showed lower changes than obese. Waist circumference (Wc) out of cut-off limits (Wc>102 cm in men, and Wc>88 cm in women) was directly related to diabetes mellitus (or: 2.62; ci: 1.31-5.19; p<0.01), hypertension (or: 2.44; ci: 1.66-3.59; p<0.001), heart failure (or: 1.23; ci: 0.34-2.47; p<0.05), and other cV diseases (or: 1.71; ci: 0.30-2.92; p<0.05). discussion
this study showed that approximately 5% of ≥65 year old Menorca men and women were underweight and 60% overweight or obese; underweight were positively and overweight and obesity negatively affected by age. the prevalence of underweight is in accordance with findings from other community based studies (24-25). Both overweight and obesity were in Menorca population at the same level than
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reported in studies of elderly subjects in england (26), and France (27), higher as found in norway (4) and switzerland (28), but lower than in italy (29), Finland (30), and national (16) and regional (31) studies in spain. According to Gutiérrez-Fisac et al. (16), an explanation for the high prevalence of overweight and obesity in Menorca elders could be also related to the birth cohorts of the study subjects. the mean height in the Menorca cohorts was 168.2 cm in men and 156.2 cm in women, which is low with respect to similar populations in the Western societies, together with the observed high body weight and body fat. this small stature may be due to socioeconomic conditions in spain, and europe, the years before the 1950s, when they were born, together with environmental factors responsible for the epidemic of obesity seen in the developed world on the last third of the XXth century (i.e.: high-calorie foods, sedentary lifestyles) that explains the observed high body weight and body fat. however, the cross-sectional design of the study does not address separate age and cohort effects, and then a longitudinal study in this way would be desirable. Furthermore, a decrease in stature usually accompanies aging, especially after 65 years of age. this impairment varies 1-2 cm per decade and it is even quicker in the people ≥85 years (32). the height reduction related to age is also demonstrated in our study by means of a decrease in the tibiale laterale-base height, a parameter useful to measure height changes in elderly people. the height reduction increases BMi and prevalence of overweight/obesity among the elders, even when body weight remains constant (16). We also found that overweight and obesity were higher in women than in men. previous authors (16) suggested that it could be related to the greater trend of women to accumulate fat, and our results also are in accordance with this fact. however, it has been also pointed out that BMi does not correlate as well with the percentage of body fat in these persons as it does in middle-aged people (33). then, the prevalence of overweight/obesity may be overestimated, but this overestimation may be compensated by the reduction in lean mass that occurs with age, and does an elderly person would have higher percentage of body fat than a younger with the same BMi (34). We also observed a lower mean BMi and higher underweight prevalence in ≥85 year old subjects than in younger participants, which can be explained by the reduced body weight that occurs with increasing age (35), as we also observed. Associations between BMi and socioeconomic factors, lifestyle, mental and health status were also showed. in our study, low education and low socioeconomic status were risk factors for malnutrition and overweight/obesity, as earlier described in adolescents and middle aged populations (36, 37). our results showed lower values than in young peers. it is necessary to consider, however, that social inequalities in health are much smaller in elderly populations (38).
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low physical activity was in this study associated with both underweight and overweight/obesity, which is accordance with previous findings (4, 6) that attributed this association to functional impairment in the elderly. We also found possible cognitive impairment among elderly persons with BMi<22 kg/m2, but this risk decreases among the higher BMi categories. these results agree previous findings that reported the risk of cognitive impairment decreases in overweight and obese institutionalized elderly persons (39), indicating that anthropometric data must take into consideration in order to identify elderly persons at high risk for cognitive impairment. A J-shaped association between BMi and hypertension, hypercholesterolemia, heart failure and other cV diseases were also found. diabetes mellitus, arthritis, and chronic bronchitis were associated with underweight and overweight/obesity in a u-shaped relation. our results are in accordance with previous results that pointed out diabetes mellitus (dM), heart failure, and cardiovascular diseases (cVd) are related to obesity (28,40), but the risk associated with overweight is limited (4). Moreover, our results also showed a high prevalence of central obesity (Wc>cut-off limits) among the Menorcan elders, which is associated with diabetes and cardiovascular risk. these results also agree previous findings in the elderly (41). however, it is necessary to consider that an increase in BMi values corresponds to a lower relative mortality risk in elderly subjects, compared to the younger population and middle-aged individuals (42), suggesting that ideal weight should be higher in elderly subjects. our findings also showed that underweight is also positively related to diabetes mellitus. these results are in accordance with a previous study that pointed out malnutrition is highly prevalent in elderly diabetic inpatients and, paradoxically, contributes to glycaemic control (43). Both studies are useful to conclude that malnutrition should be screened for in these patients in order to reduce unnecessary hypoglycemic drug therapy. several community-based studies also have showed an association between chronic pulmonary diseases and malnutrition, else partly to obesity (4,44), which can explained our results in the Menorca elders. pulmonary cachexia has been identified by a low BMi, attributed to loss of muscle mass and to insufficient nutritional intake because large meals can induce shortness of breath (45). the association between obesity and chronic pulmonary diseases has been attributed to a direct affect on airway caliber through chest wall restriction, but also to a more sedentary life-style in obese persons that may affect breathing pattern and pulmonary function adversely (45). Moreover, BMi was associated with increased risk of acute respiratory distress syndrome in a weight-dependent manner (46). the found u-shaped relationship of BMi and arthritis is related to previous findings that showed high prevalence of arthritis associated with overweight/obesity in the elderly (47), but also low BMi is associated with cardiovascular mortality in rheumatoid arthritis (48).
The Journal of Nutrition, Health & Aging© Volume 16, Number 4, 2012
OBESITY IN MENORCA ELDERS
An inverted J-shape relation was found between BMi and gastric ulcer, osteoporosis & bone fractures, cancer, and prostatitis (in men), which is in agreement with previous findings that found underweight is a risk factor for osteoporosis and bone fractures (49), and with the fact that weight loss is usual in cancer patients (50). to the best of our knowledge, no association has been found yet between gastric ulcer and BMi in the elders. however, a previous study in 20-87 year old individuals showed that peptic ulcer disease was inversely related to BMi in middle-aged overweight and obese men in 24 British towns (51), but other study found no evidence of a relation between BMi and peptic ulcer disease (52). the found inverted J-shape relationship of BMi and prostatitis in men is related to previous findings that pointed out BMi and physical activity were associated with decreased odds of prostatitis (53). it is likely these findings are due to the influence of physical activity on this relationship (53), and we also demonstrated an association between low physical activity and underweight in Menorca elders. We must recognize, however, that in advanced ages (over 70 years), underweight subjects present more health problems than those with the recommended weight. conclusions
We demonstrated that both low and high BMi are associated with a wide range of prevalent conditions and diseases in Menorca elderly men and women. these results confirm previous findings in other populations, also add new findings, and show that the above mentioned association is not a local, but worldwide phenomenon. the importance of monitoring BMi in elderly people is also confirmed. however, in spite that most attention is giving today to the link between high BMi values and diseases, underweight must be also considered as a potential health hazard in the elderly, whereas overweight just represents a small hazard in this age group. this analysis is a contribution to the knowledge about the factors related to BMi, life-style and health status in european elders.
Acknowledgements: sources of funding: spanish Ministry of health and consumption Affairs (program of promotion of Biomedical research and health sciences, project 08/1259, and red predimed-retic rd06/0045/1004), spanish Ministry of education and science (Fpu program, phd fellowship to Maria del Mar Bibiloni). Authors' contributions: the authors’ contributions were as follows: JAt conceived, designed and devised the study, AF and JAt collected and supervised the samples. AF, MMB, MeZ, Jp and JAt analyzed the data and wrote the manuscript. Ap and JAt supervised the study. Ap and JAt obtained funding. Conflict of interests: the authors state that there are no conflicts of interest.
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call for papers on the mini-nutritional assessment mna®
one of the issues of the JnhA in 2012 will be dedicated to publications on the mna®. Juergen M Bauer, Md, phd, oldenburg, Germany, will serve as guest editor of the MnA issue.
in this context the following research areas will be of special interest: • epidemiology (i.e. prevalence of malnutrition, geographical and ethnic variations, focus on specific populations – communityliving, institutional) • Methodology (i.e. the MnA ® as a monitoring tool, adaptations of the BMi/cc-cut offs due to ethnicity) • MnA ® and functionality (i.e. cognitive status, frailty, disability) • MnA ® based interventions please submit your papers by June 30, 2012 to http://jnha.edmgr.com 305