Journal of Gerontology: MEDICAL SCIENCES
2008, Vol. 63A, No. 11, 1257–1259
Copyright 2008 by The Gerontological Society of America
Cite as: J Gerontol A Biol Sci Med Sci
Special Article: Call for Papers
A Research Agenda: The Changing Relationship
Between Body Weight and Health in Aging
Dawn E. Alley,1 Luigi Ferrucci,2 Mario Barbagallo,3 Stephanie A. Studenski,4
and Tamara B. Harris5
1
Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore.
2
Longitudinal Studies Section, Clinical Research Branch, National Institute on Aging, Baltimore, Maryland.
3
University of Palermo, Italy.
4
Department of Medicine, University of Pittsburgh Medical Center, and
Department of Veterans Affairs Pittsburgh Geriatric Research, Education and Clinical Center, Pennsylvania.
5
Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, Bethesda, Maryland.
I
T is increasingly recognized that changes in weight and
body composition with age are strongly connected with
health status and physical function. Aging is typically
associated with reductions in total and lean mass, so that in
the last few years of life, older people frequently report
having lost weight and strength (1–3). We know only a few
important facts about this process. On average, muscle mass
declines with age, and even in older persons with stable
weight, muscle is replaced by fat over time (4,5). Increasing
fatty infiltration of muscle tissue is associated with decreasing muscle strength (6). The general pattern of weight
change over the lifetime is that weight increases through
approximately age 60 years and decreases thereafter (7).
Weight gain from early adulthood through midlife is related
to increases in both fat and muscle mass, but weight loss at
older ages is associated with higher risk for a disproportionate decline in muscle mass (1,8).
In addition to changes in fat and muscle mass, fat location
and muscle quality change with age. Waist circumference
and intraabdominal visceral fat increase with age at a greater
rate than total weight, reflecting changes in the distribution
of fat (9,10). The extent to which individual trajectories
of weight and body composition mirror these population
average trajectories is unclear (11). Case studies and clinical
experience suggest that most individuals actually maintain
weight until a period of accelerated body composition
change occurs, which parallels deterioration of health status.
However, the critical age of acceleration is highly variable
between individuals and is perhaps a marker of underlying
biological change, as opposed to chronological age.
Age-related changes in body composition have important
implications for health in late life. Obesity is clearly associated with disability, but the mechanism for this association
is not clear. In studies that obtained detailed measures of
body composition, muscle strength and fat mass independently predict incident disability and mobility limitation,
while there is less evidence for an association between
muscle mass and disability (10,12–17). It is unclear whether
obesity and muscle mass or strength act as synergistic risk
factors in producing excess risk of disability (14,15,17–20).
While guidelines exist for healthy body mass index (BMI)
with age, consideration of body composition may also be
important in clinical assessment.
Recently, a working group met in Erice, Italy, to discuss
gaps in our understanding of causes and consequences of
changes in body weight and composition over the aging
process. During a number of formal presentations and in
informal discussions that followed, we identified critical
research questions that would advance our understanding of
the effect of changes in weight and body composition on
health, function, and quality of life in older persons. In an
effort to focus research on potentially high impact areas,
we have selected three of these questions as immediate
priorities for publication in an upcoming special section of
JGMS.
1. WHAT FACTORS UNDERLIE THE CHANGING RELATIONSHIPS
BETWEEN BMI AND HEALTH WITH INCREASING AGE? HOW
CAN WE DISSECT BMI AND HEALTH RELATIONSHIPS TO
UNDERSTAND THE HEALTH EFFECTS OF WEIGHT ON
DISEASE, DISABILITY, AND DEATH?
Clearly, BMI is importantly related to chronic conditions,
disability, and mortality. However, for many of these outcomes, relationships between BMI and health change with
age (7,21). For instance, the relationship between BMI and
mortality is increasingly U shaped with advancing age, with
higher mortality among both underweight and obese older
persons, and the BMI associated with the lowest mortality
increases with age (22,23). BMI is a less reliable indicator of
fatness in older people because of changes with body composition in aging, including height loss and increases in
body fat even among weight-stable older persons. BMI also
does not take fat distribution into account, which is known
to influence health (24,25). Additionally, if recent weight
loss is not taken into account, BMI may be an indicator of
underlying health status, reflecting a reverse association in
which disease influences BMI, in contrast to the typically
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ALLEY ET AL.
theorized relationship in which BMI predicts health status
(26–28).
Both the factors that predict BMI and its role in health
outcomes change with age, but the causes of this change are
unclear. We would like to encourage papers that identify key
factors needed to evaluate associations between body mass
index and health in old age. For instance, what measures of
body composition are most predictive of health outcomes
for people with different BMIs? These might include
anthropometric and strength measures, measures of body
composition, biomarkers, or other health indicators. Predictors for important health outcomes may differ in those
with extreme values of traditional risk factors (29). Given
greater variability in health outcomes within BMI categories
at older ages, what characteristics distinguish healthy and
frail older persons at different points on the BMI distribution? Are these characteristics different at both extremes of
body mass—underweight and obese? To what extent are
associations between BMI and health in old age driven by
body composition, behavior, and/or underlying health
status? How and why do the effects of BMI depend on
overall health? Are there relevant animal models that would
elucidate mechanisms through which BMI and body
composition affect health at older ages?
2. WHAT ARE THE LIFETIME CHARACTERISTICS OF THOSE
WHO ARE OBESE AND FUNCTIONALLY IMPAIRED IN OLD AGE?
On average, obesity is associated with higher levels of
functional impairment and disability (23,30–33). However,
there is significant heterogeneity in the relationships
between weight, muscle mass, strength, and function. Given
the rising prevalence of obesity, the most common phenotype of frailty in the future may be an obese, disabled older
person. It is important to understand why sarcopenia, functional impairment, frailty, and disability occur in some
obese persons, but not in others. What factors measured
earlier in adulthood might distinguish between those who
are overweight and aging healthfully and those most likely
to suffer the health consequences of overweight? How do
the predictors of poor health or functioning vary in obese
and nonobese populations?
3. IS WEIGHT LOSS IN OLD AGE EVER BENEFICIAL?
IN WHAT CIRCUMSTANCES?
Numerous observational studies have reported associations between weight loss at older ages and higher mortality
(26–28,34). Although few of these studies have been able to
identify whether weight loss was intentional (35), this evidence, combined with results showing a higher ideal BMI at
older ages, has led some to conclude that weight loss of any
kind is inadvisable for older people (36). At the same time,
short-term intervention trials have demonstrated that intentional weight loss is associated with declines in cardiovascular risk factors (37) and improvements in physical
function (38,39) and strength (40) among overweight older
persons, and intentional weight loss is associated with
decreased mortality in animal models (41). American
Society for Nutrition and NAASO Obesity Society guidelines recommend weight loss therapy that minimizes muscle
and bone loss ‘‘for older persons who are obese and who
have functional impairments or medical complications that
can benefit from weight loss’’ (21). It is critical that we
develop a knowledge base addressing the efficacy and safety
of weight loss in older persons. Is there a safe and healthy
way to lose weight in old age? How do we distinguish older
persons who might benefit from weight loss interventions
from those for whom weight loss would be harmful? What
is the state-of-the-art knowledge about what interventions
help to maintain bone and lean mass with weight change?
CALL FOR PAPERS
We invite papers that address these questions for a special
section of the Journal, to be published in 2009. Papers
should be submitted no later than February 28, 2009.
Manuscripts will be selected by a rigorous peer-review
process, based on the significance of the topic, quality of
scholarship, clarity of style, and presentation. For specific
questions, authors are encouraged to contact the section
editors directly.
To submit an article, go to: http://mc.manuscriptcentral.
com/jgms.
ACKNOWLEDGMENTS
Working Group Participants
Angela Abbatecola, University of Naples, Italy; Dawn Alley, University
of Pennsylvania, USA; Lodovico Balducci, University of South Florida,
USA; Mario Barbagallo, University of Palermo, Italy; Ligia J. Dominguez,
University of Palermo, Italy; Bill Evans, University of Arkansas, USA;
Luigi Ferrucci, National Institute on Aging, Maryland, USA; Jack Guralnik,
National Institute on Aging, Maryland, USA; Tamara Harris, National
Institute on Aging, Maryland, USA; John Morley, University of Saint Louis,
Missouri, USA; Anne Newman, University of Pittsburgh, Pennsylvania,
USA; Stephanie Studenski, University of Pittsburgh, Pennsylvania, USA;
Marjolein Visser, VU University Amsterdam and VU University Medical
Center, the Netherlands; Mauro Zamboni, University of Verona, Italy.
CORRESPONDENCE
Address correspondence to Luigi Ferrucci, MD, PhD, Longitudinal
Studies Section, Clinical Research Branch, National Institute on Aging,
NIA-ASTRA Unit, Harbor Hospital, 5th Floor, 3001 S. Hanover St.,
Baltimore, MD 21225. E-mail: [email protected]
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