Waist-hip ratio should replace body mass index as indicator of mortality risk in older people

Older people with high waist-hip ratios (WHRs) have a higher mortality risk than those with a high body mass index, or BMI, a new study reveals.

Whereas justifiable attention is given to the increasing problem of obesity in the general population, far less is known about the relationship between obesity and mortality in older people, or how mortality risk should be estimated. The excess health risks associated with having a high BMI are known to decline with age, yet expert bodies such as the National Institutes of Health and the World Health Organisation have continued to use in older people the same BMI criteria as for other age groups.

This study, published in the American Journal of Clinical Nutrition, was carried out by a team based at the London School of Hygiene & Tropical Medicine. It sought to investigate the association of BMI, waist circumference (WC) and WHR with mortality and cause-specific mortality. The researchers studied 14,833 patients aged over 75 from 53 family practices in the UK; the subjects underwent a health assessment that included taking body measurements and a follow-up (with a median of 5.9 years) for mortality.

The findings confirmed that the current guidelines for BMI-based risk categories overestimate the risks of excess weight in people aged over 75 and are inappropriate for older men and women. This concurs with a previous study that found BMIs of 25-27 not to be a risk factor for all-cause and cardiovascular mortality in those aged 65 and over 1. Most consistently, the data highlighted the risk of having a low BMI, with people in the lowest quintile (less than 23 in men and less than 22.3 in women) demonstrating the highest risk of death for total mortality and for major causes of death. Very underweight men (those with a BMI of under 18.5) were found to be particularly at risk.

‘An explanation for the lack of a positive association with BMI and mortality at older ages is that, in older persons, BMI is a poor measure of body fat', say the authors. ‘The measurement of weight does not differentiate between fat and fat-free mass, and fat-free mass (especially muscle) is progressively lost with increasing age

Waist circumference (WC) has been proposed as an alternate or additional measure of obesity. The study found no association with waist circumference and mortality. The authors continue: ‘A limitation of WC alone as a measure is that it takes no account of body composition, whereas WHR is a measure of body shape and to some extent of lower trunk adiposity [abdominal fat]. Although it is possible theoretically for high WHR to coexist with thinness, our data show that those with high WHR had higher-than-average waist and average hip circumferences. We conclude that the association observed for WHR and mortality is probably explained by abdominal adiposity'.

The authors recommend that the current BMI-based health risk categories to define the burden of disease related to adult overweight and obesity be reviewed, as they are not appropriate for those over 75. They suggest that WHR should instead be used in this age group because of its positive relation with risk of death, and that attention should also be paid to the problem of underweight in old age.