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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:M19-M25 (2002)
© 2002 The Gerontological Society of America

Waist Circumference and Weight Change Are Associated With Disability Among Elderly Hispanics

Honglei Chena, Odilia I. Bermúdeza and Katherine L. Tuckera

a The Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts

Katherine L. Tucker, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington Avenue, Boston, MA 02111 E-mail: tucker{at}hnrc.tufts.edu.

Decision Editor: John E. Morley, MB, BCh


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Studies have suggested that both high and low body mass index (BMI) and weight change are related to functional disability in elderly populations. Elderly Hispanics have a high prevalence of both obesity and disability, yet few studies have examined their interrelationship in this population. Therefore, we examined these relationships in a mostly Puerto Rican group of Hispanic elders.

Methods. We investigated associations between a three-level disability score created from responses to a questionnaire on activities of daily living and BMI, waist circumference (WC), and weight change since age 50, using the proportional odds model in a cross-sectional study of 763 elderly Hispanics, aged 60 to 92 years, residing in Massachusetts.

Results. After adjusting for potential confounders, men with a WC >=109.3 cm (vs <90 cm), or with a reported weight loss of -0.32 to -0.01 kg/year, or a weight gain >=0.55 kg/year since age 50 (vs relatively stable weight, -0.01 to +0.21 kg/year [y]) were each significantly associated with an approximately threefold higher risk for greater disability. Women with a BMI >=35 kg/m2 were almost four times as likely to have higher disability as those with a BMI of 20 to 25 kg/m2. Compared with women with a WC <=85.2 cm, those with a WC of 91.5 to 106.6 cm were two times more likely, and those with a WC >=106.6 cm were five times more likely, to have higher disability scores. Compared with relatively stable weight (-0.05 to +0.23 kg/y), weight gain >=0.23 kg/year was associated with a twofold higher risk of greater disability among women. When BMI and WC were included in the same model, WC, but not BMI, remained significantly associated with disability.

Conclusions. Abdominal obesity (WC >=109.3 cm for men, or WC >=91.5 cm for women) and weight gain >=0.55 kg/year after age 50 in men or >=0.23 kg/year in women may increase the risk of disability among elderly Hispanics.

WITH the rapid aging of the U.S. population, functional disability among elderly persons has become an important public health concern. Disability substantially increases the health burden of society and is also related to higher mortality among elderly individuals (1)(2)(3)(4). Therefore, it is important to identify potential causal factors in order to better understand how to prevent or delay its occurrence. Major known determinants of disability include advancing age, female gender, low physical activity, and chronic diseases (5)(6)(7).

Several studies have suggested that higher body mass index (BMI) or weight loss may relate to greater disability among elderly populations (1)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Recent evidence suggests that abdominal fat accumulation is an independent predictor of morbidity (18)(19) and that waist circumference (WC) may be a more relevant measure for abdominal adiposity than waist-to-hip ratio (20). However, few studies (21)(22)(23) have evaluated the association between WC and disability and, to our knowledge, none have examined this among Hispanics, a rapidly increasing population segment of the United States (24). Elderly Hispanics have been shown to have a higher prevalence of disability and obesity than non-Hispanic whites (25)(26)(27)(28), and Puerto Ricans may have a higher disability prevalence than other Hispanic groups (29)(30). In this study, we investigate associations between BMI, WC, and average annual weight change since age 50, and self-reported disability among a representative sample of elderly Hispanics in Massachusetts, which included primarily Puerto Ricans (61.2%) and Dominicans (18.6%).


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Subjects and Study Design
We obtained a representative sample of elderly Hispanics in Massachusetts through a two-stage sampling approach, using the 1990 census data. Detailed sampling methods and study design have been described previously (30)(31). The protocol for this study was approved by the human investigation review board of Tufts/New England Medical Center. A total of 776 of 940 (83%) eligible Hispanics were interviewed from 1993 to 1997. Almost all of them (98%) were interviewed in Spanish. Among these, 763 (98%) subjects, with an average age of 69 years (range, 60–92 years [y]), had complete data on functional limitations and information on at least one of the following variables: BMI, WC, and recalled weight at age 50. Nine (1.2%) and 10 (1.3%) subjects had missing values on BMI and WC, respectively. Twenty-six men (9%) and 95 women (20%) did not recall their weight at age 50. Subjects with missing values were deleted from respective analyses.

Measurements
We measured functional status with a 12-item activities-of-daily-living (ADL) questionnaire, adapted from the Katz scale (32). These items include the following: (i) walking for a quarter of a mile (two or three blocks); (ii) walking up 10 steps without resting; (iii) getting outside; (iv) walking from one room to another on the same level; (v) getting out of bed or chair; (vi) eating, including holding a fork, cutting food, or drinking from a glass; (vii) dressing, including tying shoes, working zippers, and buttoning; (viii) bathing or showering; (ix) using the toilet, including getting to the toilet; (x) using a manual can opener; (xi) opening a frozen food package; and (xii) opening a milk carton (30). Each item had four levels of severity: "no difficulty" (0), "some difficulty" (1), "much difficulty" (2), or "can't do" (3). We calculated an ADL summary score by summing the scores for all 12 items. Subjects with a score of 0 were defined as having "no disability." We grouped the subjects with a summary score greater than 0 into two categories: 1 to 5 as "some disability" and 6 to 36 as "considerable disability." With this definition, 12% of the elderly Hispanics categorized with "some difficulty" reported "can't do" on one ADL item; the majority reported only "some difficulty" on one or more ADL items. Of those categorized with "considerable disability," 97% reported "much difficulty" or "can't do" on two or more ADL items.

Anthropometric measurements were taken in duplicate by trained interviewers, and the average of the two measures was used. Height and knee height were measured to the nearest 0.1 cm with a Harpenden pocket stadiometer (Holtain Ltd, Crosswell, UK). For subjects unable to stand, or with stooped posture, height was further corrected by knee height with published equations developed for elderly Hispanics (31). WC was measured with a nonstretchable measuring tape at the level of the smallest area of the waist and recorded to the nearest 0.1 cm. Weight was measured to the nearest pound with a Seca balance scale (Seca Corporation, Columbia, MD) and was later translated into kilograms. Subjects were also asked to recall their weights at the age of 50. Weight change was calculated by subtracting weight at 50 years from current weight. Because the length of time of measurement varied considerably, we used the average annual weight change (absolute weight change divided by time frame) rather than the absolute value in the analysis.

To allow for nonlinear relationships between anthropometric variables and disability score, we categorized these anthropometric variables before data analysis. BMI was categorized as <20, 20 to 25, 25 to 30, 30 to 35, and >=35 kg/m2, with 20 to 25 kg/m2 as the reference group. WC was defined by quintile categories within each gender, with the first quintile (67.1–89.8 cm for men and 56.0–85.2 cm for women) as the reference group. We also grouped annual weight change into quintile categories, and used the third quintiles (-0.01 to +0.21 kg/y for men and -0.05 to +0.23 kg/y for women), which represented the most stable weight over time, as the reference group.

In most analyses, we adjusted for age, physical activity, ethnicity, educational level, smoking status, alcohol use, living alone, and self-reported chronic conditions. Information regarding these variables was collected by questionnaire, and their definitions are presented in Table 1 . Physical activity was estimated with a modified version of the Harvard Alumni Physical Activity Questionnaire (33), and a score lower than 29 was considered as sedentary activity, assuming 8 hours of sleep, 8 hours of sitting, and 8 hours of light activity. Subjects were asked to report whether they had ever been told by a physician that they had specific conditions, including arthritis, respiratory diseases, hip fracture, cataract, stroke, cancer, diabetes, heart attack, other heart diseases, depression, or hypertension. Because of the high prevalence of arthritis and hypertension in this population, we created three variables: arthritis (yes/no), hypertension (yes/no), and other chronic conditions (yes/no, from the previous list) for inclusion in regression models.


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  		Table 1. Characteristics of the Study Sample

 
Statistical Analysis
All statistical analyses were completed with the SAS System for Windows (version 7, SAS Institute, Inc, Cary, NC). We did not find significant interactions between ethnicity and any of the independent variables; therefore, results were presented for all Hispanics combined. We calculated the age-adjusted ADL summary scores by anthropometric variable categories. To further adjust for potential confounders, we used the proportional odds model to calculate the odds ratios (OR) for higher disability score separately for men and women. This model is a natural extension of logistic regression, with consideration of the ordinal nature of the outcome variable (34). The OR for each independent variable reflects the relative odds of having higher levels of the outcome for the exposure group, compared with the reference group. In this case, this represents the likelihood of having "considerable disability" versus "moderate or no disability" and "considerable or moderate disability" versus "no disability" for the exposure group compared with the control group.

Because BMI and WC were strongly correlated (Pearson correlation coefficients = 0.89 for men and 0.86 for women), we further calculated the ORs with both variables in the same models to evaluate their independent associations with disability score. All statistical tests were two-sided, and p values less than .05 were considered statistically significant.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
The characteristics of this sample of elderly Hispanics residing in Massachusetts are presented in Table 1 . Their ages varied from 60 to 92 years of age (mean, 69 y), and they were generally inactive. The majority of the participants were Puerto Rican (61.2%) and Dominican (18.6%). Only 16% of these Hispanic men and 11% of these Hispanic women had attained more than 12 years of education. Men were more likely to be cigarette smokers or alcohol drinkers than women. However, more women than men reported chronic conditions. Approximately one third of these elderly Hispanics lived alone at the time of this investigation.

Table 2 shows the definitions of anthropometric and functional disability variables. Hispanic women had a higher average disability score (5.1 vs 3.4, p < .0001) than did men. Based on our definition, approximately 70% of women and 50% of men reported either some or considerable disability in their ADLs. According to the current definitions of overweight and obesity (19), a similar percentage of women and men were overweight (BMI, 25–29.9 kg/m2; 35% vs 39%), but a much higher proportion of women than men were obese (BMI, >=30 kg/m2; 41% vs 24%). However, men had greater average WC than women (mean, 99.6 vs 95.8 cm). Women reported greater average weight change since age 50 than did men (mean, +0.14 vs +0.11 kg/y) and a larger range of weight change (-4.0 to +4.1 vs -2.3 to +2.8 kg/y).


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  		Table 2. Definitions of Anthropometric and Disability Variables

 
Associations between age-adjusted ADL summary scores (mean ± SE) and BMI categories, WC, and annual weight change quintiles are illustrated in Fig. 1, Fig. 2, and Fig. 3. Both men and women with a BMI greater than 35 kg/m2 had significantly greater ADL scores than those in the groups with BMIs of 20 to 35 kg/m2 (Fig. 1). The lowest age-adjusted disability score was observed for men with a BMI of 25 to 30 kg/m2, whereas the curve tended to be flat below a BMI of 35 kg/m2 in women. There was a linear association between WC and ADL score among elderly Hispanic women, but not men, where those with WC of 102.6 to 109.3 cm had the lowest average ADL scores (Fig. 2). However, for both men and women, those with the highest WC (>109.3 cm and 106.6 cm, respectively) had the highest ADL scores. Fig. 3 suggests a U-shaped curve between weight change and ADL score in these elderly Hispanics, particularly for women. The groups with the smallest weight changes since age 50 (-0.01 to +0.21 kg/y for men or -0.05 to +0.23 kg/y for women) had the lowest average ADL scores. Compared with relatively stable weight, women with both the greatest weight gain (>=0.71 kg/y) or weight loss (<=0.44 kg/y) reported significantly more disability. In men, only moderate weight loss (-0.32 to -0.01 kg/y) differed significantly from the relatively stable weight category.



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  		Figure 1. Age-adjusted activities-of-daily-living (ADL) summary scores (mean ± SE) in relation to body-mass-index (BMI) categories among elderly Hispanic men and women. Means with different letters within each gender differ significantly from each other; p < .05.

 


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  		Figure 2. Age-adjusted activities-of-daily-living (ADL) summary scores (mean ± SE) in relation to waist circumference quintiles among elderly Hispanic men and women. Means with different letters within each gender differ significantly from each other; p < .05.

 


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  		Figure 3. Age-adjusted activities-of-daily-living (ADL) summary scores (mean ± SE) in relation to annual weight change quintiles among elderly Hispanic men and women. Means with different letters within each gender differ significantly from each other; p < .05.

 
In Table 3 , we present the ORs and their 95% confidence intervals for higher disability score by BMI category. After adjusting for potential confounders, elderly Hispanic women with a BMI greater than 35 kg/m2 had a 3.9-fold higher risk for greater disability score compared with women with BMIs between 20 and 25 kg/m2. A nonsignificant 3.5-fold increased risk was also observed for men. However, these associations were diminished once WC was further adjusted.


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  		Table 3. Odds Ratios and Their 95% Confidence Intervals for BMI Categories on Functional Disability From the Proportional Odds Model

 
The results for WC and functional disability are presented in Table 4 . After adjusting for potential confounders, men with a WC greater than 109.3 cm were three times as likely to have higher disability as those with a WC smaller than 90 cm. The OR increased to 7.9 once BMI was further adjusted. For women, a linear relationship (p for trend < .0001) was seen between WC and functional disability. Compared with women whose WCs were smaller than 85.2 cm, the ORs ranged from 1.5 for those with a WC between 85.3 and 91.4 cm to 5.2 for those with a WC greater than 106.6 cm. These associations persisted after further adjustment for BMI.


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  		Table 4. Odds Ratios and Their 95% Confidence Intervals for Waist Circumference (WC) Quintile Categories on Functional Disability From the Proportional Odds Model

 
As seen in Fig. 3, results shown in Table 5 show that the lowest risk of disability was found for men or women who had relatively stable weight since age 50 (-0.01 to +0.21 kg/y for men and -0.05 to +0.23 kg/y for women). Compared with men with stable weight, men who lost an average of between -0.32 and -0.01 kg/year or who gained more than 0.55 kg/year were approximately three times more likely to have higher disability. Women with annual weight gain greater than 0.23 kg/year had an approximately twofold higher likelihood of having greater disability than those with relatively stable weight.


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  		Table 5. The Odds Ratios (OR) and Their 95% Confidence Intervals (CI) for Quintile Categories of Annual Weight Change Since Age 50 on Functional Disability From the Proportional Odds Model

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
In this representative sample of elderly Hispanics in Massachusetts, we found that WC greater than 109.3 cm (vs <=89.8 cm) in men, or 91.5 cm (vs <=85.2 cm) in women, and late-adult weight gain after age 50 of more than 0.55 kg/year (vs -0.01 to +0.21 kg/y) in men, or 0.23 kg/year (vs -0.05 to +0.23 kg/y) in women, were associated with greater disability. A BMI greater than 35 kg/m2 (vs 20–25 kg/m2) was associated with significantly higher disability in women and a 3.5-fold, but nonsignificant, greater disability score in men. However, the significance of BMI was diminished after adjusting for WC.

Our study sample, with subjects of primarily Puerto Rican and Dominican origin, had high prevalences of obesity and functional disability. Mean BMIs were 26.8 kg/m2 and 29.4 kg/m2 for men and women, respectively, higher than those reported in similar ADL studies among primarily white elderly persons (10)(12)(13)(14), but similar to the Hispanic Health and Nutrition Examination Survey data reported for Puerto Ricans (35)(36).

Studies have suggested associations between BMI and disability as linear (9), as J or U shaped (12)(37)(38), or at a threshold (1)(17). These studies are not quantitatively comparable due to the lack of uniformity in study populations, variable definitions, and statistical methods. Most of these studies were done with non-Hispanic white populations, although two included Mexican Americans (38)(39). Unlike those study populations, most of our subjects were Puerto Rican or Dominican, with few Mexican Americans. In this population, we saw that only severe obesity (BMI >=35 kg/m2) was associated with significantly increased risk for disability in women and a nonsignificantly increased risk in men, while no increased risk was observed for leanness in either men and women.

Larger WC has been shown to be associated with greater risk for some chronic diseases (40)(41)(42)(43), which may further be associated with disability. However, few studies have examined the relationship between WC and disability directly. Visser and colleagues (21) did not find any significant association between WC and disability among elderly persons participating in the Framingham Heart Study, but they did not report their results in detail. In contrast, Lean and colleagues (22) and Han and colleagues (23) showed that large WC represented greater risk for overall and individual functional limitations in a relatively young population (20–59 y) in The Netherlands. We observed similar results among elderly Hispanic women, where there was a clear dose-response relationship between WC and risk for greater disability. Among men, only subjects with the largest WC had higher risk of greater functional disability.

Recent studies have suggested that greater body fat is positively associated with disability among elderly individuals (21)(44)(45). We found that WC, but not BMI, remained significantly associated with disability score when both variables were in the same model, suggesting that abdominal fat accumulation is more important than overall obesity for disability in these elderly Hispanics.

Average annual weight change was associated with a U-shaped disability score, suggesting adverse effects for both weight gain and weight loss. Studies (14)(15) have suggested that weight loss is associated with greater disability, probably due to an association between weight loss and worsening health status. We also found that weight gain was strongly associated with greater disability among these elderly Hispanics. We may have been more able to detect the effects of weight gain than other studies because 58% of this population had reported weight gain since age 50, and 36.5% gained more than 5 kg.

Compared with relatively stable weight, weight losses also tended to be associated with greater disability among our sample of elderly Hispanics, although some comparisons were not statistically significant. Among men, the associations were stronger for moderate weight loss of -0.32 to -0.01 kg/year than for larger weight loss of more than -0.32 kg/year. Further analysis showed that men with weight loss of more than -0.32 kg/year were younger and less likely to have other chronic conditions. Therefore, it is possible that residual confounding contributes to this difference. Because weight at age 50 was subject to recall bias, and because we did not have detailed information about whether the weight loss was intentional, we were unable to further explore this question.

It has been suggested that obesity and weight change could contribute to disability through their associations with chronic conditions or physical activity. Though we have shown that these chronic conditions and physical activity were significantly related to functional disability in this population (30), these potential confounders failed to explain the associations observed in this study. Our results suggest that other pathways also operate between obesity and disability.

The cross-sectional nature of the study makes it impossible for us to make causal inference, which needs to be further investigated in future prospective studies. However, it is likely that central obesity and late-adult weight change may both increase disability incidence and contribute to difficulty in disability rehabilitation. These results suggest that obesity, particularly abdominal fat accumulation as indicated by larger WC, and late-adult weight change may contribute to the high prevalence of disability seen among elderly Hispanics of Caribbean origin.


   Acknowledgments
 
This work was funded, in part, by the National Institute on Aging (Grant R01 AG10425) and by the U.S. Department of Agriculture, Agricultural Research Service (Agreement 58-1950-9-001).

Received December 15, 2000

Accepted February 14, 2001


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 Results
 Discussion
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D. R. Bouchard, S. Beliaeff, I. J. Dionne, and M. Brochu
Fat Mass But Not Fat-Free Mass Is Related to Physical Capacity in Well-Functioning Older Individuals: Nutrition as a Determinant of Successful Aging (NuAge) The Quebec Longitudinal Study
J. Gerontol. A Biol. Sci. Med. Sci., December 1, 2007; 62(12): 1382 - 1388.
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