Relationship of BMI, Waist Circumference, and Weight Change with Use of Health Services by Older Adults

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Objective: To examine the relationship of BMI, waist circumference (WC), and weight change with use of health care services by older adults.Research Methods and Procedures: This was a prospective cohort study conducted from 2001 to 2003 among 2919
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  Relationship of BMI, Waist Circumference, andWeight Change with Use of Health Services byOlder Adults  Luz M. Leo´n-Mun˜oz, Pilar Guallar-Castillo´n, Esther Lo´pez Garcı´a, Jose´ R. Banegas, Juan L. Gutie´rrez-Fisac,and Fernando Rodrı´guez-Artalejo Abstract LEO´N-MUN˜OZ, LUZ M., PILAR GUALLAR-CASTILLO´N, ESTHER LO´PEZ GARCI´A, JOSE´ R.BANEGAS, JUAN L. GUTIE´RREZ-FISAC, ANDFERNANDO RODRI´GUEZ-ARTALEJO. Relationship of BMI, waist circumference, and weight change with use of healthservicesbyolderadults. ObesRes. 2005;13:1398–1404. Objective:  To examine the relationship of BMI, waist cir-cumference (WC), and weight change with use of healthcare services by older adults.  Research Methods and Procedures:  This was a prospectivecohort study conducted from 2001 to 2003 among 2919persons representative of the non-institutionalized Spanishpopulation   60 years of age. Analyses were performedusing logistic regression, with adjustment for age, educa-tional level, size of place of residence, tobacco use, alcoholconsumption, and presence of chronic disease.  Results:  Obesity (BMI  30 kg/m 2 ) and abdominal obesity(WC  102 cm in men and  88 cm in women) in 2001 wereassociated with greater use of certain health care servicesamong men and women in the period 2001–2003. Com-pared with women with WC  88 cm, women with abdom-inal obesity were more likely to visit primary care physi-cians [odds ratio (OR): 1.36; 95% confidence limit (CL):1.06–1.73] and receive influenza vaccination (OR: 1.30;95% CL: 1.03–1.63). Weight gain was not associated withgreater health service use by either sex, regardless of base-line BMI. Weight loss was associated with greater healthservice use by obese and non-obese subjects of both sexes.In comparison with those who reported no important weightchange, non-obese women who lost weight were more likelyto visit hospital specialists (OR: 1.45; 95% CL: 1.02–2.06),receive home medical visits (OR: 1.61; 95% CL: 1.06–2.45),be hospitalized (OR: 1.88; 95% CL: 1.29–2.74), and havemore than one hospital admission (OR: 2.31; 95% CL: 1.19–4.47).  Discussion:  Obesity and weight loss are associated withgreater health service use among the elderly. Key words: BMI, waist circumference, weight change,health services use, elderly Introduction Obesity is associated with numerous chronic diseases,including hypertension, diabetes, coronary heart disease,cerebrovascular disease, certain forms of cancer, osteomus-cular disorders, and gallbladder disease (1,2). As a conse-quence, obesity is also associated with greater health serviceuse (3) and cost (4).The relationship between excess weight and health mightdiffer between the elderly and the young or middle-aged(5,6). However, information on the impact of obesity, mea-sured by BMI, on health service use by older adults is verysparse. Previous studies have been cross-sectional (7),which limits causal inference, have focused on a single typeof health care service (e.g., hospitalization) (8), or haveincluded only a small segment of the older adult population(e.g., subjects 50 to 69 years of age) (9).Obesity, and its abdominal distribution in particular, canalso be measured by waist circumference (WC), 1 which Received for review September 27, 2004.Accepted in final form May 17, 2005.The costs of publication of this article were defrayed, in part, by the payment of pagecharges. This article must, therefore, be hereby marked “advertisement” in accordance with18 U.S.C. Section 1734 solely to indicate this fact.Department of Preventive Medicine and Public Health, School of Medicine, UniversidadAuto´noma de Madrid, Madrid, Spain.Address correspondence to Fernando Rodrı´guez Artalejo, Departamento de Medicina Pre-ventiva y Salud Pu´blica, Facultad de Medicina, Universidad Auto´noma de Madrid, Avda.Arzobispo Morcillo, sn, 28029 Madrid, Spain.E-mail: fernando.artalejo@uam.esCopyright © 2005 NAASO 1 Nonstandard abbreviations: WC, waist circumference; CL, confidence limit; OR, oddsratio. 1398 OBESITY RESEARCH Vol. 13 No. 8 August 2005  seems to be a better predictor of morbidity and mortalitythan BMI, especially among the elderly (5,6). There is onlyone recent study on the relationship between WC and costof health care services (10). This study had a cross-sectionaldesign and included persons 18 to 84 years of age, withoutstratifying the results by age. In addition, it only calculatedhealth care service costs, without detailing the use of thedifferent types of services.Finally, changes in body weight are frequent among olderpersons (11–13). In addition, weight loss, which in manycases is the consequence of an underlying disease, is asso-ciated with worse quality of life and higher mortality in thispopulation group (14–16). To our knowledge, however, nostudy has yet addressed the impact of weight change onhealth service use.Therefore, this study examined prospectively the relation-ship of BMI, WC, and weight change with health service useamong the older adult population. These relationships areimportant because the impact of excess weight on health careservices provides additional information about the social bur-den of obesity, which is not measured when only the associa-tion between obesity and mortality/morbidity is contemplated. Research Methods and Procedures Study Design and Subjects This was a prospective, population-based cohort study.The cohort was established in 2001 and followed up over 2years, and was comprised of 4008 persons representative of the non-institutionalized Spanish population   60 years of age. Study subjects were selected through probabilistic mul-tistage cluster sampling. Census sections were selected atrandom and stratified by region of residence and size of town, followed by individual households where informationwas obtained from subjects. Data were collected on a totalof 420 census sections in Spain, with subjects being selectedin sex and age strata. Subjects were replaced after 10 failedvisits by the interviewer or because of subject’s incapacity,death, institutionalization, or refusal to participate. Therewas an overall study response rate of 71%. Data werecollected by home-based personal interview and physicalexamination by trained and certified personnel.In 2003, an attempt was made to contact the subjectsagain. Contact was successful in 3235 cases (80.7%). Thispopulation did not differ significantly in any sociodemo-graphic or lifestyle-related characteristic from those lost inthe follow-up, except for the number of chronic diseasesdiagnosed and reported in 2001 (1.4 diseases among peoplefollowed vs. 1.2 diseases among those lost). In 2003, datawere collected through a phone interview conducted bytrained staff. We have recent evidence in Spain showing thatphone interviews through computer-assisted technology arereliable and also valid against face-to-face interviews at thehome of the study participants to measure both lifestyle andhealth services use (17,18).In all cases, informed consent was obtained from subjectsor next of kin. The study was approved by the ClinicalResearch Ethics Committee of the “La Paz” UniversityTeaching Hospital in Madrid. Variables Use of health care services was assessed in 2003 with thefollowing questions regarding the preceding 2 years. Howoften did you visit your health center or primary caredoctor? How often did you visit your hospital specialist?How often did your doctor visit you at home? Did youreceive a vaccination against influenza during the last sea-son? Have you ever been admitted to the hospital? Howmany times have you been admitted to the hospital? Howlong did you spend in the hospital the last time you wereadmitted? How many times have you had surgery? Haveyou ever been admitted to the intensive care unit?The three main independent variables were BMI in 2001,WC in 2001, and weight change in the period 2001 to 2003.Body weight was measured to the nearest 0.1 kg using acalibrated precision scale (Seca Model 812; Vogel & Halke,Hamburg, Germany), with subjects lightly clothed and shoe-less. Stature was measured to the nearest 0.1 cm, using aportable wall-mounted stadiometer (KaWe, Asperg, Ger-many), with subjects standing in stockinged feet against awall that had no skirting board. WC was deemed to belocated at the midpoint between the lowest ribs and the iliaccrest (hip bone) and was measured using a plastic, inelastic,flexible belt-type tape, with subjects lightly clothed. An-thropometric measurements were obtained using standard-ized procedures (19) and were validated on a randomsample of 100 individuals. The intraclass correlation coef-ficients were 0.97 for weight; 0.92 for height; and 0.89 forWC. BMI was calculated as weight in kilograms divided bythe square of the height in meters, and subjects were clas-sified as normal weight (BMI    18.5 to 24.9 kg/m 2 ),overweight (BMI  25 to 29.9 kg/m 2 ), or obese (BMI  30kg/m 2 ). Abdominal obesity was defined as WC  102 cm inmen and  88 cm in women (2). Weight change was ascer-tained by asking subjects in 2003 whether they had noticedimportant changes in weight over the preceding 2 years.When the reply was affirmative, a second question wasasked—did the change involve weight gain or weight loss?We also collected baseline information on age (60 to 69,70 to 79, and   80 years), educational level (no formaleducation, primary, secondary, and higher education), sizeof place of residence (  5000, 5001 to 50,000, 50,001 to100,000, 100,001 to 500,000, and   500,000 inhabitants),tobacco use (never smoker, ex-smoker, and smoker), andalcohol consumption (non-drinker, past drinker, moderatedrinker, and heavy drinker). The limit between moderateand excessive alcohol consumption was 30 g/d in men and20 g/d in women. Finally, information was gathered onchronic diseases diagnosed by the physician and reported by Obesity, Weight Change, and Use of Health Services, Leo´n-Mun˜oz et al.OBESITY RESEARCH Vol. 13 No. 8 August 2005 1399  patients in 2001, as well as any new diseases diagnosed inthe period 2001 to 2003. The diseases considered wereosteoarthritis, hypertension, chronic obstructive pulmonarydisease, ischemic heart disease, cerebrovascular disease,cancer (any site), diabetes, cataracts without treatment, anddepression with need for treatment. Previous studies haveshown that the degree of agreement between self-reporteddiseases and medical history is high among the elderlypopulation (20,21). Statistical Analysis A total of 316 subjects were removed from the analysis:245 who died during the 2 years of follow-up; 53 who didnot furnish information on one or more of the health careservices studied; 13 with a BMI  18.5 kg/m 2 in 2001; and5 who failed to provide information on the remaining vari-ables of interest. Consequently, the analysis was performedusing a total of 2919 subjects.The relationship of BMI, WC, and weight change withhealth service use was summarized using odds ratios (ORs)obtained from logistic regression. These associations wereadjusted for age, educational level, size of place of resi-dence, tobacco use, and alcohol consumption. To ascertainwhether obesity-related diseases might explain the relation-ship between obesity and health service use, models weresubsequently adjusted for chronic diseases reported in 2001.The association between weight change and health serviceuse was stratified according to obesity in 2001 (BMI  30kg/m 2 ) and was adjusted for the above-mentioned variablesand for any new diseases reported in the period 2001 to2003. All variables were modeled using dummies. Healthcare service variables with several categories of frequency(e.g., number of visits to general practitioners, number of visits to hospital specialists) were dichotomized using acategory close to the median as a cut-off. The number of chronic diseases was modeled using three dummies for thefollowing four categories (0, 1, 2, and  3 diseases).Separate analyses were performed for men and women,using the SAS software, version 8.2 (22). Results The mean age of subjects at baseline was 70.7 years(range, 60 to 93 years) for men and 72.0 years (range, 60 to98 years) for women. A total of 53.0% of men and 42.5% of women were overweight, and 29.5% of men and 41.5%of women were obese. Abdominal obesity affected 47.1%of men and 73.2% of women. During the 2-year follow-up,16.1% of men reported weight gain and 11.0% reportedweight loss vs. 16.9% and 19.0% of women, respectively.Visiting the primary care physician was the most usedservice, with 69.1% of men and 72.9% of women reportinga visit at least once every 2 to 3 months. Other widely usedservices were influenza vaccination (64.8% in men and61.3% in women); visits to hospital specialists at least twiceper year (41.1% in men and 40.4% in women); emergencyservices at least once per year (32.8% in men and 39.8% inwomen); hospital admission at least once per year (27.9% inmen and 25.0% in women); and home medical visit at leastonce per year (14.3% in men and 20.8% in women). Inaddition, 9.3% of men were admitted to the hospital morethan once, with stays  6 days in 17.4% of the admissions,3.5% underwent more than one operation, and 4.5% wereadmitted to the intensive care unit. In women, the respectivepercentages were 8.4%, 15.3%, 3.6%, and 2.1%.Table 1 shows the relationship among BMI, WC, andhealth service use, adjusted for the main confounders. Over-weight men (BMI    25 to 29.9 kg/m 2 ) were less likely toreceive home medical visits than normal weight subjects.However, obese men (BMI  30 kg/m 2 ) were more likelyto be hospitalized for   6 days and to be admitted to theintensive care unit. Furthermore, men with abdominal obe-sity were more likely to visit the primary care physician andto be hospitalized for   6 days. In women, not only wasobesity positively associated with visits to primary carephysicians, but, in addition, a greater proportion of womenwith abdominal obesity also visited primary care physiciansand received an influenza vaccination. While adjustment forchronic diseases somewhat reduced the magnitude of theOR in both sexes, the associations remained statisticallysignificant (data not shown), with the following exceptions.In women, the significance of the association between obe-sity and visits to primary care physicians was lost [OR:1.18; 95% confidence limit (CL): 0.84 to 1.64], as well asbetween abdominal obesity and this same service (OR:1.18; 95% CL: 0.92 to 1.52) and influenza vaccination (OR:1.21; 95% CL: 0.96 to 1.52); however, adjustment forchronic diseases showed that a lower proportion of obesewomen underwent more than one operation (OR: 0.49; 95%CL: 0.26 to 0.96).Table 2 shows the relationship between weight change andhealth service use adjusted for the main confounders andstratified by BMI. Weight gain was not associated with greaterhealthserviceuseineithersex,regardlessofbaselineBMI.Weonly observed that a lower proportion of those who gainedweight visited the primary care physician a minimum of onceevery 2 to 3 months compared with obese men.In comparison with those who reported no importantweight change, non-obese men who lost weight were morelikely to visit hospital specialists and to be hospitalizedmore than once. Among obese men, those who lost weightwere more likely to receive home medical visits, make useof emergency services, be hospitalized, and be admitted tothe intensive care unit (Table 2).In comparison with those who reported no importantweight change, non-obese women who lost weight weremore likely to visit hospital specialists, receive home med-ical visits, be hospitalized, and have more than one hospitaladmission. Among obese women, those who lost weight Obesity, Weight Change, and Use of Health Services, Leo´n-Mun˜oz et al.1400 OBESITY RESEARCH Vol. 13 No. 8 August 2005  Table 1.  OR of use of health care services by BMI and abdominal obesity in men and women BMI Abdominal obesity18.5 to 24.9 kg/m 2 25 to 29.9 kg/m 2 > 30 kg/m 2 No YesOR OR (95% CL) OR (95% CL) OR OR (95% CL) Men ( n  219) ( n  664) ( n  369) ( n  662) ( n  590)Visit to primary care physician 1 0.91 (0.65 to 1.28) 1.35 (0.92 to 1.97) 1 1.28 (1.02 to 1.62)*Hospital specialist 1 0.86 (0.63 to 1.18) 0.93 (0.66 to 1.32) 1 1.03 (0.82 to 1.30)Home medical visits 1 0.55 (0.35 to 0.85)† 0.98 (0.61 to 1.57) 1 1.10 (0.78 to 1.55)Emergency services 1 0.74 (0.53 to 1.03) 1.10 (0.77 to 1.57) 1 1.14 (0.89 to 1.45)Influenza vaccination 1 1.09 (0.78 to 1.51) 1.31 (0.91 to 1.89) 1 1.26 (0.98 to 1.61)Hospital admission 1 1.01 (0.71 to 1.43) 1.33 (0.91 to 1.96) 1 1.05 (0.81 to 1.35)More than one hospital admission 1 1.48 (0.74 to 2.96) 0.87 (0.41 to 1.86) 1 1.17 (0.71 to 1.92)Duration of hospital stay  6 days 1 1.15 (0.62 to 2.16) 2.41 (1.19 to 4.86)* 1 2.17 (1.33 to 3.54)†More than one surgical intervention 1 0.77 (0.31 to 1.93) 0.96 (0.37 to 2.51) 1 1.23 (0.61 to 2.47)Admission to intensive care unit 1 1.65 (0.62 to 4.45) 2.74 (1.01 to 7.64)* 1 1.10 (0.59 to 2.05)Women ( n  266) ( n  709) ( n  692) ( n  447) ( n  1220)Visit to primary care physician 1 1.27 (0.93 to 1.74) 1.43 (1.04 to 1.98)* 1 1.36 (1.06 to 1.73)*Hospital specialist 1 1.21 (0.90 to 1.63) 1.17 (0.86 to 1.58) 1 1.05 (0.84 to 1.32)Home medical visits 1 1.08 (0.75 to 1.56) 1.21 (0.83 to 1.76) 1 1.08 (0.81 to 1.44)Emergency services 1 0.90 (0.67 to 1.21) 1.06 (0.79 to 1.43) 1 0.95 (0.76 to 1.19)Influenza vaccination 1 1.10 (0.82 to 1.48) 1.19 (0.88 to 1.61) 1 1.30 (1.03 to 1.63)*Hospital admission 1 1.04 (0.74 to 1.46) 1.31 (0.93 to 1.85) 1 1.20 (0.92 to 1.56)More than one hospital admission 1 1.05 (0.56 to 1.99) 1.03 (0.54 to 1.97) 1 0.84 (0.52 to 1.37)Duration of hospital stay  6 days 1 0.84 (0.45 to 1.59) 0.74 (0.39 to 1.40) 1 0.89 (0.55 to 1.44)More than one surgical intervention 1 0.90 (0.35 to 2.29) 1.00 (0.40 to 2.50) 1 0.56 (0.30 to 1.07)Admission to intensive care unit 1 0.46 (0.16 to 1.36) 0.78 (0.28 to 2.14) 1 1.16 (0.48 to 2.82) Model adjusted for age, educational level, size of place of residence, tobacco use, and alcohol consumption.For abdominal obesity, WC  102 cm in men and  88 cm in women.*  p  0.05; †  p  0.01.  O b  e s i   t    y  ,W ei     gh t   C h  an  g e , an d  U s  e of   H e al   t  h  S  er  v i    c e s  ,L  e o´   n-M un˜    oz  et   al   . OB E  S I   T Y R E  S E A R  C HV  ol   .1  3 N o. 8 A  u  g u s t  2  0  0  5 1 4  0 1   Table 2.  OR of use of health care services by weight change, according to baseline BMI in men and women Weight gain Weight lossBMI < 30 kg/m 2 OR (95% CL)BMI  > 30 kg/m 2 OR (95% CL)BMI < 30 kg/m 2 OR (95% CL)BMI  > 30 kg/m 2 OR (95% CL) Men ( n  123) ( n  78) ( n  97) ( n  41)Visit to primary care physician 0.92 (0.59 to 1.43) 0.44 (0.23 to 0.82)† 1.00 (0.61 to 1.64) 1.59 (0.51 to 4.98)Hospital specialist 1.00 (0.65 to 1.50) 1.73 (0.99 to 3.04) 2.08 (1.32 to 3.28)† 0.89 (0.43 to 1.86)Home medical visits 0.62 (0.32 to 1.21) 1.73 (0.75 to 3.95) 1.22 (0.68 to 2.20) 3.14 (1.27 to 7.77)*Emergency services 0.95 (0.61 to 1.47) 1.62 (0.91 to 2.86) 1.27 (0.80 to 2.03) 2.40 (1.15 to 5.01)*Influenza vaccination 1.45 (0.93 to 2.25) 1.26 (0.70 to 2.28) 1.10 (0.68 to 1.78) 1.90 (0.80 to 4.55)Hospital admission 0.75 (0.46 to 1.21) 1.73 (0.95 to 3.15) 1.48 (0.92 to 2.38) 3.22 (1.52 to 6.82)†More than one hospital admission 0.69 (0.26 to 1.82) 0.68 (0.16 to 2.88) 2.97 (1.27 to 6.94)* 3.39 (0.87 to 13.13)Duration of hospital stay  6 days 0.80 (0.34 to 1.89) 0.46 (0.11 to 1.95) 1.60 (0.70 to 3.67) 2.34 (0.50 to 10.98)More than one surgical intervention 1.13 (0.30 to 4.34) NE 2.32 (0.75 to 7.23) 0.85 (0.15 to 4.78)Admission to intensive care unit 1.13 (0.32 to 4.03) 0.37 (0.05 to 2.91) 1.03 (0.34 to 3.13) 16.42 (3.37 to 79.92)‡Women ( n  143) ( n  138) ( n  181) ( n  136)Visit to primary care physician 1.01 (0.65 to 1.56) 1.56 (0.91 to 2.66) 0.96 (0.65 to 1.42) 0.98 (0.61 to 1.57)Hospital specialist 1.05 (0.71 to 1.55) 1.22 (0.81 to 1.84) 1.45 (1.02 to 2.06)* 1.79 (1.17 to 2.72)†Home medical visits 1.16 (0.69 to 1.96) 0.98 (0.57 to 1.70) 1.61 (1.06 to 2.45)* 1.64 (1.02 to 2.63)*Emergency services 1.36 (0.92 to 2.00) 1.14 (0.76 to 1.72) 1.15 (0.81 to 1.63) 1.44 (0.95 to 2.18)Influenza vaccination 0.87 (0.59 to 1.29) 1.02 (0.67 to 1.56) 0.87 (0.61 to 1.25) 0.98 (0.64 to 1.50)Hospital admission 1.31 (0.84 to 2.05) 1.15 (0.73 to 1.83) 1.88 (1.29 to 2.74)† 1.74 (1.12 to 2.69)*More than one hospital admission 1.92 (0.83 to 4.44) 1.56 (0.65 to 3.76) 2.31 (1.19 to 4.47)* 1.31 (0.59 to 2.88)Duration of hospital stay  6 days 0.54 (0.24 to 1.23) 1.15 (0.50 to 2.64) 0.88 (0.45 to 1.75) 1.37 (0.65 to 2.89)More than one surgical intervention 2.34 (0.80 to 6.81) 2.19 (0.80 to 5.98) 1.20 (0.43 to 3.37) 0.78 (0.26 to 2.37)Admission to intensive care unit 1.30 (0.31 to 5.41) 1.12 (0.33 to 3.88) 0.83 (0.23 to 2.94) 0.65 (0.18 to 2.41) Reference category in the analysis: subjects who reported no important weight change. Model adjusted for age, educational level, size of place of residence, tobacco use, alcoholconsumption, number of diseases at start of follow-up, and number of diseases diagnosed during follow-up.*  p  0.05; †  p  0.01; ‡  p  0.001.NE, not possible to estimate.  O b  e s i   t    y  ,W ei     gh t   C h  an  g e , an d  U s  e of   H e al   t  h  S  er  v i    c e s  ,L  e o´   n-M un˜    oz  et   al   .1 4  0 2  OB E  S I   T Y R E  S E A R  C HV  ol   .1  3 N o. 8 A  u  g u s t  2  0  0  5 
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