Changes in weight at the end of life: characterizing weight loss by time to death in a cohort study of older men

The changing relationship between bodyweight and longevity in high- and low-income countries

Standard measures of bodyweight (overweight and obese, for example) fail to reflect differences across populations and technological progress over time. This paper builds on the pioneering work of Hans Waaler (1984) and Robert Fogel (1994) to empirically estimate how the relationship between body mass index (BMI) and longevity varies across high-, middle-, and low-income countries. Importantly, we show that these differences are so profound that the share of national populations above mortality-minimizing bodyweight is not clearly greater in countries with higher overweight and obesity rates (as traditionally defined)-and in fact, relative to current standards, a larger share of low-income countries' populations can be unhealthily heavy.

Blood biomarker profiles and exceptional longevity: comparison of centenarians and non-centenarians in a 35-year follow-up of the Swedish AMORIS cohort

Comparing biomarker profiles measured at similar ages, but earlier in life, among exceptionally long-lived individuals and their shorter-lived peers can improve our understanding of aging processes. This study aimed to (i) describe and compare biomarker profiles at similar ages between 64 and 99 among individuals eventually becoming centenarians and their shorter-lived peers, (ii) investigate the association between specific biomarker values and the chance of reaching age 100, and (iii) examine to what extent centenarians have homogenous biomarker profiles earlier in life. Participants in the population-based AMORIS cohort with information on blood-based biomarkers measured during 1985-1996 were followed in Swedish register data for up to 35 years. We examined biomarkers of metabolism, inflammation, liver, renal, anemia, and nutritional status using descriptive statistics, logistic regression, and cluster analysis. In total, 1224 participants (84.6% females) lived to their 100th birthday. Higher levels of total cholesterol and iron and lower levels of glucose, creatinine, uric acid, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, lactate dehydrogenase, and total iron-binding capacity were associated with reaching 100 years. Centenarians overall displayed rather homogenous biomarker profiles. Already from age 65 and onwards, centenarians displayed more favorable biomarker values in commonly available biomarkers than individuals dying before age 100. The differences in biomarker values between centenarians and non-centenarians more than one decade prior death suggest that genetic and/or possibly modifiable lifestyle factors reflected in these biomarker levels may play an important role for exceptional longevity.

Association of changes in waist circumference, waist-to-height ratio and weight-adjusted-waist index with multimorbidity among older Chinese adults: results from the Chinese longitudinal healthy longevity survey (CLHLS)

BACKGROUND

The association of changes in waist circumference (WC), waist-to-height ratio (WHtR) and weight-adjusted-waist index (WWI) with subsequent risk of multimorbidity remains unclear among older Chinese adults. Therefore, we aimed to assess this association by utilizing data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS).

METHODS

Our study was based on the 2011/2012 wave of the CLHLS whose follow-up surveys were conducted in 2014 and 2017/2018. A total of 2900 participants aged 65 and above at baseline were enrolled. WC, WHtR, and WWI were calculated from measured height, weight, and waist circumference. Multimorbidity refers to the coexistence of two or more of 18 chronic diseases. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95%CIs) to evaluate the effect of three-year changes in WC, WHtR, and WWI on the risk of multimorbidity.

RESULTS

During a mean follow-up time of 4.2 (2.0) years, 906 multimorbidity cases were identified. Compared to participants in the persistently low WC group, those in the WC gain group and the persistently high WC group had a higher multimorbidity risk with adjusted HRs (95%CI) of 1.23 (1.01-1.50) and 1.34(1.14-1.58), respectively. Participants in the WHtR gain group and the persistently high WHtR group also had higher risks of multimorbidity with HRs (95%CI) of 1.35 (1.08-1.67) and 1.27 (1.05-1.53), respectively, relative to the persistently low WHtR group. Compared to the persistently low WWI group, those in the WWI loss group had a lower risk of multimorbidity with HRs (95%CI) of 0.80 (0.66-0.98). For every standard deviation increase in WC, WHtR, and WWI over three years, the risk of multimorbidity was higher by 12% (95%CI: 1.05-1.19), 13% (95%CI: 1.06-1.20), and 12% (95%CI: 1.05-1.20), respectively.

CONCLUSIONS

Associations of changes in WC, WHtR and WWI with multimorbidity are significant among older Chinese adults. The findings highlight the importance of evaluating changes in WC, WHtR, and WWI in screening and prevention of multimorbidity in older adults.

Terminal Decline in Physical Function in Older Adults

BACKGROUND

It is currently unclear whether (and when) physical function exhibits a terminal decline phase, that is, a substantial acceleration of decline in the very last years before death.

METHODS

702 deceased adults aged 70 years and older from the Yale PEP Study provided 4 133 measurements of physical function (Short Physical Performance Battery, SPPB) up to 20 years before death. In addition, continuous gait and chair rise subtest scores (in seconds) were assessed. Generalized mixed regression models with random change points were used to estimate the onset and the steepness of terminal decline in physical function.

RESULTS

Decline accelerated in the last years of life in all 3 measures of physical function. The onset of terminal decline occurred 1 year before death for the SPPB, and at 2.5 and 2.6 years before death for chair rise and gait speed test scores, respectively. Terminal declines in physical function were 6-8 times steeper than pre-terminal declines. Relative to those whose condition leading to death was frailty, participants who died from dementia and cancer had an up to 6 months earlier and 3 months later onset of terminal decline in SPPB, respectively.

CONCLUSIONS

Terminal decline in physical function among older adults is comparable to the more established terminal decline phenomenon in cognition. Our results provide additional evidence of late-life rapid decline in physical function due to impending death.

Associations Between Mid- to Late-Life Body Mass Index and Chronic Disease-Free Survival: A Nationwide Twin Study

BACKGROUND

Some studies have linked late-life overweight to a reduced mortality risk compared to normal body mass index (BMI). However, the impact of late-life overweight and its combination with mid-life BMI status on healthy survival remains unclear. We aimed to investigate whether and to what extent mid- and/or late-life overweight are associated with chronic disease-free survival.

METHODS

Within the Swedish Twin Registry, 11 597 chronic disease-free twins aged 60-79 years at baseline were followed up for 18 years. BMI (kg/m2) was recorded at baseline and 25-35 years before baseline (ie, midlife) and divided as underweight (<20), normal (≥20-25), overweight (≥25-30), and obese (≥30). Incident chronic diseases (cardiovascular diseases, type 2 diabetes, and cancer) and deaths were ascertained via registries. Chronic disease-free survival was defined as years lived until the occurrence of any chronic diseases or death. Data were analyzed using multistate survival analysis.

RESULTS

Of all participants, 5 640 (48.6%) were overweight/obese at baseline. During the follow-up, 8 772 (75.6%) participants developed at least 1 chronic disease or died. Compared to normal BMI, late-life overweight and obesity were associated with 1.1 (95% CI, 0.3, 2.0) and 2.6 (1.6, 3.5) years shorter chronic disease-free survival. Compared to normal BMI through mid- to late life, consistent overweight/obesity and overweight/obesity only in mid-life led to 2.2 (1.0, 3.4) and 2.6 (0.7, 4.4) years shorter disease-free survival, respectively.

CONCLUSIONS

Late-life overweight and obesity may shorten disease-free survival. Further research is needed to determine whether preventing overweight/obesity from mid- to late life might favor longer and healthier survival.

Association of Later-Life Weight Changes With Survival to Ages 90, 95, and 100: The Women's Health Initiative

BACKGROUND

Associations of weight changes and intentionality of weight loss with longevity are not well described.

METHODS

Using longitudinal data from the Women's Health Initiative (N = 54 437; 61-81 years), we examined associations of weight changes and intentionality of weight loss with survival to ages 90, 95, and 100. Weight was measured at baseline, year 3, and year 10, and participants were classified as having weight loss (≥5% decrease from baseline), weight gain (≥5% increase from baseline), or stable weight (<5% change from baseline). Participants reported intentionality of weight loss at year 3.

RESULTS

A total of 30 647 (56.3%) women survived to ≥90 years. After adjustment for relevant covariates, 3-year weight loss of ≥5% vs stable weight was associated with lower odds of survival to ages 90 (OR, 0.67; 95% CI, 0.64-0.71), 95 (OR, 0.65; 95% CI, 0.60-0.71), and 100 (OR, 0.62; 95% CI, 0.49-0.78). Compared to intentional weight loss, unintentional weight loss was more strongly associated with lower odds of survival to age 90 (OR, 0.83; 95% CI, 0.74-0.94 and OR, 0.49; 95% CI, 0.44-0.55, respectively). Three-year weight gain of ≥5% vs stable weight was not associated with survival to age 90, 95, or 100. The pattern of results was similar among normal weight, overweight, and obese women in body mass index (BMI)-stratified analyses.

CONCLUSIONS

Weight loss of ≥5% vs stable weight was associated with lower odds of longevity, more strongly for unintentional weight loss than for intentional weight loss. Potential inaccuracy of self-reported intentionality of weight loss and residual confounding were limitations.

Trends in Obesity Prevalence among US Older Adults in the Last Two Years of Life, 1998-2018

CONTEXT

The prevalence of obesity has grown in the US over the decades. The temporal trends of body mass index categories in the last two years of life are poorly understood.

OBJECTIVES

To describe the trends in body mass categories in the last two years of life over the past two decades controlling for other demographic changes.

METHODS

We performed a cross-sectional study of prospectively collected survey data from the nationally representative Health and Retirement Study (HRS) among decedents who died between 1998 and 2018. We categorized BMI into five categories and calculated the proportion of decedents with each BMI category during each four epochs (1998-2003, 2004-2008, 2009-2013, 2014-2018). We examined trends in regression models with survey wave groupings modeled as an orthogonal polynomial and adjusted for factors commonly associated with BMI: sex, age, race, ethnicity, education, and tobacco use.

RESULTS

The analytic cohort included 14,797 decedents. From 1998-2003 to 2014-2018 time periods, those categorized as having mild-to-moderate obesity in the last two years of life increased from 12.4% to 14.8% (linear trend P < 0.001), a 19% increase. Severe obesity increased from 1.9% to 4.3%, a 126% increase (linear trend P < 0.001). Underweight decreased from 9.9% to 5.9%, a 40% decrease (linear trend P < 0.001), adjusted for demographic factors. Adjusted quadratic temporal trends for BMI category were nonsignificant, except for in mild-to-moderate obesity.

CONCLUSION

Severe obesity has increased greatly while underweight has decreased. As obesity increases in the final years of life, it is critical to assess how the existing and future palliative services and end of life care system address body size and weight.

Association of Obesity With Cognitive Decline in Black and White Americans

BACKGROUND AND OBJECTIVES

There are disparities in the prevalence of obesity by race, and the relationship between obesity and cognitive decline is unclear. The objective of this study was to determine whether obesity is independently associated with cognitive decline and whether the association between obesity and cognitive decline differs in Black and White adults. We hypothesized that obesity is associated with greater cognitive decline compared with normal weight and that the effect of obesity on cognitive decline is more pronounced in Black adults compared with their White counterparts.

METHODS

We pooled data from 28,867 participants free of stroke and dementia (mean, SD: age 61 [10.7] years at the first cognitive assessment, 55% female, 24% Black, and 29% obese) from 6 cohorts. The primary outcome was the annual change in global cognition. We performed linear mixed-effects models with and without time-varying cumulative mean systolic blood pressure (SBP) and fasting plasma glucose (FPG). Global cognition was set to a t-score metric (mean 50, SD 10) at a participant's first cognitive assessment; a 1-point difference represents a 0.1 SD difference in global cognition across the 6 cohorts. The median follow-up was 6.5 years (25th percentile, 75th percentile: 5.03, 20.15).

RESULTS

Obese participants had lower baseline global cognition than normal-weight participants (difference in intercepts, -0.36 [95% CI, -0.46 to -0.17]; p < 0.001). This difference in baseline global cognition was attenuated but was borderline significant after accounting for SBP and FPG (adjusted differences in intercepts, -0.19 [95% CI, -0.39 to 0.002]; p = 0.05). There was no difference in the rate of decline in global cognition between obese and normal-weight participants (difference in slope, 0.009 points/year [95% CI, -0.009 to 0.03]; p = 0.32). After accounting for SBP and FPG, obese participants had a slower decline in global cognition (adjusted difference in slope, 0.03 points/year slower [95% CI, 0.01 to 0.05]; p < 0.001). There was no evidence that race modified the association between body mass index and global cognitive decline (p = 0.34).

DISCUSSION

These results suggest that obesity is associated with lower initial cognitive scores and may potentially attenuate declines in cognition after accounting for BP and FPG.

Body Mass Index Trajectories Preceding Incident Mild Cognitive Impairment and Dementia

Importance

Body mass index (BMI) trajectories before the onset of mild cognitive impairment (MCI) and during the progression from MCI to dementia remain unclear.

Objective

To assess the long-term BMI trajectories preceding incident MCI and dementia and explore whether they are associated with brain pathologies.

Design, Setting, and Participants

The Rush Memory and Aging Project (MAP) was an ongoing community-based cohort study. This study included cognitively intact participants aged 60 to 90 years at baseline with annual follow-up from October 1997 to December 2020 (maximum follow-up of 22 years). During the follow-up, participants underwent brain autopsies. Data were analyzed from August 2021 to February 2022 using mixed-effect models.

Exposures

BMI was calculated using height and weight measured at baseline and follow-ups.

Main Outcomes and Measures

Incident MCI and dementia were diagnosed following standard criteria. Neuropathological assessments (including global Alzheimer disease and vascular pathology) were performed for autopsies.

Results

A total of 1390 participants (mean [SD] age, 78.4 [6.5] years; 1063 female [76.5%]) were included in the study. In the analysis of BMI trajectories before MCI (n = 939), during the follow-up (median [IQR] duration, 6 [3-9] years), 371 participants (39.5%) developed MCI, of whom 88 (23.7%) progressed to dementia. Those who developed MCI were older (mean [SD] age, 79.6 [5.9] years vs 76.9 [6.6] years), consumed less alcohol (median [IQR] consumption, 0 [0-5.8] g/day vs 1.1 [0-6.9] g/day), had a lower BMI (mean [SD], 27.2 [4.9] vs 28.2 [5.9]), and were more likely to be apolipoprotein E (APOE) ε4 carriers (89 of 371 [24.0%] vs 98 of 568 [17.3%]) compared with those who remained cognitively intact over follow-up. Those who developed dementia were older (mean [SD] age, 81.0 [5.2] years vs 79.1 [6.0] years), had a lower level of physical activity (median [IQR] activity, 1.0 [0-2.5] h/week vs 1.8 [0.2-3.8] h/week), and were more likely to be APOE ε4 carriers than those who were dementia-free (33 of 88 [37.5%] vs 56 of 283 [19.8%]). Compared with participants who remained cognitively intact, in those with incident MCI, BMI tended to decline earlier and faster. From 7 years before diagnosis, people with incident MCI had an associated significantly lower BMI (mean difference, -0.96; 95% CI, -1.85 to -0.07) than those who were cognitively intact. Among people with incident MCI, the slopes of BMI decline did not differ significantly between those who did and did not develop dementia (β, -0.03; 95% CI, -0.21 to 0.15). In the analysis of BMI trajectories before autopsy (n = 358), BMI was associated with a faster declination among participants with a high burden of global Alzheimer disease pathology (β for pathology × time highest vs lowest tertile, -0.14; 95% CI, -0.26 to -0.02) or vascular pathology (β for pathology × time2 highest vs lowest tertile, 0.02; 95% CI, 0-0.05).

Conclusions and Relevance

Results of this cohort study suggest that among cognitively intact people, significantly lower BMI occurs beginning approximately 7 years before MCI diagnosis. After MCI diagnosis, BMI declines at the same pace in people who develop dementia and those who do not. High brain pathologies may underly the BMI decline preceding dementing disorders.

Emergence of heartbeat frailty in advanced age I: perspectives from life-long EKG recordings in adult mice

The combined influences of sinoatrial nodal (SAN) pacemaker cell automaticity and its response to autonomic input determine the heart's beating interval variability and mean beating rate. To determine the intrinsic SAN and autonomic signatures buried within EKG RR interval time series change in advanced age, we measured RR interval variability before and during double autonomic blockade at 3-month intervals from 6 months of age until the end of life in long-lived (those that achieved the total cohort median life span of 24 months and beyond) C57/BL6 mice. Prior to 21 months of age, time-dependent changes in intrinsic RR interval variability and mean RR interval were relatively minor. Between 21 and 30 months of age, however, marked changes emerged in intrinsic SAN RR interval variability signatures, pointing to a reduction in the kinetics of pacemaker clock mechanisms, leading to reduced synchronization of molecular functions within and among SAN cells. This loss of high-frequency signal processing within intrinsic SAN signatures resulted in a marked increase in the mean intrinsic RR interval. The impact of autonomic signatures on RR interval variability were net sympathetic and partially compensated for the reduced kinetics of the intrinsic SAN RR interval variability signatures, and partially, but not completely, shifted the EKG RR time series intervals to a more youthful pattern. Cross-sectional analyses of other subsets of C57/BL6 ages indicated that at or beyond the median life span of our longitudinal cohort, noncardiac, constitutional, whole-body frailty was increased, energetic efficiency was reduced, and the respiratory exchange ratio increased. We interpret the progressive reduction in kinetics in intrinsic SAN RR interval variability signatures in this context of whole-body frailty beyond 21 months of age to be a manifestation of "heartbeat frailty."

How does it all end? Trends and disparities in health at the end of life

OBJECTIVES

To consider trends and disparities in end-of-life health in the US.

METHODS

I use data from the National Health Interview Survey, linked to death records through 2015, for respondents who died at ages 65+ to compare the prevalence of three health outcomes in the last six years of life across time, sex, age, race, and educational attainment. Self-rated health (SRH) is available for respondents interviewed in years 1987-2014, while information on activities of daily living (ADL) and instrumental activities of daily living (IADL) is available for the period 1997-2014.

RESULTS

By the end of the study period, individuals reported two fewer months of fair/poor health at the end of life than those dying in earlier years. In contrast, time lived with at least one activity limitation at the end of life generally remained comparable. Compared to men, women on average reported an additional year of living with an IADL limitation before death, and an additional eight months with an ADL limitation. Despite sex differences in disability, both sexes reported similar periods of fair/poor SRH before death. Similarly, while individuals who lived to older ages experienced a longer disabled period before death than individuals who died at younger ages, all age groups were equally likely to report fair/poor SRH. Black adults and adults with less formal schooling also spent more time with an end-of-life disability. For men, these racial and socioeconomic disparities lessened as death approached. For women, inequalities persisted until death.

DISCUSSION

These findings suggest that despite increasing life expectancy, the period of poor health and disability prior to death has not recently been extended. Black women and women with less than a high school degree, require extended support at the end of life.

Trajectories of cognitive change following stroke: stepwise decline towards dementia in the elderly

Stroke events increase the risk of developing dementia, 10% for a first-ever stroke and 30% for recurrent strokes. However, the effects of stroke on global cognition, leading up to dementia, remain poorly understood. We investigated: (i) post-stroke trajectories of cognitive change, (ii) trajectories of cognitive decline in those who develop dementia over periods of follow-up length and (iii) risk factors precipitating the onset of dementia. Prospective cohort of hospital-based stroke survivors in North-East England was followed for up to 12 years. In this study, we included 355 stroke survivors of ≥75 years of age, not demented 3 months post-stroke, who had had annual assessments during follow-up. Global cognition was measured annually and characterized using standardized tests: Cambridge Cognition Examination-Revised and Mini-Mental State Examination. Demographic data and risk factors were recorded at baseline. Mixed-effects models were used to study trajectories in global cognition, and logistic models to test associations between the onset of dementia and key risk factors, adjusted for age and sex. Of the 355 participants, 91 (25.6%) developed dementia during follow-up. The dementia group had a sharper decline in Cambridge Cognition Examination-Revised (coeff. = -1.91, 95% confidence interval = -2.23 to -1.59, P < 0.01) and Mini-Mental State Examination (coeff. = -0.46, 95% confidence interval = -0.58 to -0.34, P < 0.01) scores during follow-up. Stroke survivors who developed dementia within 3 years after stroke showed a steep decline in global cognition. However, a period of cognitive stability after stroke lasting 3 years was identified for individuals diagnosed with dementia in 4-6 years (coeff. = 0.28, 95% confidence interval = -3.28 to 3.8, P = 0.88) of 4 years when diagnosed at 7-9 years (coeff. = -3.00, 95% confidence interval = -6.45 to 0.45, P = 0.09); and of 6 years when diagnosed at 10-12 years (coeff. = -6.50, 95% confidence interval = -13.27 to 0.27, P = 0.06). These groups then showed a steep decline in Cambridge Cognition Examination-Revised in the 3 years prior to diagnosis of dementia. Risk factors for dementia within 3 years include recurrent stroke (odds ratio = 3.99, 95% confidence interval = 1.30-12.25, P = 0.016) and previous disabling stroke, total number of risk factors for dementia (odds ratio = 2.02, 95% confidence interval = 1.26-3.25, P = 0.004) and a Cambridge Cognition Examination-Revised score below 80 at baseline (odds ratio = 3.50, 95% confidence interval = 1.29-9.49, P = 0.014). Our unique longitudinal study showed cognitive decline following stroke occurs in two stages, a period of cognitive stability followed by rapid decline before a diagnosis of dementia. This pattern suggests stroke may predispose survivors for dementia by diminishing cognitive reserve but with a smaller impact on cognitive function, where cognitive decline may be precipitated by subsequent events, e.g. another cerebrovascular event. This supports the assertion that the development of vascular dementia can be stepwise even when patients have small stroke lesions.

Long-term body weight change assessed by non-contact load cells under the bed in older people with and without eating assistance: a preliminary study

Utilizing automatic daily body weight (BW) measurements may be helpful for assessing nutritional status and detecting underlying diseases particularly in older people who require nursing care. This preliminary study aimed to verify effectiveness of eating assistance for maintaining BW in older people using a contact-free load cells under the bed (Bed Sensor System: BSS). BW was measured every night for 3 months in eight nursing home older people with severe cognitive and physical dysfunctions. Body composition of the subject's trunk and each limb was measured using a segmented multi-frequency bioelectrical impedance analyzer (BIA). A monthly BW loss was estimated as a slope of linear regression of the daily BW plot. BSS successfully measured daily BW for the study period in all participants. The 4 residents with eating assistance gained slightly more weight, while the 4 residents without eating assistance lost weight. There was a significant difference between the two groups in the monthly BW change (- 0.79 ± 0.51 kg/month versus 0.20 ± 0.49 kg/month, P = 0.030). None of the BIA-derived parameters was associated with the monthly BW change. BSS revealed effectiveness of eating assistance to maintain BW in nursing home residents with severe cognitive and physical dysfunctions.

Long-term weight loss as a predictor of mortality in haemodialysis patients

BACKGROUND

Serial weight decrease can be a prognostic predictor in chronic haemodialysis (HD) patients. We investigated the impact of long-term post-HD body weight (BW) changes on all-cause mortality among HD patients.

METHODS

This longitudinal cohort study and post-hoc analysis evaluated participants of a previous randomised controlled trial conducted between 2006 and 2011 who were followed up until 2018. Weight change slopes were generated with repeated measurements every 6 months during the trial for patients having ≥5 BW measurements. Participants were categorised into four groups based on quartiles of weight change slopes; the median weight changes per 6 months were -1.02 kg, -0.25 kg, +0.26 kg, and +0.86 kg. Cox proportional hazard regression was used to evaluate differences in subsequent survival among the four groups. BW trajectories were plotted with a backward time-scale and multilevel regression analysis to visualise the difference in BW trajectories between survivors and non-survivors.

RESULTS

Among the 461 patients, 404 were evaluated, and 168 (41.6%) died within a median follow-up period of 10.2 years. The Cox proportional hazard regression adjusted for covariates and baseline BW showed that a higher rate of weight loss was associated with higher mortality. The hazard ratios were 2.02 (1.28-3.20), 1.77 (1.10-2.85), 1.00 (reference), and 1.11 (0.67-1.83) for the first, second, third (reference), and fourth quartiles, respectively. BW trajectories revealed a significant decrease in BW in non-survivors.

CONCLUSIONS

Weight loss elucidated by serial BW measurements every 6 months is significantly associated with higher mortality among HD patients.

Annual Body Weight Change and Prognosis in Chronic Obstructive Pulmonary Disease

Purpose

Low body mass index (BMI) has been reported to be associated with poor prognosis in patients with chronic obstructive pulmonary disease (COPD). In contrast, a detailed analysis of the association between body weight change over time and prognosis is not sufficient, particularly in Japanese patients with COPD who have been reported to be much thinner compared to Westerners. This study aimed to investigate the relationship between annual body weight change and long-term prognosis in Japanese patients with COPD in two independent cohorts.

Patients and Methods

We analyzed 279 patients with COPD who participated in the Hokkaido COPD cohort study as a discovery cohort. We divided participants into three groups according to quartiles of annual body weight change calculated by the data from the first 5 years: weight loss group (<-0.17 kg/year), no change group (−0.17 to ≤0.20 kg/year), and weight gain group (>0.20 kg/year). The association between annual body weight change and prognosis was replicated in the Kyoto University cohort (n = 247).

Results

In the Hokkaido COPD cohort study, the weight loss group had significantly worse mortality than the other groups, whereas there was no difference in BMI at baseline. In the multivariate analysis, annual body weight change was an independent risk factor for all-cause mortality, which was confirmed in the Kyoto University cohort.

Conclusion

Annual body weight loss is associated with poor prognosis in Japanese patients with COPD, independent of baseline BMI. Longitudinal assessment of body weight is important for the management of COPD.

Long-term, induced expression of Hand2 in peripheral sympathetic neurons ameliorates sarcopenia in geriatric mice

BACKGROUND

The discovery of adrenoceptors, which mediate the effects of the sympathetic nervous system neurotransmitter norepinephrine on specific tissues, sparked the development of sympathomimetics that have profound influence on skeletal muscle mass. However, chronic administration has serious side effects that preclude their use for muscle-wasting conditions such as sarcopenia, the age-dependent decline in muscle mass, force, and power. Devising interventions that can adjust neurotransmitter release to changing physiological demands will require understanding how the sympathetic nervous system affects muscle motor innervation and muscle mass, which will prevent sarcopenia-associated impaired mobility, falls, institutionalization, co-morbidity, and premature death. Here, we tested the hypothesis that prolonged heart and neural crest derivative 2 (Hand2) expression in peripheral sympathetic neurons (SNs) ameliorates sympathetic muscle denervation, motor denervation, and sarcopenia in geriatric mice.

METHODS

We delivered either a viral vector encoding the transcription factor Hand2 or an empty vector (EV) driven to SNs by the PRSx8 promoter by injecting the saphenous vein in 16-month-old C57BL/6 mice that were sacrificed 10-11 months later. Studies relied on sympathetic and muscle immunohistochemistry analysed by confocal microscopy, nerve and muscle protein expression assessed by immunoblots, nerve-evoked and muscle-evoked maximal muscle contraction force, extensor digitorum longus (EDL) muscle RNA sequencing, SN real-time PCR, and tests of physical performance using an inverted-cling grip test and in an open-arena setting.

RESULTS

Examining the mice 10-11 months later, we found that inducing Hand2 expression in peripheral SNs preserved (i) the number of neurons (EV: 0.32 ± 0.03/μm² , n = 6; Hand2: 0.92 ± 0.08/μm² , n = 7; P < 0.0001) and size (EV: 279 ± 18 μm² , n = 6; Hand2: 396 ± 18 μm² , n = 7; P < 0.0001); (ii) lumbricalis muscle sympathetic innervation (EV: 1.4 ± 1.5 μm/μm² , n = 5; Hand2: 12 ± 1.8 μm/μm² , n = 5; P < 0.001); (iii) tibialis anterior, gastrocnemius, EDL, and soleus muscles weight and whole-body strength (EV: 48 ± 6.4 s, n = 6; Hand2: 102 ± 6.8 s, n = 6; P < 0.001); (iv) EDL type IIb, IIx, and II/IIx and soleus type I, IIa, IIx, IIa/IIx, and IIb/IIx myofibre cross-sectional area; (v) nerve-evoked (EV: 16 ± 2.7 mN; Hand2: 30 ± 4.4 mN; P < 0.001) and muscle-evoked (EV: 24 ± 3.8 mN, n = 5; Hand2: 38 ± 3.0 mN, n = 8; P < 0.001) muscle force by 150 Hz-3 s pulses; and (vi) motor innervation assessed by measuring presynaptic/postsynaptic neuromuscular junction area overlay.

CONCLUSIONS

Preserving Hand2 expression in SNs from middle-aged to very old mice attenuates decreases in muscle mass and force by (i) maintaining skeletal muscle sympathetic and motor innervation, (ii) improving membrane and total acetylcholine receptor stability and nerve-evoked and muscle-evoked muscle contraction, (iii) preventing the elevation of inflammation and myofibrillar protein degradation markers, and (iv) increasing muscle autophagy.

Body mass trajectories and multimorbidity in old age: 12-year results from a population-based study

BACKGROUND & AIMS

Body weight changes reflect and impact several health conditions in older age, but little is known about its relationship with multimorbidity. We aimed to study the association of long-terms trajectories of body mass index (BMI) with contemporaneous changes in multimorbidity -and multimorbidity type- development in a population-based cohort of older adults.

METHODS

Twelve-year BMI trajectories (2001-2013) were identified in subjects aged 60+ years from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) using growth mixture models (N = 2189). Information on 60 chronic diseases and multimorbidity was ascertained based on clinical examinations, lab tests, medications, and inpatient and outpatient medical records. Linear mixed models were used to study the association between BMI trajectories and the speed of chronic disease accumulation, in general and by groups of cardiovascular and neuropsychiatric diseases.

RESULTS

Eighty percent of the study population was included in what we defined a stable BMI trajectory, 18% in a slow-decline trajectory with an accelerated BMI decline from age 78 onwards, and 2% in a fast-decline trajectory that reached underweight values before age 85. A significantly higher yearly rate of chronic disease accumulation was observed in the fast-decline versus stable trajectory (β = 0.221, 95% CI 0.090-0.352) after adjusting the model for age cohort, sex, education and time to death. Subjects in the slow-decline trajectory showed a significantly higher yearly rate of cardiovascular disease accumulation (β = 0.016, 95% CI 0.000-0.031); those in the fast-decline trajectory showed a faster accumulation of both cardiovascular (β = 0.020, 95% CI -0.025, 0.064) and neuropsychiatric diseases (β = 0.102, 95% CI 0.064-0.139), even if the former association did not reach statistical significance.

CONCLUSION

Our results provide further evidence of the importance of carefully monitoring older adults with sustained weight loss, which is an early indicator of accelerated health deterioration, reflected in our study by a faster accumulation of chronic -especially neuropsychiatric- diseases.

The Weight Problem: Overview of the Most Common Concepts for Body Mass and Fat Distribution and Critical Consideration of Their Usefulness for Risk Assessment and Practice

The prevalence of obesity already reached epidemic proportions many years ago and more people may die from this pandemic than from COVID-19. However, the figures depend on which measure of fat mass is used. The determination of the associated health risk also depends on the applied measure. Therefore, we will examine the most common measures for their significance, their contribution to risk assessment and their applicability. The following categories are reported: indices of increased accumulation of body fat; weight indices and mortality; weight indices and risk of disease; normal weight obesity and normal weight abdominal obesity; metabolically healthy obesity; the obesity paradox. It appears that BMI is still the most common measure for determining weight categories, followed by measures of abdominal fat distribution. Newer measures, unlike BMI, take fat distribution into account but often lack validated cut-off values or have limited applicability. Given the high prevalence of obesity and the associated risk of disease and mortality, it is important for a targeted approach to identify risk groups and determine individual risk. Therefore, in addition to BMI, a measure of fat distribution should always be used to ensure that less obvious but risky manifestations such as normal weight obesity are identified.

Restoration of energy homeostasis by SIRT6 extends healthy lifespan

Aging leads to a gradual decline in physical activity and disrupted energy homeostasis. The NAD⁺-dependent SIRT6 deacylase regulates aging and metabolism through mechanisms that largely remain unknown. Here, we show that SIRT6 overexpression leads to a reduction in frailty and lifespan extension in both male and female B6 mice. A combination of physiological assays, in vivo multi-omics analyses and ¹³C lactate tracing identified an age-dependent decline in glucose homeostasis and hepatic glucose output in wild type mice. In contrast, aged SIRT6-transgenic mice preserve hepatic glucose output and glucose homeostasis through an improvement in the utilization of two major gluconeogenic precursors, lactate and glycerol. To mediate these changes, mechanistically, SIRT6 increases hepatic gluconeogenic gene expression, de novo NAD⁺ synthesis, and systemically enhances glycerol release from adipose tissue. These findings show that SIRT6 optimizes energy homeostasis in old age to delay frailty and preserve healthy aging.

Whole-life body composition trajectory and longevity: role of insulin

The present study assessed the body composition trajectory of rats (N = 96) placed into 5 groups according to lifespan, using dual-energy x-ray absorptiometry every 6 months until end-of-life. A striking linearity between lifespan and bone mass percentage (not absolute bone mass) was observed. Long-lived rats show a higher bone mass percentage with a delayed insulin rise to a similar peak level as short-lived counterparts, followed by insulin declines and bone mass loss. Decreasing insulin after streptozotocin (STZ) injection caused a rapid bone mass loss (-10.5%) with a decreased 5-day survival rate to 35% in old rats (20 months). Insulin replacement to STZ-injected rats completely blocked bone mass loss and increased the survival rate to 71%. Normal old rats (20 months) had faster lean mass loss despite greater myofiber regeneration (centronucleation) compared with the young rats (4 months). Increased CD68⁺ and CD163⁺ cell infiltration into insulin-depleted muscle suggests a bone marrow cell exhaustion by aging muscle. Bone produces stem cells and phagocytes to continuously rejuvenate peripheral tissues. Our data suggests that aging and unsustainable life is associated with development of disproportionality between bone and the growing body size, partly due to insulin reversal from hyperinsulinemia during late life.

Body mass index trajectories during mid to late life and risks of mortality and cardiovascular outcomes: Results from four prospective cohorts

BACKGROUND

Our understanding of the weight-outcome association mainly comes from single-time body mass index (BMI) measurement. However, data on long-term trajectories of within-person changes in BMI on diverse study outcomes are sparse. Therefore, this study is to determine the associations of individual BMI trajectories and cardiovascular outcomes.

METHODS

The present analysis was based on data from 4 large prospective cohorts and restricted to participants aged ≥45 years with at least two BMI measurements. Hazard ratios (HR) and 95% confidence intervals(95%CI) for each outcome according to different BMI trajectories were calculated in Cox regression models.

FINDINGS

The final sample comprised 29,311 individuals (mean age 58.31 years, and 77.31% were white), with a median 4 BMI measurements used in this study. During a median follow-up of 21.16 years, there were a total of 10,192 major adverse cardiovascular events (MACE) and 11,589 deaths. A U-shaped relation was seen with all study outcomes. Compared with maintaining stable weight, the multivariate adjusted HR for MACE were 1.53 (95%CI 1.40-1.66), 1.26 (95%CI 1.16-1.37) and 1.08 (95%CI 1.02-1.15) respectively for rapid, moderate and slow weight loss; 1.01 (95%CI 0.95-1.07), 1.13 (95%CI 1.05-1.21) and 1.29 (95%CI 1.20-1.40) respectively for slow, moderate and rapid weight gain. Identical patterns of association were observed for all other outcomes. The development of BMI differed markedly between the outcome-free individuals and those who went on to experience adverse events, generally beginning to diverge 10 years before the occurrence of the events.

INTERPRETATION

Our findings may signal an underlying high-risk population and inspire future studies on weight management.

FUNDING

National Natural Science Foundation of China, Guangdong Natural Science Foundation.

Longitudinal Changes in Resting Metabolic Rates with Aging Are Accelerated by Diseases

Resting metabolic rate (RMR) declines with aging and is related to changes in health status, but how specific health impairments impact basal metabolism over time has been largely unexplored. We analyzed the association of RMR with 15 common age-related chronic diseases for up to 13 years of follow-up in a population of 997 participants to the Baltimore Longitudinal Study of Aging. At each visit, participants underwent measurements of RMR by indirect calorimetry and body composition by DEXA. Linear regression models and linear mixed effect models were used to test cross-sectional and longitudinal associations of RMR and changes in disease status. Cancer and diabetes were associated with higher RMR at baseline. Independent of covariates, prevalent COPD and cancer, as well as incident diabetes, heart failure, and CKD were associated with a steeper decline in RMR over time. Chronic diseases seem to have a two-phase association with RMR. Initially, RMR may increase because of the high cost of resiliency homeostatic mechanisms. However, as the reserve capacity becomes exhausted, a catabolic cascade becomes unavoidable, resulting in loss of total and metabolically active mass and consequent RMR decline.

Unique Mortality Profile in Japanese Patients with COPD: An Analysis from the Hokkaido COPD Cohort Study

Purpose

Causes of death may be unique and different in Japanese patients with COPD because they are generally older, thinner, experience fewer exacerbations, and live longer than those in other countries. We investigated the detailed mortality profile in the Hokkaido COPD cohort study, which completed a 10-year follow-up with a very low dropout rate.

Patients and Methods

We prospectively examined the 10-year natural history in 279 Japanese patients with COPD (GOLD 1, 26%; GOLD 2, 45%; GOLD 3, 24%; and GOLD 4, 5%). The majority of patients were male, and the average age at baseline was 69 years old. About 95% of all patients had accurate mortality data. The risk factors for mortality were also analyzed.

Results

During the 10 years, 112 patients (40%) died. Their median survival time was 6.1 years (interquartile range: 4.7–7.9 years), and age at death was 79 ± 6 years old (mean ± SD). Respiratory diseases, including pneumonia, were the leading causes of death in 45 (40%), followed by lung cancer in 24 (21%), other cancers in 18 (16%), and cardiovascular diseases in 12 (11%). In particular, lung cancer-related death was equally distributed across all COPD stages, with a higher proportion of lung cancer in the relatively younger generation (<64 years old). Older age at baseline, lower BMI, and severer emphysema were significant risk factors for all-cause mortality.

Conclusion

The unique mortality profile observed in this study should be considered when designing strategies for the management of patients with COPD in any geographic region.

Association of Weight Loss Between Early Adulthood and Midlife With All-Cause Mortality Risk in the US

IMPORTANCE

Describing potential mortality risk reduction associated with weight loss between early adulthood and midlife is important for informing primary and secondary prevention efforts for obesity.

OBJECTIVE

To examine the risk of all-cause mortality among adults who lost weight between early adulthood and midlife compared with adults who were persistently obese over the same period.

DESIGN, SETTING, AND PARTICIPANTS

Combined repeated cross-sectional analysis was conducted using data from the National Health and Nutrition Examination Survey III (1988-1994) and continuous waves collected in 2-year cycles between 1999 and 2014. The data analysis was conducted from February 10, 2019, to April 20, 2020. Individuals aged 40 to 74 years at the time of survey (baseline) were included in the analyses (n = 24 205).

EXPOSURES

Weight history was assessed by self-reported weight at age 25 years, at 10 years before baseline (midlife: mean age, 44 years; interquartile range, 37-55), and measured weight at baseline. Body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) at each time was categorized as normal (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0). Weight change patterns were assessed from age 25 years (early adulthood) to 10 years before baseline (midlife).

MAIN OUTCOMES AND MEASURES

Incident all-cause mortality using linked data from the National Death Index.

RESULTS

Of the 24 205 participants, 11 617 were women (49.0%) and 11 567 were non-Hispanic White (76.9%). The mean (SD) BMI was 29.0 (6.1) at baseline. During a mean (SD) follow-up of 10.7 (7.2) years, 5846 deaths occurred. Weight loss from obese to overweight was associated with a 54% (hazard ratio, 0.46; 95% CI, 0.27-0.77) reduction in mortality risk compared with individuals with stable obesity between early adulthood and midlife. An estimated 3.2% (95% CI, 1.6%-4.9%) of early deaths could have been avoided if those who maintained an obese BMI instead lost weight to an overweight BMI by midlife. Overall, an estimated 12.4% (95% CI, 8.1%-16.5%) of early deaths may be attributable to having weight in excess of the normal BMI range at any point between early and mid-adulthood.

CONCLUSIONS AND RELEVANCE

In this study, weight loss from obesity to overweight between early adulthood through midlife appeared to be associated with a mortality risk reduction compared with persistent obesity. These findings support the importance of population-based approaches to preventing weight gain across the life course and a need for greater emphasis on treating obesity early in life.

Change in weight and personality in middle-aged and older adults

Objective: Personality is associated with weight change and the development of obesity across adulthood. The present study examines whether significant weight change, including weight loss and weight gain, is related to personality change in a large longitudinal sample of middle-aged and older adults.Design: Participants were adults aged 50-92 years (N > 5000; 59% women, Mean age = 65.51, SD = 8.20) drawn from the Health and Retirement Study (HRS). Personality, demographic, health and staff assessed weight and height were obtained at baseline and 8 years later.Main Outcome Measures: Personality traits.Results: Both weight loss and weight gain greater than 10% of baseline weight were related to a steeper decline in extraversion, openness and conscientiousness. Weight loss was further associated with the maintenance of neuroticism and to a steeper decline in agreeableness. This overall pattern of personality change was also associated with both unhealthy and healthy weight change. The associations were not moderated by BMI and generally remained significant after accounting for disease burden.Conclusion: The present study provides new evidence that both weight loss and weight gain are related to change in personality.

Cross-Sectional Nutrition Profile of Palliative Home Care Clients in Ontario and Performance of the interRAI Palliative Care Nutrition Clinical Assessment Protocol

BACKGROUND

The nutrition profile of palliative home care clients is unknown. This study describes this group and their nutrition issues and evaluates the performance of the interRAI nutrition Clinical Assessment Protocol (CAP).

METHODS

This was a cross-sectional secondary analysis using Ontario interRAI Palliative Care (interRAI PC) Assessment data. The sample represents 74,963 unique Ontario home care clients assessed between 2011 and 2018. Frequencies and standardized differences (stdiffs) of nutrition characteristics were presented for cancer (n = 62,394) and noncancer (n = 12,569) diagnostic subgroups. Rates of triggering the nutrition CAP were presented by nutrition issue to evaluate its performance.

RESULTS

Of this sample, 16.7% were ≥85 years of age, 52.6% had a prognosis between 6 weeks and 6 months, and 41.4% required assistance with eating. The prevalence was higher among those with nervous/mental/behavioral disorders (72.6%) compared with those with cancer (37.6%; stdiff = 0.75). However, most nutrition issues experienced were similar (stdiff < 0.20) across diagnostic groups. Of the entire sample, 21% triggered the nutrition CAP, indicating a need for further evaluation or intervention. Yet, 73.4% of those who experienced dry mouth, 71.8% of those who required assistance with eating, and 68.4% of those who received a nutrition consult within the last 3 days did not trigger the nutrition CAP.

CONCLUSIONS

Nutrition issues are prevalent in palliative home care clients, regardless of diagnosis; yet the nutrition CAP identified a small fraction of this group. There is a need to focus research and care guidelines toward life-limiting illnesses beyond cancer and address nutrition-related issues in this population.

Lower tumorigenesis without life extension in rats receiving lifelong deep ocean minerals

Naturally occurring tumor in animals receiving high minerals from deep oceans (DOM: hardness 600 mg/L) from 6 months of age until natural death was firstly assessed in 200 Sprague Dawley rats, randomized into four groups: Control (C), DOM (D), Fructose (F), and Fructose + DOM (FD). Fructose drink contained 11% fructose. Tumor incidence (necropsy at death) in the D group was ~40% lower than that in the C group (P < .05), together with lower body mass gain and greater locomotive activity during their initial 18 months (P < .05) but not during later life. X‐ray image analysis on abnormal solid tissue among survivors at 18 and 24 months of age confirms a similar trend, exhibiting ~50% and ~65% lower tumor incidence than the C and F groups, respectively. Reduced‐to‐oxidized glutathione ratio (GSH/GSSG) declined with age for the first three quarters of life on all groups (P < .05), followed by a resurgence during end‐life among survivors at 24 months. This resurgence is markedly associated with lower tumor expansion but unrelated with DOM supplementation. Our results demonstrate valuable application of minerals and trace elements from deep oceans, as a vastly available natural source, on tumor suppression during normal aging.

Representation of obese participants in obesity-related cancer randomized trials

Background

Obesity is a risk factor for numerous cancer types, and may influence cancer treatment outcomes. Underrepresentation of obese patients in obesity-related cancer randomized controlled trials (RCTs) may affect generalizability of results. We aimed to assess the reporting of information about eligibility and enrollment of obese participants in obesity-related cancer RCTs.

Methods

We conducted a systematic review of RCTs of 10 obesity-related cancer types (esophagus, colon/rectum, liver, gallbladder, pancreas, postmenopausal breast, endometrium, ovary, kidney, and thyroid cancer). We selected RCTs published between 2013 and 2016 in five major journals. For each trial, we examined the article, the protocol, and the registration record. We assessed if eligibility criteria limiting the enrollment of obese participants were reported, the proportion of obese participants that were enrolled, and if a subgroup analysis according to obesity status was reported. We systematically contacted corresponding authors and asked for information about eligibility of obese participants and the proportion of obese participants.

Results

We included 76 RCTs. Colon/rectum (n = 20), postmenopausal breast (n = 11), and kidney (n = 11) cancers were the most frequent types. Based on publicly available sources, information on the eligibility of obese participants was available in 5 (7%) trials. The proportion of obese participants could be estimated in 9 (12%) trials only. We found a subgroup analysis in only one RCT. When considering unpublished information, the eligibility of obese participants was explicitly stated in 31 (41%) trials but it was unclear if the remaining 59% trials considered obese participants as eligible and what proportion of obese participants was included. Across 22 trials, the median proportion of obese participants included was 18% (Q1-Q3 11-23).

Conclusion

Information on the eligibility and enrollment of obese participants in cancer RCTs is dramatically underreported. More transparency is needed to understand the applicability of obesity-related cancer RCT results to obese patients with cancer.

Can mesenchymal stem cell lysate reverse aging?

Recent findings regarding uses of adipose-derived mesenchymal stem cell (MSC)-lysate on weight loss and improved glucose tolerance in mice on a high-fat diet suggest an encouraging possibility of using MSC lysate for an anti-aging intervention in humans. However, weight loss and lipopenia during late life can be as life-threatening as hyperglycemia during early adulthood. For this 3-year lifelong experiment, a total of 92 rats were randomized into the vehicle-injected group (F=22; M=24) and the MSC lysate injected group (F=22, M=24). We examined longevity, spontaneous locomotor activity, and body composition in rats maintained on a normal diet and received an intermittent treatment of human adipose-derived MSC lysate (3 times a week, 11 times a month given every second month), starting at 12 months of age until natural death. In substantiating previous knowledge regarding the effects of long-term MSC lysate treatments on fat loss and insulin resistance, the present findings also highlighted a shortened average lifespan, a longer inactive time, and a greater bone loss with a relative increase of lean mass in MSC lysate rats with respect to controls. Conclusion: Our data suggest that MSC lysate treatments stimulate disparity in tissue development and produce a cachexia-like effect to decrease longevity.

Body mass index and clinical outcomes in patients after ischaemic stroke in South Korea: a retrospective cohort study

OBJECTIVES

Although obesity is a risk factor for stroke, its impact on mortality in patients with stroke remains unclear. In this study, we aimed to evaluate the relationship between body mass index (BMI) and mortality due to ischaemic stroke among adults aged 20 years and above in Korea.

DESIGN

Retrospective cohort study.

SETTING

A tertiary-hospital-based stroke registry linked to the death records.

PARTICIPANTS

3599 patients admitted for ischaemic stroke from January 2007 to June 2013.

OUTCOME MEASURES

The HRs for all-cause and stroke-related mortality were calculated using Cox proportional hazards models. Progression from stroke-related mortality was assessed using the Fine-Grey competing risk model, treating other-cause mortality as a competing risk. Adjustments were made for age, gender, smoking status, Charlson comorbidity index, cardiovascular or non-cardiovascular comorbidities, stroke severity, severity related to other medical conditions, complications and enrolment year. We repeated the analysis with stratification based on age groups (less than 65 vs 65 years and above).

RESULTS

For stroke-related mortality, there was no significant difference among the four BMI groups. The risk of all-cause mortality was 36% higher in the underweight group than in the normal weight group (long-term HR=1.36, 95% CI: 1.04 to 1.79), whereas the mortality risk of the obese group was significantly lower (HR=0.66, 95% CI: 0.54 to 0.81). Although this relationship was not estimated in the younger group, it was found that obesity had a protective effect on the all-cause mortality in the elderly (long-term HR=0.66, 95% CI: 0.52 to 0.83).

CONCLUSIONS

Obesity is more likely to reduce mortality risk than normal weight, especially in elderly patients.

Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

Perceptions of What Is Important for Appetite-An Interview Study With Older People Having Food Distribution

The proportion of older people in the population increases and more and more continue living in their own homes. Appetite among the elderly people is important to their nutrition and health. The increased risk of unintended weight loss and malnutrition is linked to food distribution among home-living elderly people. The aim was to describe experiences and perceptions of what matters to appetite among home-living elderly people having food distribution. The design was qualitative where interview data were collected among 13 interviewees in 2017 to 2018. Data were analyzed using qualitative content analysis. The results are presented in three domains: the food, the meal situation, and the adaptation to meal service with categories and themes responding to each domain. The six themes related to appetite among the elderly people concerned the following: eating tasty, savory, and culturally adapted food; eating healthy and sustainable food; eating alone or together with others; eating in a pleasant meal environment; having choices to make about the meal; and last, accepting disabilities and increased dependency. One conclusion is that many aspects should be taken into consideration when promoting appetites of people who also get food distribution. It is highly individual and an understanding of which aspects are relevant must be considered; consequently, person-centered care is suggested to promote appetite.

Patterns of weight change associated with disease diagnosis in a national sample

BACKGROUND

The incidence and/or diagnosis of a major disease may activate weight change. Patterns of weight change associated with diagnoses have not been systematically documented.

METHODS

We use data on adults ages 30+ in the National Health and Nutrition Examination Survey (NHANES) from 1999-2014. Self-reported current weight and weight one year prior are used to estimate percent weight change in the last year. We use self-reported data on arthritis, diabetes, cancer, cardiovascular disease, liver conditions, and respiratory disease diagnoses to compare weight change among individuals never diagnosed with these conditions, individuals diagnosed 0-1 years ago, and individuals diagnosed 2+ years ago. Multinomial logistic regressions adjust for the presence of multiple conditions.

RESULTS

17.7% of the adult population experienced weight loss of 5.0% or more in the year prior to survey. Individuals diagnosed with any of the conditions were less likely to maintain their weight than those without a diagnosis. Arthritis, diabetes, cancer, cardiovascular disease, and liver conditions were associated with net weight loss, whereas respiratory diseases were associated with higher probabilities of both losing and gaining weight. Among those losing 10% or more, 56.7% had been diagnosed with one of the conditions. Cancer was associated with the highest probability of unintentional weight loss and diabetes with the highest probability of intentional weight loss.

CONCLUSIONS

Disease-associated weight changes leave a distinct imprint on patterns of weight change in the population. Individuals losing at least 10% of their weight in the last year have likely been diagnosed with one of the six conditions.

The translation of age-related body composition findings from rodents to humans

The objective of this review is to highlight changes in body composition in rodent models as a result of healthy aging in order to enhance translational research. Aging is associated with alterations in body composition, particularly fat mass and fat-free mass, which may be accompanied by adverse health effects, especially nearing middle age to old age. In humans, it is generally understood that fat mass tends to increase while fat-free mass concurrently declines with aging. However, the effect of aging on body composition in rodent models is less well studied, and how these changes compare and contrast with observations in humans has not yet been fully elucidated. Though, it appears as though the constituent-level alterations occur in humans and rodents at different life phases thereby having a potential effect on the outcomes of basic biomedical research. Though highly strain-dependent, this review suggests that FM changes begin at a much earlier life phase in rodents than in humans. Conversely, FFM appears to increase throughout middle age and into old age in rodents, whereas middle age is associated with the initiation the subsequent decline of FFM in humans. Given the essentiality of rodent models in basic biomedical research, careful consideration of these differences in age-related BC findings is imperative when the research is aimed for human translation.

Discrepancies between reported and cadaveric body size measurements associated with a modern donated skeletal collection

Body mass and stature estimation methods used in biological anthropology require materials with known body size information. There are several types of body size data that can be associated with skeletal collections. However, discussion regarding the reliability and suitability of these types of information for anthropological research is scarce. This paper focuses on differences between reported and recorded cadaver weights and heights associated with a modern donated skeletal collection, similar to these commonly used in anthropological research. In addition, the study identifies factors that may influence these discrepancies. The results show statistically significant differences between reported and cadaver body size information. Generally, reported weights, statures and body mass indices (BMI) were greater compared to the cadaver information in this sample. However, potential effects on these discrepancies varied depending on sex and information type. Age was found to influence stature discrepancy in females, and donation type had an effect on the female weight discrepancy. The results also show that body size range (weight, stature and BMI) can contribute to these discrepancies. Even though the differences between reported and cadaver data may not be significant at the population level, the individual variation can cause misclassifications of individuals depending on the data used. This study encourages researchers using modern documented collections and their body size information to openly acknowledge the types of weight and stature data used and to discuss potential problems associated with them.

Obesity Progression Between Young Adulthood and Midlife and Incident Diabetes: A Retrospective Cohort Study of U.S. Adults

OBJECTIVE

Understanding how changes in weight over the life course shape risk for diabetes is critical for the prevention of diabetes. Using data from the National Health and Nutrition Examination Survey (NHANES), we investigated the association between self-reported weight change from young adulthood to midlife and incident diabetes.

RESEARCH DESIGN AND METHODS

We categorized individuals into four weight-change groups: those who remained nonobese (stable nonobese), those who moved from an obese BMI to a nonobese BMI (losing), those who moved from a nonobese BMI to an obese BMI (gaining), and those who remained obese (stable obese). Diabetes status was determined by self-report of a prior diagnosis, and age at diagnosis was used to establish time of diabetes onset. Hazard ratios (HRs) relating weight change to incident diabetes over 10 years of follow-up were calculated using Cox models adjusting for covariates.

RESULTS

Those who were obese and lost weight exhibited a significantly lower risk (HR 0.33; 95% CI 0.14, 0.76) of diabetes compared with those with stable obesity. We also observed lower risk among those who were stable nonobese (HR 0.22; 95% CI 0.18, 0.28) and those in the gaining category (HR 0.70; 95% CI 0.57, 0.87). Further, there was evidence of an increased incidence of diabetes among obese individuals who lost weight compared with individuals who were stable nonobese; however, weight loss was rare, and the association was not statistically significant. If those who were obese had become nonobese during the 10-year period, we estimate that 9.1% (95% CI 5.3, 12.8) of observed diabetes cases could have been averted, and if the population had maintained a normal BMI during the period, 64.2% (95% CI 59.4, 68.3) of cases could have been averted.

CONCLUSIONS

The findings from this study underscore the importance of population-level approaches to the prevention and treatment of obesity across the life course of individuals.

The contribution of differences in adiposity to educational disparities in mortality in the United States

BACKGROUND

There are large differences in life expectancy by educational attainment in the United States. Previous research has found obesity’s contribution to these differences to be small. Those findings may be sensitive to how obesity is estimated.

METHODS

This analysis uses discrete-time logistic regressions with data from the National Health and Nutrition Examination Survey (NHANES), pooled from 1988 to 1994 and 1999 to 2010, to estimate the contribution of differences in adiposity, or body fat, to educational differences in mortality. I show that results depend upon the measure of adiposity used: body mass index (BMI) at the time of survey or lifetime maximum BMI.

RESULTS

College graduates were less likely than high school graduates to be obese at the time of survey (25% vs. 34.6%, respectively) and were also less likely to have ever been obese (35.7% vs. 49.4%, respectively). Lifetime maximum BMI performed better than BMI at the time of survey in predicting mortality using criteria for model selection. Differences in maximum BMI were associated with between 10.3% and 12% of mortality differences between college graduates and all others, compared to between 3.3% and 4.6% for BMI at the time of survey. Among nonsmokers, between 18.4% and 27.6% of mortality differences between college graduates and all others were associated with differences in maximum BMI.

CONTRIBUTION

Adiposity is an overlooked contributor to educational differences in mortality. Previous findings that obesity does not contribute to educational disparities were based on BMI at the time of survey, which is less informative than maximum BMI. The contribution of adiposity to educational mortality differences will likely grow as smoking prevalence declines. Health surveys should collect information on weight history.

Blood Pressure Trajectories in the 20 Years Before Death

IMPORTANCE

There is mixed evidence that blood pressure (BP) stabilizes or decreases in later life. It is also unclear whether BP trajectories reflect advancing age, proximity to end of life, or selective survival of persons free from hypertension.

OBJECTIVE

To estimate individual patient BP for each of the 20 years before death and identify potential mechanisms that may explain trajectories.

DESIGN, STUDY, AND PARTICIPANTS

We analyzed population-based Clinical Practice Research Datalink primary care and linked hospitalization electronic medical records from the United Kingdom, using retrospective cohort approaches with generalized linear mixed-effects modeling. Participants were all available individuals with BP measures over 20 years, yielding 46 634 participants dying aged at least 60 years, from 2010 to 2014. We also compared BP slopes from 10 to 3 years before death for 20 207 participants who died, plus 20 207 birth-year and sex-matched participants surviving longer than 9 years.

MAIN OUTCOMES AND MEASURES

Clinically recorded individual patient repeated systolic BP (SBP) and diastolic BP (DBP).

RESULTS

In 46 634 participants (51.7% female; mean [SD] age at death, 82.4 [9.0] years), SBPs and DBPs peaked 18 to 14 years before death and then decreased progressively. Mean changes in SBP from peak values ranged from -8.5 mm Hg (95% CI, -9.4 to -7.7) for those dying aged 60 to 69 years to -22.0 mm Hg (95% CI, -22.6 to -21.4) for those dying at 90 years or older; overall, 64.0% of individuals had SBP changes of greater than -10 mm Hg. Decreases in BP appeared linear from 10 to 3 years before death, with steeper decreases in the last 2 years of life. Decreases in SBP from 10 to 3 years before death were present in individuals not treated with antihypertensive medications, but mean yearly changes were steepest in patients with hypertension (-1.58; 95% CI, -1.56 to -1.60 mm Hg vs -0.70; 95% CI, -0.65 to -0.76 mm Hg), dementia (-1.81; 95% CI, -1.77 to -1.87 mm Hg vs -1.41; 95% CI, -1.38 to -1.43 mm Hg), heart failure (-1.66; 95% CI, -1.62 to -1.69 mm Hg vs -1.37; 95% CI, -1.34 to -1.39 mm Hg), and late-life weight loss.

CONCLUSIONS AND RELEVANCE

Mean SBP and DBP decreased for more than a decade before death in patients dying at 60 years and older. These BP decreases are not simply attributable to age, treatment of hypertension, or better survival without hypertension. Late-life BP decreases may have implications for risk estimation, treatment monitoring, and trial design.

Body Mass Index, Weight Loss, and Cause-Specific Mortality in Rheumatoid Arthritis

OBJECTIVE

To examine associations of body mass index (BMI) and weight loss with cause-specific mortality in rheumatoid arthritis (RA).

METHODS

A cohort of US veterans with RA was followed until death or through 2013. BMI was categorized as underweight, normal, overweight, and obese. Weight loss was calculated as the 1) annualized rate of change over the preceding 13 months, and 2) cumulative percent. Vital status and cause of death were obtained from the National Death Index. Multivariable competing-risks regression models were utilized to assess the time-varying associations of BMI and weight loss with cause-specific mortality.

RESULTS

Among 1,600 participants and 5,789 patient-years of followup, 303 deaths occurred (95 cardiovascular, 74 cancer, and 46 respiratory). The highest weight-loss rate and weight-loss percent were associated with a higher risk of cardiovascular mortality (rate: subdistribution hazard ratio [sHR] 2.27 [95% confidence interval (95% CI) 1.61-3.19]; percent: sHR 2.31 [95% CI 1.06-5.01]) and cancer mortality (rate: sHR 2.36 [95% CI 1.11-5.01]; percent: sHR 1.90 [95% CI 1.00-3.62]). Overweight BMI was protective of cardiovascular mortality (sHR 0.59 [95% CI 0.38-0.91]), while underweight BMI was associated with a near 3-fold increased risk of respiratory mortality (sHR 2.93 [95% CI 1.28-6.67]). Incorporation of time-varying BMI and weight loss in the same models did not substantially alter individual associations for cardiovascular and cancer mortality, but an association between weight-loss percentage and respiratory mortality was attenuated after BMI adjustment.

CONCLUSION

Both BMI and weight loss are predictors of cause-specific mortality in RA. Weight loss is a strong predictor of cardiovascular and cancer mortality, while underweight BMI is a stronger predictor of respiratory mortality.

Weight Change During the Early Rheumatoid Arthritis Period and Risk of Subsequent Mortality in Women With Rheumatoid Arthritis and Matched Comparators

OBJECTIVE

To investigate whether weight change during the early rheumatoid arthritis (RA) period is associated with subsequent mortality and to evaluate whether there is an RA-specific effect.

METHODS

We identified patients with incident RA during the Nurses' Health Study (NHS; 1976-2016) and created a comparison cohort by matching each RA patient with up to 10 non-RA comparators by age and calendar year of the RA diagnosis (index date). To capture weight change around the early RA period ("peri-RA/index"), we used weight measurements collected 2-4 years before and 2-4 years after the index date. We used Cox regression analysis to estimate hazard ratios (HRs) for mortality according to peri-RA/index weight change categories, separately in each cohort and in the combined cohorts, evaluating for an RA-specific effect.

RESULTS

Among 121,701 women in the NHS, 902 patients with incident RA were identified and matched to 7,884 non-RA comparators. In the RA cohort, 371 deaths (41.1%) occurred during a mean follow-up of 17.0 years after the early RA period, and 2,303 deaths (29.2%) occurred in the comparison cohort during a mean follow-up of 18.4 years. Weight loss of >30 pounds during the peri-RA period had a hazard ratio (HR) for mortality of 2.78 (95% confidence interval [95% CI] 1.58-4.89) compared to stable weight; results in the comparison cohort were similar (HR 2.16, 95% CI 1.61-2.88). A weight gain of >30 pounds had no association with mortality in patients with RA (HR 1.45, 95% CI 0.69-3.07) or comparators (HR 1.19, 95% CI 0.89-1.59). For mortality, there was no statistically significant interaction between RA/comparator status and weight change category (P = 0.68).

CONCLUSION

Severe weight loss during the early RA period was associated with an increased subsequent mortality risk for women with and those without RA. These results extend prior observations by including non-RA comparators and finding no protective association between weight gain and mortality, providing evidence against an RA-specific obesity paradox for mortality.

Prevalence and Trends in Lifetime Obesity in the U.S., 1988-2014

INTRODUCTION

Estimates of obesity prevalence based on current BMI are an important but incomplete indicator of the total effects of obesity on a population.

METHODS

In this study, data on current BMI and maximum BMI were used to estimate prevalence and trends in lifetime obesity status, defined using the categories never (maximum BMI ≤30 kg/m²), former (maximum BMI ≥30 kg/m² and current BMI ≤30 kg/m²), and current obesity (current BMI ≥30 kg/m²). Prevalence was estimated for the period 2013-2014 and trends for the period 1988-2014 using data from the National Health and Nutrition Examination Survey. Predictors of lifetime weight status and the association between lifetime weight categories and prevalent disease status were also investigated using multivariable regression.

RESULTS

A total of 50.8% of American males and 51.6% of American females were ever obese in 2013-2014. The prevalence of lifetime obesity exceeded the prevalence of current obesity by amounts that were greater for males and for older persons. The gap between the two prevalence values has risen over time. By 2013-2014, a total of 22.0% of individuals who were not currently obese had formerly been obese. For each of eight diseases considered, prevalence was higher among the formerly obese than among the never obese.

CONCLUSIONS

A larger fraction of the population is affected by obesity and its health consequences than is suggested in prior studies based on current BMI alone. Weight history should be incorporated into routine health surveillance of the obesity epidemic for a full accounting of the effects of obesity on the U.S.

What is the impact of underweight on self-reported health trajectories and mortality rates: a cohort study

Background

Utilizing a cohort study design combining a survey approach with repeated physical examinations, we examined the independent effects of BMI on mortality and self-reported health (SRH) and whether these independent effects change as people grow older.

Methods

The Tromsø Study consists of six surveys conducted in the municipality of Tromsø, Norway, with large representative samples of a general population. In total, 31,985 subjects participated in at least one of the four surveys administered between 1986 and 2008. Outcomes of interest were SRH and all-cause mortality.

Results

Overweight and underweight subjects reported significantly lower levels of SRH, but age affected the thinnest subjects more than all others. The SRH trajectory of underweight subjects at age 25 was slightly above the other categories (0.08), but it fell to −.30 below the reference category at age 90. For obese subjects, the difference was −0.15 below the reference category at age 25 and −0.18 below at age 90. This implies that even though a low BMI was slightly beneficial at a young age, it represented an increasing risk with age that crossed the reference curve at age 38 and even crossed the obese trajectory at age 67 in the full fitted model. The proportional hazard ratio for those who were underweight was 1.69 (95% CI: 1.38-2.06) for all-cause death as compared to 1.12 (95% CI: 1.02-1.23) for obese subjects.

Conclusion

BMI affected SRH and all-cause mortality independently from comorbidity, mental health, health-related behaviors and other biological risk factors. Being underweight was associated with excess mortality as compared to all others, and age affected the thinnest subjects more than all others. Weight increase was beneficial for mortality but not for SRH among the underweight. The rapid decline of SRH with increasing age suggests that particular attention should be paid to underweight after 38 years of age.

Electronic supplementary material

The online version of this article (10.1186/s12955-017-0766-x) contains supplementary material, which is available to authorized users.

Central adiposity and the overweight risk paradox in aging: follow-up of 130,473 UK Biobank participants

Background: For older groups, being overweight [body mass index (BMI; in kg/m²): 25 to <30] is reportedly associated with a lower or similar risk of mortality than being normal weight (BMI: 18.5 to <25). However, this "risk paradox" is partly explained by smoking and disease-associated weight loss. This paradox may also arise from BMI failing to measure fat redistribution to a centralized position in later life.Objective: This study aimed to estimate associations between combined measurements of BMI and waist-to-hip ratio (WHR) with mortality and incident coronary artery disease (CAD).Design: This study followed 130,473 UK Biobank participants aged 60-69 y (baseline 2006-2010) for ≤8.3 y (n = 2974 deaths). Current smokers and individuals with recent or disease-associated (e.g., from dementia, heart failure, or cancer) weight loss were excluded, yielding a "healthier agers" group. Survival models were adjusted for age, sex, alcohol intake, smoking history, and educational attainment. Population and sex-specific lower and higher WHR tertiles were <0.91 and ≥0.96 for men and <0.79 and ≥0.85 for women, respectively.Results: Ignoring WHR, the risk of mortality for overweight subjects was similar to that for normal-weight subjects (HR: 1.09; 95% CI: 0.99, 1.19; P = 0.066). However, among normal-weight subjects, mortality increased for those with a higher WHR (HR: 1.33; 95% CI: 1.08, 1.65) compared with a lower WHR. Being overweight with a higher WHR was associated with substantial excess mortality (HR: 1.41; 95% CI: 1.25, 1.61) and greatly increased CAD incidence (sub-HR: 1.64; 95% CI: 1.39, 1.93) compared with being normal weight with a lower WHR. There was no interaction between physical activity and BMI plus WHR groups with respect to mortality.Conclusions: For healthier agers (i.e., nonsmokers without disease-associated weight loss), having central adiposity and a BMI corresponding to normal weight or overweight is associated with substantial excess mortality. The claimed BMI-defined overweight risk paradox may result in part from failing to account for central adiposity, rather than reflecting a protective physiologic effect of higher body-fat content in later life.

Weight History and All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies

BACKGROUND

The relationship between body mass index (BMI) and mortality is controversial.

OBJECTIVE

To investigate the relationship between maximum BMI over 16 years and subsequent mortality.

DESIGN

3 prospective cohort studies.

SETTING

Nurses' Health Study I and II and Health Professionals Follow-Up Study.

PARTICIPANTS

225 072 men and women with 32 571 deaths observed over a mean of 12.3 years of follow-up.

MEASUREMENTS

Maximum BMI over 16 years of weight history and all-cause and cause-specific mortality.

RESULTS

Maximum BMIs in the overweight (25.0 to 29.9 kg/m2) (multivariate hazard ratio [HR], 1.06 [95% CI, 1.03 to 1.08]), obese I (30.0 to 34.9 kg/m2) (HR, 1.24 [CI, 1.20 to 1.29]), and obese II (≥35.0 kg/m2) (HR, 1.73 [CI, 1.66 to 1.80]) categories were associated with increases in risk for all-cause death. The pattern of excess risk with a maximum BMI above normal weight was maintained across strata defined by smoking status, sex, and age, but the excess was greatest among those younger than 70 years and never-smokers. In contrast, a significant inverse association between overweight and mortality (HR, 0.96 [CI, 0.94 to 0.99]) was observed when BMI was defined using a single baseline measurement. Maximum overweight was also associated with increased cause-specific mortality, including death from cardiovascular disease and coronary heart disease.

LIMITATION

Residual confounding and misclassification.

CONCLUSION

The paradoxical association between overweight and mortality is reversed in analyses incorporating weight history. Maximum BMI may be a useful metric to minimize reverse causation bias associated with a single baseline BMI assessment.

PRIMARY FUNDING SOURCE

National Institutes of Health.