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Is it time to update body mass index standards in the elderly or embrace measurements of body composition?

European Journal of Clinical Nutrition volume 71, pages 1029–1032 (2017)Cite this article

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It is widely recognized that the standard World Health Organization (WHO) definition of normal body mass index (BMI) to minimize morbidity and mortality1 is not applicable for geriatric populations. To date, no age adjustments have been made to the WHO recommendation of 18.5–24.9 kg/m2, and until recently disagreement existed regarding the validity of its use for predicting mortality. This controversy, known as ‘the BMI Paradox’, was widely publicized and presented evidence indicating that individuals categorized as overweight (25–29.9 kg/m2) may actually benefit from lower mortality rates.2 Subsequently, it was argued that the BMI paradox is based on methodological and statistical errors such as dichotomous stratification of smoking, without a ‘former smokers’ category,3, 4 or the inclusion of participants with higher mortality risks that are characterized by weight loss, as in cancer.3, 5 Furthermore, in a meta-analysis that stratified for mean duration of follow-up of cohorts, a protective effect for a 5-unit increment in BMI was observed only in studies that had less than 5 years of follow-up. This beneficial effect was lost with longer durations of follow-up, resulting in an HR of 1.07 (CI, 1.05–1.08) for 10–15 years of follow-up, or 1.15 (CI, 1.11–1.19) for longer than 25 years of follow-up.6 These variables, when not adjusted, can result in an artifact of reverse causation, implying that a low body weight might be the result rather than the cause.

The Global BMI Mortality Collaboration (GBM Collaboration)7 was established to provide standardized associations of BMI with mortality. This working group analyzed data covering four million subjects on four continents, aged 20–90 years, followed up for a mean period of 13.7 years. Bias from reverse causality was limited by excluding patients with pre-existing chronic disease, or those who died within the first 5 years of follow-up, and ever-smokers. In addition, BMI traditional WHO categories of normal and overweight were stratified into subgroups. Their results revised the BMI range for lowest mortality risk for all adult-ages to 20–24.9 kg/m2. Excess mortality risk was associated with the overweight group, thus rejecting the BMI paradox in the general population, as shown in Table 1. It should be noted that the lowest end of the current WHO-defined normal BMI range, namely 18.5–20.0 kg/m2, was also associated with excess mortality risk by the GBM Collaboration. Similarly, in a meta-analysis by Aune et al.,6 which included 230 cohort studies with 30.3 million participants, similar results were presented after restricting for the same major sources of bias. Both meta-analyses concluded that the desirable BMI for longevity for all adults is within the range of 20–24.9 kg/m2.6,7

Table 1 Mortality risk hazard ratios associated with stratifying BMI normal or overweight ranges for all adults
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Acknowledgements

We thank the Pears Foundation and The Hebrew University—International School of Agricultural Sciences for their financial support of Ms Ainembabazi in her MSc studies.

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  1. School of Nutritional Sciences, The Hebrew University of Jerusalem, Robert H Smith Faculty of Agriculture, Food and Environment, Rehovot, Israel

    L Ben-Yacov, P Ainembabazi & A H Stark

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  1. L Ben-Yacov
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Correspondence to L Ben-Yacov.

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Ben-Yacov, L., Ainembabazi, P. & Stark, A. Is it time to update body mass index standards in the elderly or embrace measurements of body composition?. Eur J Clin Nutr 71, 1029–1032 (2017). https://doi.org/10.1038/ejcn.2017.39

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