The Nexus Between Obesity,Health and Social Care Needs for Older Adults: A Literature Review

Objective

The primary objective of this article is to provide a conceptual model that can be tested in subsequent research with the help of identified gaps from the literature review. This article examines various evidence and data sources in measuring the effects of obesity in the older adults and analyzes nationally representative and more commonly used research works on health or well-being and social care needs due to an increased risk of obesity. The primary purpose of this article has been to critically analyze different studies carried out in the context of obesity in the older adults and its association with health, well-being, and social care need. Moreover, the extensive literature helps to identify the research gaps, and accordingly, four key research questions are developed.

Background

Obesity in older adults is one of the increasingly important issues for today’s society. According to the Centre for Policy on Ageing (2013), this is partly due to the rapid increase in older adults in the United Kingdom. However, there are significant variations among countries or ethnic groups, and even between genders. Based on mortality rates between 1982 and 2007 in the United Kingdom, life expectancy has increased by over 6 years for males to 77.2 years and over 4 years for females to 81.5 years and is expected to continue to rise in the near future and this has resulted in an ageing population (Han, Tajar, & Lean, 2011). Mathus-Vliegen (2012) stated that it was likely there would be 32 million obese older adults by 2015 in the European Union. As stated earlier, obesity is a severe problem in the United Kingdom, and by 2050, one in two adults might experience this condition (Local Government Association, 2013). However, the National Institute for Health and Care Excellence (NICE, 2014) expressed that these approximations could be on the bright side. Consequently, this highlights that there is an indication of the growing prevalence of obesity in the aging populations.

In England, treating obesity costs the National Health Service an estimated £5 billion a year (McKinsey Global Institute, 2014). However, the broader cost to the economy is estimated at closer to £20 billion a year, if factors such as lost productivity along with sick days are considered (Public Health England, 2013). According to Ng et al.,2014 (Djalalinia, Qorbani, Peykari, & Kelishadi 2015), obesity is evaluated to be the root source of more than 3.4 million deaths, 4% of life years lost, and at least 4% of “Disability-Adjusted Life Years” throughout the world. There are several studies which looked into the factors that influence disability. However, there are not enough studies exploring the association between obesity in older adults, complex morbidity, and disability.

There are plenty of theories about obesity to explain the etiological factors behind it: which can be environmental, demographical, genetic, and physiological. Along with elements that aid in reducing obesity, but none is relevant to all individuals. The causes and drivers of overweight and obesity are complex. Uniquely, the growing prevalence of overweight and obesity in older adults is integrated with many psychophysical health problems (Obara-Golebiowska, Brycz, Lipowska, & Lipowski, 2018). The effect of obesity is more complicated in an elderly population than a young population because the aging process itself is associated with various types of noncommunicable diseases and movement limitations. On top of that, the presence of Sarcopenia in older adults, which is degenerative muscle loss adds more complexity (Gill, Bartels, & Batsis, 2015). The disease burden of increasing numbers of chronically sick older adults (defined as 65+ years old by the WHO) is a significant issue (Han et al., 2011).

Despite the widely known deleterious effects of obesity on overall health, obesity in old age has to be analyzed with caution due to the controversial medical hypothesis of obesity paradox (Chapman, 2008), which states that the increasing body weight can be positively associated with maximal survival increases with increasing age for older adults. Unlike the controversial relationship between high BMI and mortality in older adults, the link between obesity, diabetes, and the metabolic syndrome is very similar in older adults compared with younger adults (Samper-Ternent & Al Snih, 2012).

Elderly or aging is, therefore, a pivotal phase of developmental change in the life course in terms of experience and prolonged practice toward health behavior, food, and lifestyle throughout life; and at the same time, exposure to most chronic diseases is due to not only the biological aging process but also the prolonged practice of detrimental health habits. Moreover, the impact of life course transformations and adaptations on behavior has been predominantly ignored in relation to obesity (Musingarimi, 2008). Consequently, the impact of obesity in older adults is an essential field of research. Furthermore, from the report of the Local Government Association in 2013 (Copley, Cavil, Wolstenholme, Fordham, & Rutter 2017), due to the link between obesity and chronic medical conditions, social care is primarily needed. Moreover, as the report states obese older adults might also have physical and social impairments, and social care is needed to support them in their daily living to help the individual to live as independently as possible. However, according to the Social care and obesity discussion paper by the Local Government Association, 2013 (Copley et al., 2017) “there is lack of published data that directly link obesity with social care need” (p. 2), especially for older adults.

Moreover, the relationships between disability, the need for help, and social services are poorly known, which is an important public health issue (Almazán-Isla et al., 2017). Although, the study by Copley et al. (2017) found that self-reported need for social care is positively related to the BMI, once sociodemographic factors and limiting long-term illness were adjusted for. However, the study used secondary cross-sectional survey data from private households to measure BMI with social care need and was modeled as the need for care rather than the receipt of care. To our knowledge, there is no study so far to evaluate whether there is a difference in social care need by BMI.

Conceptual Framework

A research framework is developed that is linked with the research questions to display the flow of this research. This framework is connected to the research objectives and the aims of the study. This framework is drawn to organize our concepts, assumptions, and expectations and informs the research. This framework is a process that involves mapping out or visualizing the theoretical threads (as discussed earlier) to form a diagrammatic representation of inner relatedness (Sinclair, 2007). The framework elucidates the variables of interest in the study. Moreover, the structure describes the aspects, and the theoretical background supports the links between the variables of this research study. Figure 1 shows the relationships or connections between concepts to shed light on the phenomenon of interest.

OPEN IN VIEWER

Figure 1.

Conceptual framework. Source: constructed by authors.

Obesity Concerning Disabilities, Comorbidities, and Dependencies for Older Adults

It is evident that obesity is the source of many chronic diseases, particularly for older adults. The foremost concernsare related to numerous health risks, medical comorbidities such as metabolic syndrome, diabetes mellitus, hypertension, heart failure, obstructive sleep apnea, pressure ulcers, and difficulty with mobility. As a result, obesity increases health-care resource use, functional decline, and homebound status (Jensen et al., 2006). According to Cancer Research UK (2016), being overweight increases the risk of developing 10 different types of cancer.

In addition, the three most common types of arthritis affecting older adults have an adverse effect on aging, mostly due to its impact on overall physical and mental health and disability, as arthritis impairs physical activity (Samper-Ternent & Al Snih, 2012). Whereas obesity accelerates the deterioration of joint function in older adults with arthritis and negatively affects some outcomes from surgical interventions (Samper-Ternent & Al Snih, 2012). Reynolds and McIlvane (2009) found that obesity reduces the probability of recovery from disability in older adults.

Moreover, it is observed that obese older adults spend more time as hospital inpatients due to the problems associated with the skeletomuscular system and orthopedic procedures, which increases costs. The existing comorbidities such as hypertension and metabolic syndrome related to overweight and obesity continues to be an essential burden to society and individual, mainly because of the costs involved in pharmacotherapy for these conditions (Rössner, 2001). Consequently, it is evident that the excess utilization of hospital resources, workforce, and expenditures associated with obesity are explained by chronic conditions and poor health status (Musich et al., 2016).

A causal model of comorbidity was proposed by Kessler and Price in 1993 (Department of Health, 2003). It suggests four potential causal links between comorbid disorders. All the links are associated with the design of joint preventive efforts (Department of Health, 2003). Firstly, the disorder may directly lead to disease. Thus, the effect of obesity in older adults may directly lead to raising the obesity-related subclinical risk factors (e.g., increasing blood pressure or hypertension, impaired fasting glucose level, and elevated level of liver enzymes), physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue), psychopathology, functional limitations or impairment of well-being (The Edmonton obesity staging system; Ording & Sorensen, 2013).

Second, the occurrence of comorbidity can be due to the indirect consequences of one disorder on another. Thus, comorbidities such as Type 2 diabetes, hypertension, sleep apnea, cancer, cardiovascular diseases, and osteoarthritis can be independently coexisted with obesity. Third, one disorder may be related to the contexts that potentiate the possibility of another. Thus, severe disabilities from obesity-related chronic diseases may potentiate the likelihood of severe disabling psychopathology, severe functional limitations, and severe impairment of well-being (The Edmonton obesity staging system; Ording & Sorensen, 2013). Fourth, comorbid conditions may share a common etiology. That is, each of the comorbid conditions may facilitate developing potential disability and risk factors. In addition, these disability and risk factors may represent the different developmental stages of new comorbid conditions (Department of Health, 2003). Thus, the co-occurrence of obesity in older adults, along with other comorbidities (obesity-related or age-related), facilitates significant developing psychopathology. This leads to the potential risk factor of cognitive impairment and severe intellectual disability.

Adults with severe obesity may have physical impairments that inhibit activity with daily living. According to the social model of disability, this can have resource implications for social care services such as housing adaptations for specialist mattresses, doors, toilet frames, hoists, and stairlifts, provision of appropriate transport and facilities such as specialist leisure services (Public health England, 2013). However, these services raise the cost of health and social care service. In contrary, according to the medical model of disability, if obesity is only considered a disease or something is wrong with that individual, then it creates low expectations. Moreover, people will lose independence and overall control of their lives. The human rights model of disability demands fundamental human rights for the individual with disabilities, and the critical disability studies model raises questions on the dualism between impairment and disability (Simon, 2013).

Seven studies use activities of daily living to define disability (Samper-Ternent & Al Snih, 2012), that is difficulty performing one or more activities and three studies also use instrumental activities of daily living to define disability. Each study summarizes that obesity raises the risk of the identified disability, which in turn also increases the degree of dependency. However, there is no significant association established between obesity and difficulties with learning a new task or recall (Boateng, Adams, Boateng, Luginaah, & Taabazuing, 2017). In fact, according to Boateng et al. (2017), overweight older adults are less likely to have difficulties with recall or learning new tasks.

However, older adults who are morbidly obese (BMI ≥ 40) encounter many more complex issues and challenges (Zamboni et al., 2005). problems are faced by home health-care providers when caring for morbidly obese clients in the home care setting (Gallagher, 1998).

Simultaneously, a normal aging process, on top of overweight and obesity, is also associated with a different level of disabilities, especially with the presence of Sarcopenia. Currie (2016) provides a definition of health status, stating that when health is regarded as a person’s body composition and it's functionality as well as the presence or absence of disease or illness then it is called health status (Health Knowledge, 2016).

Overall, it is essential to examine the level of disabilities and level of dependency between obese older adults and non-obese older adults in terms of the degree of help needed with activities of daily living and instrumental activities of daily living and to examine the link with their current health status.

Research Question 1: Is there any relationship between obesity, disability, and comorbidities in older adults?

Obesity, Health, and the Quality of Life Nexus

The WHO (2006) defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.” However,health is a controversial term, and it was proposed by Huber et al. in 2011 (Health Knowledge, 2016) that health may be defined as the ability of people to adapt to their situation and ability to self-manage. Which contradicts the view by the traditional, medical model, of health- that health is the absence of illness or disease and that stresses the role of clinical diagnosis and intervention (Health Knowledge, 2016). However, the biopsychosocial model of health emphasizes the influence of social, psychological, and physiological factors and the interactions between these factors on health and illness (Health Knowledge, 2016). However, in reality, the meaning of health and well-being may differ from person to person and relies on the context . The biomedical model evaluates that is ill-health mainly caused by biological factors, including lifestyle choices such as smoking, unhealthy diets, and lack of exercise, as stated by Browne in 2011 (UK Essays, 2003–2019). However, the biomedical model is criticized by Moore in 2008 (UK Essays, 2003–2019), as the overall health is associated far more with environmental and social changes, rather than medical impact.

Obesity affects the quality of life among older adults (Giuli et al., 2014). Although the elderly population, in general, goes through different transitional phases of life such as retirement, financial hardship (Conklin et al., 2013), widowhood, and empty nest syndrome. Conklin et al. (2013) explored these transitional phases of life which can force older adults to change their lifestyle and behavior in respect of healthy eating and physical activity, which may eventually leads to either malnutrition or obesity.

Numerous studies have established the fact that obese persons experience significant impairments in quality of life as a result of their extra weight gain, with greater impairments associated with higher degrees of obesity (Kolotkin et al., 2001). However, old age and different transitional phases associated with this stage of life may have added extra burden and complications, which in turn reduces an individual’s quality of life and well-being.

Therefore, no doubt, adding obesity-related disabilities on top of this transitional phase of life would reduce the quality of life for older adults.

Interestingly, Doll, Petersen, & Stewart-Brown (2000) find that physical well-being can deteriorate markedly with increasing degree of overweight. However, that is not always true in terms of emotional well-being, especially in individuals who were obese without any chronic condition. Whereas, they also agreed that individuals with obesity along with two or three chronic illnesses are particularly vulnerable in both dimensions of physical and emotional well-being. Consequently, from their research (Doll et al., 2000), it is significant that the added burden of obesity is connected with a significant deterioration in physical well-being. However, emotional well-being can be stable or unaffected for individuals with similar levels of chronic illness (Doll et al., 2000).

Also, according to Health Knowledge (2016), traditionally, health-related quality of life was being connected to patient outcomes and was generally showcased on deficits in functioning (e.g., pain and negative affect). In contrast, it is evident from the above discussion, “wellbeing focuses on assets in functioning, including positive emotions and psychological resources (e.g., positive affect, autonomy, and mastery) as key components” (Health Knowledge, 2016).

However, according to the 2016 Health Survey for England (Health Survey for England, 2017) mental well-being is not just the lack of mental ill-health, it is a measure of overall health status, including loneliness, depression, anxiety, self-confidence, and sleep disturbance. Each of which or all can contribute to a poor well-being status. Obese adults may also experience mental health problems as a result of stigma and bullying or discrimination in society or workplaces due to their impairment, as described by Puhl and Heuer in 2009 (NICE, 2015).

Simultaneously, well-being is perceived as life positivity, the presence of positive emotions and moods, the absence of negative emotions, positive functioning, overall satisfaction or fulfillment with life (Centers for Disease Control and Prevention, 2016). There are plenty of differential opinions about well-being, quality of life, or life satisfaction. However, according to Diener and Biswas-Diener in 2008 (Centers for Disease Control and Prevention, 2016), it is evident in many studies well-being is the combined effect of mental health (mind) and physical health (body). Moreover, these higher levels of welfare are considered to be influential in reducing the risk of injury, disease, illness as well as increased longevity, better immune functioning, and speedier recovery (Centers for Disease Control and Prevention, 2016). Besides, Fayers and Machin in 2000 (Health Knowledge, 2016) stated, “Quality of life is a measure of the difference between the hopes and expectations of the individual and the individual’s present experience.” Therefore, it is apparent that well-being usually needs to be determined to evaluate the degree of quality of life or overall life satisfaction. However, in public health, only physical well-being (e.g., full of energy or feeling very healthy) can be judged as critical to overall prosperity (Health Knowledge, 2016), and the concept of emotional well-being is not well determined than that of physical well-being. NICE (2015) guidelines on obesity management emphasize on the overall satisfaction of people using services with their care to ensure that people have a positive experience of care and support as part of the Adult Social Care Outcomes Framework 2015–2016.

The Obesity Care Pathway Toolkit, developed by National Obesity Forum (2005), Care pathway for the management of overweight and obesity by National Health Service (2006), NICE (2014) guidance on obesity, Wandsworth Healthy Weight Care Pathway Toolkit by Public Health Wandsworth Council (2018), and The Report of the working group into: Joined-up clinical pathways for obesity by a joint working group with representation from various health regulatory bodies of England (National Health Service England, 2014), may be argued, do little to address the care pathway for older adults for all aspects of their well-being and quality of life related to current health status As Amarya, Singh and Sabharwal (2014) find quality of life may be the most important goal of therapy in older adults. Bell et al. (2016) stated “care of older adults should be designed to better respond to a broader perspective of patient-centred concerns, and target not only improved longevity, but improved function, independence, and quality of life.” It is essential to explore the link between current health status and well-being among older adults with obesity; consequently, it is crucial to examine the following:

Research Question 2: Is there any link between current health status and overall well-being of obese older adults in England?

Social Care Needs of Obese Older Adults

Obesity and social care are directly related, as discussed earlier, obesity is responsible for the development of numerous long-term conditions along with physical and social disabilities, depending on the degree of obesity and this highlights the implications for health and social care. According to Public Health England (2013), dramatically increasing obesity prevalence in older adults along with the growing demands of an aging population reveals serious challenges and cost implications to both the health and social care systems. The Health and Social Care Bill of 2011 (Public Health England, 2013) defined adult social care as, “all forms of personal care and other practical assistance for individuals who (require it) by reason of age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs, or any other similar circumstances” (p. 3).

The role of carers in supporting individuals with disabilities, especially obese older adults with intellectual disabilities has been recognized as an essential factor in meeting the needs of individuals, as evaluated by NHS Health Scotland in 2004 (Spanos et al., 2013). Therefore, carers may have a strong influence on an individual’s health behavior. However, according to Smyth and Bell in 2006 (Spanos et al., 2013), if carers have poor knowledge about an individual’s health condition, who they are caring for, this may impact on the health risks of individuals they support.

Moreover, as Spanos et al. (2013) have explored, sometimes, for family carers to provide care and support for the obese older individual can be stressful. In addition, family carers may have difficulties in coping with busy lives. However, due to the controversial medical hypothesis the “obesity paradox” (as discussed earlier), it is not established if high BMI is associated with social care needs in older adults in England. Therefore, it is crucial to investigate this:

Research Question 3: Is there any association between high body mass index and social care needs in older adults?