As the population ages and the prevalence of obesity increases, the risk for obesity-related disease in the older adult escalates (National Center for Health Statistics, 2015). Obesity is one of the strongest risk factors for metabolic syndrome, type 2 diabetes (T2D), and cardiovascular disease (CVD) (American Diabetes Association [ADA], 2013; Garvey et al., 2016). Central obesity is present when there is an increased amount of intra-abdominal or visceral body fat (Centers for Disease Control and Prevention Diabetes Cost-Effectiveness Study Group, 1998). Waist circumference measurements >40 inches in men and >35 inches in women indicate increased disease risk (Obesity Society, 2016). Total obesity, a less reliable indicator for disease risk, measured by body mass index (BMI), is calculated as body weight (kg) divided by body height (m2) (Cornier et al., 2011; Garvey et al., 2016).
Physiological changes in body composition, secondary to aging, increase older adults' risk for central obesity. Waist measurement is a practical, accurate measure for central obesity and a reliable indicator of disease risk (Ganpule-Rao et al., 2013; Garvey et al., 2016, Siren, Erikkson, & Vanhanen, 2012; Usui et al., 2010). In cross-sectional and prospective studies, increased waist measurements reliably predicted risks for metabolic syndrome, T2D, CVD, and CVD events (Garvey et al., 2016). BMI is a less accurate measurement of obesity, as it lacks specificity in detecting disease risk in the older adult population (Cornier et al., 2011; Garvey et al., 2016). The American Association of Clinical Endocrinologists and the American College of Endocrinology (Mechanick, Hurley, & Garvey, 2017) comprehensive clinical practice guidelines for medical care of patients with obesity recommend annual waist circumference measurement in all patients at risk for obesity-related disease. The American College of Cardiology, American Heart Association, and Obesity Society (Jensen et al., 2014) recommend waist circumference measurement more than annually in obese patients.
Contrary to empirical evidence and recommendations supporting waist measurement, primary care providers (PCPs), including adult gerontological nurse practitioners (AGNPs), physicians, and physician assistants, routinely assess patients' BMI and rarely measure patients' waists (Gaynor, Habermann, & Wright, 2018; Sebo, Haller, Pechère-Bertschi, Bovier, & Herrmann, 2015). Individuals with a BMI <30 kg/m2 may be centrally obese and at risk for obesity-related disease. Consequently, older adults with central obesity and BMI <30 kg/m2 who are at risk for metabolic syndrome, T2D, and CVD may not be identified or informed about their risk for preventable disease.
Adults >70 years old have additional risks of decreased mobility and quality of life and increased morbidity and mortality in the presence of central obesity (Djoussé et al., 2012; Heim et al., 2011; Kuk & Ardern, 2009; Peterson, Al Snih, Stoddard, Shekar, & Hurvitz, 2014; Rossi et al., 2016; Tyrovolas et al., 2015). These additional risks were not correlated with total obesity, as measured by BMI, in these studies (Heim et al., 2011; Kuk & Ardern, 2009). Older adults with central obesity may have sarcopenic obesity that is characterized with decreased muscle mass and function that leads to disability, poor quality of life, and increased health care costs (Brown & McCarthy, 2015; Villareal, Banks, Siener, Sinacore, & Klein, 2004). In the presence of sarcopenic obesity, waist circumference measurement is predictive of CVD risk, but BMI is not predictive (Garvey et al., 2016). The exclusion of waist circumference measurement in the primary care of older adults represents a stark gap between evidence-based knowledge and clinical practice. A comprehensive and holistic examination of obesity could help detect potential health issues in older adults earlier and prevent obesity-related morbidity and mortality.
Patients' health behaviors are significantly influenced by information provided during primary care office visits (Singh et al., 2010). Patients are more likely to make positive behavior changes when they are informed by their health provider about their disease risks and health benefits of positive behaviors (Singh et al., 2010). The combination of waist measurement and recommendation to improve health behaviors by PCPs, including AGNPs, may be associated with successful disease risk reduction in the older adult population.
Barriers to waist measurement in medical and nursing practice include time, workload, provider comfort, lack of measurement experience, and perceived patient discomfort (Gaynor et al., 2018; Sebo et al., 2015). It is unknown if older adult patients perceive waist measurement as an unacceptable experience or if patients are unwilling to have their waists measured during health care visits. The current study examined community-based older adults' experience with, acceptance of, and willingness toward waist measurement to inform provider use of waist measurement in practice. Demonstrating acceptability of waist measurement among community-based older adults may be key to overcoming barriers to waist measurement and facilitate adoption of waist measurement in practice. Adoption of waist measurement may promote detection of central obesity and disease risk and may encourage health behaviors in older adults that promote health and prevent or control central obesity–related disease.
Complete detailed methods can be found in the primary investigator's (PI) dissertation (Gaynor, 2017). Following approval from the University of Delaware Institutional Review Board, volunteers were recruited by flyers, posters, word of mouth, and respective senior center newsletters in two senior centers located in urban settings. Male and female members of both senior centers were invited to participate. The PI screened each volunteer, via telephone, considering study inclusion and exclusion criteria using the Telephone Interview for Cognitive Status™ (TICS; Brandt, Spencer, & Folstein, 1988) and a medical health history questionnaire. Older adults with a score ≤30 on the TICS, the cut-off for probable cognitive impairment, were excluded (Brandt et al., 1988). Inclusion criteria were limited to senior center membership; functional independence; absence of significant pathophysiological conditions; and the ability to speak, read, and write using the English language. Because the minimum age for membership at each senior center was 50 years, participants age ≥50 were included in the study. Functional independence was defined as living independently and performing basic activities of daily living (ADLs) with minimal or no caregiver support. Basic ADLs included eating, bathing, dressing, transferring, and toileting. Volunteers who reported, during the telephone interview, a lack of functional independence or significant health conditions (e.g., end-stage liver failure, end-stage kidney disease, uncontrolled congestive heart failure, Cushing's syndrome) that prohibited exercise, dietary modifications, and/or significantly altered the measurements of waist circumference and BMI were excluded.
A self-report, written survey was used to collect participant demographic characteristics (Table 1). Waist measurement and BMI experience were measured using written self-report 3-point Likert scaled items developed by the authors. Items were phrased “How often does your primary health care provider measure your waist?” and “How often does your primary health care provider measure your body mass index?” Response options included never (1 point), sometimes (2 points), or all of the time (3 points). Acceptance of waist measurement was assessed using a 3-point Likert scaled item developed by the authors phrased “How comfortable do you feel having your waist measured?” Response options included not at all (1 point), somewhat (2 points), and very (3 points). No valid and reliable tool to measure willingness toward waist circumference measurement was found in the literature. Therefore, participant willingness toward waist measurement was developed from the valid and reliable Rapid Eating Assessment for Patients willingness to change diet survey item (Gans et al., 2006). Willingness toward waist measurement response options ranged from not at all willing to very willing (1 to 4 points). Participant physical activity was assessed using the valid and reliable Rapid Assessment of Physical Activity (Topolski et al., 2006).
Participant Demographics (N = 99)
All data were collected by the PI during spring and summer 2016 at each respective senior center. The PI met oneon-one with each participant to obtain informed consent and administer the self-report surveys. Each session lasted approximately 30 minutes.
One hundred twenty-three senior center members submitted their names to be study participants. Twenty-four potential participants were excluded due to a variety of reasons, including not meeting physical or cognitive inclusion criteria. The sample was 71% female, with a mean age of 70 years (range = 54 to 92 years; SD = 8.07 years). Most participants were non-Hispanic White (76.8%), educated (i.e., 50% completed ≥4 years of college and 29% completed some college or a 2-year degree), and physically active (70% met American College of Sports Medicine  recommended guidelines for aerobic physical activity). Ninety-two percent reported never having their waist measured, and 75.8% reported never having their BMI calculated in the primary care setting (Table 2). Despite this lack of waist measurement experience, 62.6% reported they felt very comfortable having their waist measured, and 82.8% were very willing to have their waist measured. Only one participant reported she was not at all willing to have her waist measured.
Experience with Waist Measurement and Body Mass Index (BMI) in Primary Care (N = 99)
The current study examined community-based older adults' experience with, acceptance of, and willingness toward waist measurement. Despite lack of waist measurement experience, older adult participants were very accepting of and very willing to have their waists measured. Participant reports of never having waist measurement in the primary care setting further supported the literature that reported PCPs do not routinely measure patient waist circumference (Gaynor et al., 2018; Sebo et al., 2015). Unexpectedly, most participants reported their PCPs never calculated their BMI. This finding conflicts with research that showed providers reported frequent use of BMI calculation in practice and with the ADA's (2013) recommended use of BMI calculation to screen adults for T2D risk (Gaynor et al., 2018; Sebo et al., 2015). Benefits of BMI calculation over waist measurement, reported by providers, included patient comfort with height and weight measurements and convenience of pre-programmed BMI calculators in the patient electronic medical record (Gaynor et al., 2018; Sebo et al., 2015). It may be speculated that PCPs review and consider a patient's BMI calculation while reviewing the patient electronic medical record but may not discuss the calculated value with each patient. This process might account for the discrepancy between patient and PCP reported use of BMI calculation in the primary care setting. It is also possible that some PCPs may not use BMI calculation in the care of older adults. Underuse of obesity screening measures in primary care settings may contribute to the estimate that 25% of the U.S. diabetic population is undiagnosed (ADA, 2013). The possibility that PCPs are not discussing BMI calculation, in addition to not measuring waist circumference, may be a contributing factor to diabetes underdiagnosis in the older adult population. Thus, a newer approach to obesity in the older adult population that includes waist circumference measurement and discussing BMI calculation in primary care settings is encouraged. This newer approach may identify older adults at risk earlier and prevent poor health outcomes over time. Specialists and AGNPs working in specialty settings are also encouraged to use waist circumference measurement in the care of older adults.
Prior evidence confirmed that providers perceived patients to be unaccepting of and unwilling toward waist measurement (Gaynor et al., 2018). High levels of acceptance of and willingness toward waist measurement in the current study did not align with prior research findings. Overall, the sample was educated and physically active. Health-conscious tendencies and higher levels of education among participants may have contributed to high levels of acceptance of and willingness toward waist measurement. A sample with normally distributed levels of education and physical activity may provide more representative data about community-based older adults' acceptance of and willingness toward waist measurement.
Generalizability of study findings is limited due to small sample size and homogeneity. In addition, participants attained higher educational levels and were more physically active than the general older adult population. Although the physical activity tool was validated in prior studies and the willingness item was derived from a validated tool, survey items that assessed waist measurement acceptance, waist measurement experience, and BMI calculation experience were not validated in prior studies.
The current study found that PCPs are not measuring community-based older adults' waists to screen for central obesity and are likely not informing older patients about BMI. Findings from this study provide empirical evidence that debunks the perception that older adult patients are uncomfortable and unwilling to have their waist measured. Informing older adults about their central and total obesity status may impact health behaviors. In turn, these health behaviors may decrease disease risk, delay disease onset, or control current disease. Further research examining the effect of waist measurement on older adults' health outcomes, health beliefs, and health behaviors is recommended to further support adoption of waist measurement in primary care of older adults.
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Participant Demographics (N = 99)
| Female||70 (71%)|
| Male||29 (29%)|
| Non-Hispanic White||76 (76.8)|
| Non-Hispanic African American||19 (19.2)|
| Other||2 (2)|
| Native American or Pacific Islander||1 (1)|
| Declined response||1 (1)|
| High school diploma or GED||10 (10.1)|
| Vocational, trade, or business school after high school||10 (10.1)|
| Some college or 2-year degree||29 (29.3)|
| 4-year college degree||16 (16.2)|
| Postgraduate degree||34 (34.3)|
Experience with Waist Measurement and Body Mass Index (BMI) in Primary Care (N = 99)
|Never||Sometimes||All the Time|
|Waist measurement||91 (91.9)||7 (7.1)||1 (1)|
|BMI||75 (75.8)||15 (15.2)||9 (9.1)|