Aging Clinical and Experimental Research

https://doi.org/10.1007/s40520-018-0933-x

ORIGINAL ARTICLE

Waist circumference is a better predictor of risk for frailty than BMI

in the community-dwelling elderly in Beijing
Qiuju Liao2,4 · Zheng Zheng1,2,6 · Shuangling Xiu2,5 · Piu Chan1,2,3,6

Received: 5 January 2018 / Accepted: 8 March 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract
Aim  Obesity is found to be associated with frailty. Body mass index (BMI) and waist circumference (WC) are the commonly
used measures for obesity, the former is more closely related to general obesity and body weight; the latter can more accu-
rately reflect abdominal obesity and is more closely associated with metabolic disorders. In this study, we intend to study
the relationship between frailty, BMI and WC among older people.
Methods  Data were derived from the Beijing Longitudinal Study on Aging II Cohort, which included 6320 people 65 years
or older from three urban districts in Beijing. A Frailty Index derived from 33 items was developed according to Rockwood’s
cumulative deficits method. A Frailty Index ≥ 0.25 was used as the cut-off criteria. BMI was classified as underweight, nor-
mal, overweight, or obese (< 18.5, 18.5–< 24.0, 24.0–27.9, ≥ 28.0 kg/m2, respectively). High WC was defined as WC ≥ 85 cm
in men and ≥ 80 cm in women.
Results  People with a larger BMI (≥ 28.0 kg/m2, 22.6%) or a larger WC (18.5%) were more likely to be frail. People with
normal BMI and overweight people do not suffer from higher prevalence for frailty. In comparison with individuals with
normal BMI (18.5–< 24.0 kg/m2) and normal WC (< 85 cm in men, <80 cm in women), the risk of frailty was higher among
individuals who have normal BMI and large WC (odds ratio 1.68; 95% CI 1.33–2.12), have overweight and large WC (odds
ratio 1.58; 95% CI 1.23–1.96), or have obesity and large WC (odds ratio 2.28; 95% CI 1.79–2.89). In people with normal
WC, only those who are underweight have a higher risk for frailty (odds ratio 1.65, 95% CI 1.08–2.52). In comparison with
BMI, the relation of WC with the risk for frailty was much closer.
Conclusions  Abdominal obesity is more closely associated with incidence of frailty than general obesity in the elderly. Older
adults with large waist circumference are more likely to be frail. Frailty in the elderly might be more closely related to meta-
bolic disorders. WC might be a better measurement to detect frailty than BMI, given its relationship with metabolic disorders.

Keywords  Body mass index · Waist circumference · Frailty · Older adults · Prevalence

4
* Piu Chan Department of Rheumatology, Beijing Institute of Geriatrics,
pbchan@hotmail.com Xuanwu Hospital of Capital Medical University,
Beijing 100053, China
Qiuju Liao
5
qiujumm@sina.com Department of Endocrinology, Beijing Institute of Geriatrics,
Xuanwu Hospital of Capital Medical University,
1
Department of Neurobiology, Beijing Institute of Geriatrics, Beijing 100053, China
Xuanwu Hospital of Capital Medical University, No. 45 6
Key Laboratory on Neurodegenerative Disease of Ministry
Changchun St., Xicheng District, Beijing 100053, China
of Education, and Beijing Key Laboratory for Parkinson’s
2
Department of Geriatrics, Beijing Institute of Geriatrics, Disease, Parkinson’s Disease Center of Beijing Institute
Xuanwu Hospital of Capital Medical University, for Brain Disorders, Beijing 100053, China
Beijing 100053, China
3
Department of Neurology, Beijing Institute of Geriatrics,
Xuanwu Hospital of Capital Medical University,
Beijing 100053, China

13
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Introduction
Population aging has been accelerating in China lead-
ing to an increased vulnerability to diseases and physical
frailty [1]. Frailty is a common problem in the elderly and
increases the risk for disability and raises the demand for
institutional care and even hastens death [2]. In China,
the obesity epidemic is unfolding much faster than it has
ever been observed in Western countries, especially so
in Beijing [3]. With the increase in age, older adults are
likely to have obesity [4], metabolic syndrome (MetS)
[5] and diabetes [6]. Reports have shown that obese older
people are at a higher risk of being frail [7]. Metabolic
disorders [8] and diabetes [9, 10] are also found to be
correlated with frailty in the elderly population. Body
mass index (BMI) and waist circumference (WC) reflect
metabolic problems with different measures, the former
is more closely related to general obesity and weight, and
the latter is more closely associated with abdominal obe-
sity and metabolic-related diseases (e.g., MetS, diabetes,
coronary heart disease et al.) [11–14]. WC is also associ-
ated with chronic inflammation, oxidative stress and insu-
lin resistance [15, 16], which are also associated with the
risk of frailty [17]. Although previous evidence has shown
that BMI and WC are associated with increased risks for
frailty, which of the two is more accurate in predicting
frailty is not known. This study intends to investigate the
relationship of BMI and WC with frailty in community-
dwelling older people in Beijing.
Methods
Study participants and design
This was a secondary analysis of data from the Beijing
Longitudinal Study on Aging II (BLSA II), which was
launched in 2009 in Beijing, China, and a follow-up study
was performed 1 year later, from August 2010 to January
2011 [18]. A multi-stage cluster random sampling method
was used to select a representative community cohort aged
55 and older from both urban and rural areas. It found a
12.3% prevalence and a 13% incidence of frailty in com-
munity-dwelling Chinese older adults with the Rockwood
Frailty Index method. Being frail significantly predicted
adverse geriatric outcomes. In a separate analysis, diabe-
tes was found to be an independent chronic condition that
increased the risk of frailty in community-dwelling older
adults in China [19]. In the current study, we selected par-
ticipants who were 65 or older recruited from only the
three urban districts in Beijing (Xuanwu, Xicheng and
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Aging Clinical and Experimental Research
Dongcheng) in 2009 to exclude the potential bias of envi-
ronmental exposures and life styles between urban and
rural areas. In total, 6320 subjects people were involved.
Definition of frailty
The original Frailty Index (FI) consisting of 34 items was
defined according to the BLSA-II Frailty Index (BLSA-FI)
model, on the basis of Rockwood’s accumulation of deficits
method [20, 21]. In the current study, BMI was not included
in the calculation of the FI, making the FI consisting of only
33 items. These deficits were defined as symptoms, signs,
disabilities and diseases deficits [22], including: (1) 12
chronic conditions, for which the participants were asked
“Have you ever been diagnosed for the following conditions
by a doctor?” Chronic conditions included hypertension, car-
diovascular disease, chronic obstructive pulmonary disease
(COPD), diabetes, stroke, dementia, arthritis, tumor, cata-
ract, deafness, heart failure and renal failure; (2) 4 functional
assessment scales (Mini-Nutrition assessment [MNA] [23],
Tinetti performance-oriented mobility assessment[POMA]
[24], Mini-Mental State Examination [MMSE] [25], Geri-
atric Depression Scale-15 [GDS-15] [26]); (3) 6 disease
screening questionnaires (joint pain and inflammation, gout,
risk of fall, osteoporosis, arterial sclerosis and Parkinson’s
disease); (4) 8 self-reported geriatric symptoms (less activ-
ity, fatigue, weight loss, urinary inconsistence, fecal incon-
sistence, memory loss, vision and hearing loss), and (5) 3
blood test measurements (fasting plasma glucose, blood
lipids [triglycerides, total cholesterol, and low and high
density lipoprotein-cholesterols] and uric acid). All items
had less than 5% missing values, and continuous measures
were dichotomized into frailty markers 15 (1 = presence,
0 = absence) based on referenced cutoffs for Chinese. Each
individual’s deficit points were summed and divided by the
total number of deficits considered (in this case 33) to yield
an FI with a theoretical range 0–1. The cut-off criterion was
FI ≥ 0.25 [21], that is to say, a FI of 0.25 or greater indicated
frailty.
Body mass index and waist circumference
The BMI was calculated as weight in kilograms divided
by the square of the height in meters (kg/m 2). Accord-
ing to the criteria of the Cooperative Meta-analysis
Group of China Obesity Task Force [27], individuals
were classified as underweight, normal, overweight, or
obese (< 18.5, 18.5–<  24.0, 24.0–27.9, ≥ 28.0  kg/m 2,
respectively). The WC was measured at the middle point
between the rib margin and iliac crests in a horizontal
plane using an inelastic measuring tape. The whole meas-
urement was also completed by well-trained investigators.
Each measurement was repeated twice; if the measured
Aging Clinical and Experimental Research

values were within 0.5  cm of one another, then their Results

average was calculated. If the difference between the two
measurements exceeded 0.5 cm, then a third measurement
was conducted. The normal cut-off values for Chinese are
80 cm for females and 85 cm for males [27].
Statistical analyses
Chi-square tests were used to analyze the prevalence
of frailty with different BMI and WC levels. Logistic
regression model with progressive levels of adjustment
was used to evaluate the association of BMI and WC
with frailty. Because socio-demographic, physical and
lifestyle-related factors were associated with frailty, so
sex and age were adjusted in Model 1. Model 2 represents
the results adjusted for sex, age, smoking and alcohol
consumption, number of diseases, living alone, exercise,
sleeping and education. All analyses were performed with
SAS statistical software version 9.2 (SAS Institute Inc,
Cary, NC, USA). All tests were 2-tailed; P < 0.05 was
considered statistically significant.
Association of BMI and WC with frailty
The prevalence of frailty with socio-demographic, lifestyle
and clinical characteristics is shown in Table 1. It shows that
people with obese (BMI ≥ 28.0 kg/m2) were significantly
more likely to be frail compared with normal BMI individu-
als (22.6 vs 15%, P < 0.0001). In addition, the data show
that people with higher WC (≥ 85 cm in men and ≥ 80 cm
in women) were significantly more likely to develop frailty
compared with those with normal WC (18.5 vs 12.1%,
P < 0.0001).
The odds ratios (OR) with 95% confidence interval (CI)
of the BMI and WC for frailty risks are shown in Table 2.
People with obese (BMI ≥ 28.0 kg/m2) were associated with
an increased risk for frailty (OR 1.37, 95% CI 1.13–1.67,
P = 0.03). After adjusting for sex and age, we observed
that obesity (BMI ≥ 28.0  kg/m2) significantly increased
the risk for frailty (OR 1.41, 95% CI 1.59–1.72, P = 0.008)
(model 1). But in the second stepwise multiple regression
analysis, further adjusted for parameters (sex, age, smok-
ing, alcohol consumption, number of diseases, living alone,

Table 1  Baseline characteristics of Beijing longitudinal study on aging II

Characteristics Total sample Nonfrail N = 5259 (%) Frail N = 1061 (%) P
N = 6320 (%)

Age (years)
 65–74 3513(55.6) 3067(87.3) 446(12.7) < 0.0001
 75–84 2568(40.6) 2015(78.5) 553(21.5)
 ≥ 85 239(3.8) 177(74.1) 62(25.9)
Gender
 Women 3888(61.5) 3154(81.1) 734(18.9) < 0.0001
 Men 2432(38.5) 2105(86.6) 327(13.4)
Marriage
 Unmarried, widowed or divorced 1497(23.7) 1148(76.7) 349(23.3) < 0.0001
 Married 4823(76.3) 4111(85.2) 712(14.8)
Education
 Less than high school 3644(57.7) 3083(84.6) 561(15.4) 0.0005
 High school/GED/some college 2670(42.3) 2171(81.3) 499(18.7)
BMI (kg/m2)
 Underweight (< 18.5) 199(3.2) 167(83.9) 32(16.1) 0.67
 Normal (18.5–< 24.0) 2379(37.9) 2023(85) 356(15) Ref
 Overweight (24.0–27.9) 2640(42.1) 2212(83.8) 428(16.2) 0.22
 Obese (≥ 28.0) 1051(16.8) 813(77.4) 238(22.6) < 0.0001
WC (cm)
 Normal WC (< 85men, < 80 women) 1658(26.4) 1458(87.9) 200(12.1) Ref
 High WC (≥ 85 men, ≥ 80 women) 4631(73.6) 3772(81.5) 859(18.5) < 0.0001

Chi-square test was used to compare prevalence rates of frailty among subgroups
BMI body mass index, WC waist circumference

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 Aging Clinical and Experimental Research

Table 2  Frailty risk according to BMI and WC

Unadjusted Model 1 Model 2

BMI (kg/m2) OR (95% CI) P OR (95% CI) P OR (95% CI) P

Underweight (< 18.5) 1.35 (0.9–2.02) 0.31 1.21 (0.81–1.82) 0.7 1.31 (0.83–2.07) 0.41
Normal (18.5–< 24.0) Ref Ref Ref Ref Ref Ref
Overweight (24.0–27.9) 0.95 (0.8–1.11) 0.005 0.98 (0.83–1.15) 0.04 0.95 (0.79–1.14) 0.03
Obese (≥ 28.0) 1.37 (1.13–1.67) 0.03 1.41 (1.59–1.72) 0.008 1.31 (1.06–1.64) 0.11
WC (cm)
 Normal WC (< 85men, < 80 women) Ref Ref Ref Ref Ref Ref
 High WC (≥ 85 men, ≥ 80 women) 1.65 (1.36–1.98) < 0.0001 1.59 (1.31–1.92) < 0.0001 1.3 (1.05–1.61) 0.01

Model 1: adjusted for sex and age

Model 2: adjusted for sex, age, smoking, alcohol consumption, number of diseases, living alone, exercise, sleeping, and education
BMI body mass index, WC waist circumference

a normal WC but underweight (BMI < 18.5) showed a higher

Fig. 1  Association of BMI after taking into consideration WC with
regard to the prevalence of frailty. *P < 0.05
prevalence of frailty.
Stratification of participants by combination of BMI and
WC categories showed that the risk of frailty was signifi-
cantly higher among individuals who were underweight but
with normal WC (OR 1.65, 95% CI 1.08–2.52, P = 0.04),
normal BMI but a large WC (OR 1.68, 95% CI 1.33–2.12,
P < 0.0001), overweight but a large WC (OR 1.58, 95% CI
1.23–1.96, P < 0.0001), and with both obese and large WC
(OR 2.28, 95% CI 1.79–2.89, P < 0.0001) in comparison
with individuals with normal BMI (18.5–< 24.0 kg/m2)
and normal WC (< 85 cm in men, < 80 cm in women). The
results also showed statistical significance after adjustment
with Model 1 or Model 2 (Table 3).

exercise, sleeping, and education), the influence of obesity Discussion

(BMI ≥ 28.0 kg/m2) on frailty showed no statistical signifi-
cance (OR 1.31, 95% CI 1.06–1.64, P = 0.11) (model 2).
People with large WC were positively related to increased
risk of frailty (OR 1.65, 95% CI 1.36–1.98, P < 0.0001). The
results also showed statistical significance after adjustment
with Model 1 (OR 1.59, 95% CI 1.31–1.92, P < 0.0001) or
Model 2 (OR 1.3, 95% CI 1.05–1.61, P = 0.01).
Association of BMI with the prevalence of frailty
in relation to WC
The prevalence of frailty increased with a normal or
increased BMI in people with high WC, whereas a lower
frequency of frailty was observed in people with a nor-
mal or even overweight (BMI 24.0–27.9) when their WC
was normal (Fig. 1). On the other hand, as long as a large
WC was present the prevalence of frailty was significantly
increased compared to people with normal BMI and WC,
except elderly underweight (BMI < 18.5). Those elderly with
The current study investigated the relationship between
frailty, BMI and WC in Chinese elderly in the urban com-
munity. We found that abdominal obesity demonstrated by
the measure of WC was more consistently associated with
an increased risk for frailty even for individuals with a nor-
mal BMI, suggesting large WC which increased the risk
for metabolic disorders might be more closely related to an
increased risk of frailty in the elderly population. For those
who had normal BMI or even overweight, the risk for frailty
was not increased if they had a normal WC. These results
suggest that WC is a better predictor of frailty than BMI for
the elderly.
Many reports demonstrated a close relation between
BMI and risk of frailty [7, 28–30]. However, there were
still controversies about the risk of frailty in overweighed
people. A cross-sectional analysis with 599 community-
dwelling women aged 70–79 from the Women’s Health and
Aging Studies I (1992) and II (1994) cohorts found that
being overweight (BMI 25–< 30 kg/m2) did not increase

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Aging Clinical and Experimental Research

Table 3  Frailty risk according to BMI after taking into consideration of WC

WC (cm) BMI (kg/m2)
Underweight (< 18.5) Normal (18.5–< 24.0) Overweight (24.0–27.9) Obese (≥ 28.0)

Unadjusted Normal WC 1.65* Ref 0.91 1.64

(< 85men, < 80women) (1.08–2.52) 126/1096 (0.62–1.34) (0.65–3.91)
n events/total 28/170 37/349 5/35
High WC 1.24 1.68* 1.58* 2.28*
(≥ 85men, ≥ 80women) (0.42–3.59) (1.33–2.12) (1.23–1.96) (1.79–2.89)
n events/total 4/29 230/1283 391/2291 232/1016
Model 1 Normal WC 1.52* Ref 0.96 1.49
(< 85men, < 80women) (1.2–2.16) (0.65–1.42) (0.6–3.69)
High WC 1.04 1.66* 1.56* 2.25*
(≥ 85men, ≥ 80women) (0.49–2.97) (1.31–2.1) (1.25–1.94) (1.75–2.87)
Model 2 Normal WC 1.72* Ref 1.1 1.37
(< 85men, < 80women) (1.07–2.89) (0.72–1.69) (0.51–3.68)
High WC 0.8 1.45* 1.27* 1.77*
(≥ 85men, ≥ 80women) (0.27–2.81) (1.12–1.88) (1.13–1.62) (1.34–2.32)

Model 1: adjusted for sex and age

Model 2: adjusted for sex, age, smoking, alcohol consumption, number of diseases, living alone, exercise, sleeping, and education
BMI body mass index, WC waist circumference
*P < 0.05

the risk of frailty [29]. However, results from 40,657
women aged 65–79 who participated in the Women’s
Health Initiative [30], and were followed up for 3 years,
confirmed that being overweight could markedly increase
the risk of frailty. Although it is now known the exact
cause of this discrepancy, our study showed that being
overweight (BMI 24.0–27.9 kg/m2) increased the risk of
frailty only for those with increased but not normal WC,
suggesting that it is the abdominal obesity that is associ-
ated with frailty. Since we have adjusted sex and age in the
analysis, it is less likely that this relationship between WC
and frailty was only relevant for oldest old.
Despite numerous studies focused on relationship
between BMI and frailty, there were only few on WC and
frailty. There were quite few studies on relationship of
frailty related to metabolic disorders. Metabolic disorders
are well known to be closely related to cardiovascular dis-
eases and diabetes. Older people with metabolic disorders
are more likely to suffer from chronic diseases and are
prone to suffer adverse health outcomes [31, 32]. One of
the most accepted indicators of abdominal obesity is WC.
To some extent, it reflects how fats are distributed across
the body. Although CT or MRI are more precisely discern
specific components of body composition (e.g., visceral
versus subcutaneous adipose tissue or ectopic fat in tis-
sues and organs) [33], WC is widely used for its ease of
measurement. The earliest report on frailty and abdomi-
nal obesity was a British cross-sectional study, suggested
that a large WC was closely related to frailty, even among
underweight people [28]. Our results are consistent with
their findings, and, in fact, there were quite other studies
that also replicated the results [34, 35].
As people grow old, muscle mass and strength decrease,
and body fat increases, and BMI is the most commonly used
anthropometric measurement to assess adiposity [36, 37].
However, our study has shown that overweight individuals
did not have an increased risk for frailty if they had a normal
WC, only those with a larger WC had an increased risk for
frailty even if with a normal BMI. These results suggest that
WC is a better indicator of frailty than BMI. We speculate
that WC is associated with abdominal obesity or more vis-
ceral fat, and with metabolic disorders [17, 35]. Fat cells can
secrete cytokines such as leptin, adiponectin, resistin, TNF,
IL-6 and visfatin, which play important roles in metabolism,
inflammation, blood coagulation, fibrinolysis, endothelium
function and transmitting metabolic information between
different organs [17, 31, 35, 38, 39]. Abdominal obesity
exerts an anti-insulin effect, which leads to abnormal glu-
cose tolerance. Moreover, people with abdominal obesity
also suffer from chronic stress and chronic inflammation
[40]. All these factors have been proposed to mediate the
mechanisms leading to frailty [35]. Furthermore, increased
WC has also suggested to be markers of oxidative stress,
independent from BMI [16]. Excessive and unopposed oxi-
dative stress may be the core mechanism leading to age-
associated frailty [41]. Increased overall adiposity is a factor
linked to higher rates of depression, cognitive decline [42]
and osteoporosis [43] in the elderly, ailments which all are
components related to frailty. BMI is affected by many fac-
tors, such as body size (humpback in the elderly), skeletal

13

and muscular weight, and it does not reflect the body fat
distribution [16]. In the elderly in particular, body weight
could be an important indication of their health status, more
weight (a higher BMI) may demonstrate a better preserve
or healthy as compared to the adults. While larger WC may
suggest increased risk for metabolic disturbance even when
the elderly with a normal body weight. Therefore, these data
support that people with large WC are more prone to be frail.
It is interesting to note that we found those who were
underweight but with a normal WC had a higher risk for
frailty, while the risk for frailty decreased when WC was
increased. Our results are different from previous report
by Hubbard et  al. that found people with large WC but
underweighted had an increased risk for frailty [28]. These
contradicted results might be explained by possible differ-
ent mechanisms leading to frailty between underweighted
and overweighed. The low BMI may represent low reserve
capacity and weight loss, a key component of frailty. Under-
weight may result from chronic diseases or undernourish-
ment and sarcopenia, which were also associated with
increased risk for frailty [44].
Although this is a community study, there were also some
limitations. First, cross-sectional study can only demonstrate
association, but not causation. Second, many confounding
factors were included, we still cannot rule out some residual
confounding influence due to co-morbid conditions. Further
well-designed prospective studies are warranted to explore
the association between frailty, BMI and WC.
Conclusion
This community study on urban elderly in Beijing dem-
onstrated that abdominal obesity or in the presentation of
larger WC is more closely associated with increased risk
for frailty than general obesity in the elderly as indicated
by BMI. Increased WC may be a better predictor of risk for
frailty in the elderly.
Acknowledgements This project was funded by grants from
the Beijing Municipal Commission on Science and Technology
(D07050701130000 and D07050701130701), and Ministry of Health
of China (201002011), Ministry of Science and Technology of China
(2012AA02A514, 0S2012GR0150, 2012ZX09303-005). We thank
all the participants and their families and the healthcare professionals
involved.
Author contribution  Study concept and design: Dr. Piu Chan, Dr.
Qiuju Liao; acquisition of subjects and/or data: Dr. Piu Chan; analysis
and interpretation of data: Dr. QiujuLiao, Dr. Zheng Zheng, Dr. Shuan-
gling Xiu; preparation of manuscript: Dr. Piu Chan, Dr. Qiuju Liao.
Funding  This project was funded by grants from the Beijing Munici-
pal Commission on Science and Technology (D07050701130000 and
D07050701130701), and Ministry of Health of China (201002011),
13
Aging Clinical and Experimental Research
Ministry of Science and Technology of China (2012AA02A514,
0S2012GR0150, 2012ZX09303-005).
Compliance with ethical standards 
Conflict of interest  No potential conflicts of interest were disclosed.
Ethics approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the
Research Ethics Committee of Xuanwu Hospital, Capital Medical
University. In addition, this study was performed in accordance with
the ethical principles of the Declaration of Helsinki.
Informed consent  Written informed consent was obtained from all
participants.
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