Are the Elderly Supposed to be Overweight and Hypertensive?

Most people gain fat and lose muscle as they age.  One framing has been that "Old people are fat and weak because they don't spend enough time at the gym!".  But these anatomic changes are simply the normal process of aging, and are actually adaptive in the sense that they improve survival.  Insisting that the body composition, lab values, and marathon times of the elderly match that of their 20-year-old selves seems silly.  Accepting such changes as part of successful aging might improve both physical and mental health.

Growth and Development

After birth children undergo rapid and remarkable genetically programmed changes, an arrangement that takes kids seamlessly from newborn to infant through childhood and adolescence and then more slowly on into adulthood.  This breathtakingly complex process happens without effort, moment by moment, and usually without mishap.  We embrace it as at once miraculous and normal.

But bodily changes continue even after adulthood is reached, and we seem more conflicted about this part of the miracle.  On the one hand some anatomic losses go uncontested, such as brain volume, immune function, and hair and dermal thickness.  Degradation of some physiologic parameters, such as hearing acuity, nerve conduction velocity, and VO₂ max are also somehow also accepted as unavoidable.  Maximum heart rate also falls with age¹, another change that passes without comment, possibly because most people don’t keep track of their maximum heart rate.  But the change is real, regular as clockwork:

BMI and Aging

In stark contrast to the above changes, age-related increase of fat and loss of muscle are often portrayed as an unacceptable failure of one’s diet, supplement, or exercise regimens, or perhaps all three.  Even, perhaps, as a moral failing

But is this a reasonable distinction?  Does the increase in BMI that comes with aging really make people less healthy?  The surprising answer is no: it turns out that older people are actually less likely to die if they have a higher than “normal” BMI.  Note that this is only true for older people; the young are least likely to die when they have a normal BMI.  Also, these are not small effects.  Here’s a graph of the hazard ratio as a function of BMI separated into three age groups, created from two recent articles in The Lancet² and Obesity³

I do not mean to suggest that one should force feed junk food and desserts in a misguided effort to drive up BMI in order to improve one’s chances of surviving.  A healthful diet with a minimum of highly processed products, along with adequate sleep and exercise remain the basis for enjoying a healthy old age.  And note that even small changes in these pillars can produce big benefits: just 5 minutes more sleep, two minutes more exercise, and a half serving of vegetables each day adds up to an additional year of lifespan⁴.   That works out to be a 10 to 1 return on investment.

The substantive point, however, is this: modest weight gain and a BMI into the “overweight” range are not inherently harmful in older adults. In fact, increased fat store is associated with lower mortality than the "normal" BMI standards of earlier decades. Although the absolute benefit is modest, perhaps an additional year of lifespan, the psychological benefit may be more profound: we can finally relax the burden of maintaining our college-aged weight, understanding that gradual weight gain with age is not a failure requiring correction, but rather a normal, protective physiological adaptation.

 

Blood Pressure Changes with Age as Well

The idea that different health norms should apply to seniors has much wider application than just body composition.  Take for example systolic blood pressure.  In the young and middle aged, elevated blood pressure (>120) is associated with a host of adverse consequences including heart disease, stroke, and increased all-cause mortality.  But blood pressure reliably rises with age, a consequence of stiffer arteries caused by loss of elastin in their walls.  So, while a systolic blood pressure of 120 has traditionally been considered normal, it turns out that “normal” changes with age:  75% of people over the age of 60 have “high blood pressure” (>130).  

But if most people over that age of 60 have “high” blood pressure, is it really “abnormal”?  It turns out we can also answer this question with data.  A careful review article concluded that "keeping systolic blood pressure in older adults below 150 is important, but that level is also good enough. …there was no significant evidence that more intensive management improved outcomes"⁵  Because treating blood pressure involves drugs, expense, and risk, not treating people who won’t benefit from treatment is an important part of their health care.  This idea is so important that a new word, “deprescribing”, has entered medicine just in the last decade.  The practice of systematically discontinuing medicines in older people for whom “normal” values have changed over time is now considered simply good health care.⁶

 

Public Health Implications

Adjusting medications based upon age corrected norms turns out to have profound implications for public health, because while blood pressure up to 150 is actually the norm in the elderly (40%-60%), blood pressure over 150 is relatively rare, affecting only 16%.  So, by simply shifting our threshold to treat “high” blood pressure to this higher value we’ve cured 45 million “hypertensive” Americans.   This is important because absent this new “normal” value, most seniors would be treated with drugs, and so exposed to the substantial risk, expense, and inconvenience of taking these medicines for the rest of their lives while receiving no actual benefit.

Effect size is important, and the effect size of allowing higher BMI in the elderly is real but modest.  We can expect to improve lifespan by about a year by simply adjusting our expectations for weight as people age.  

 

Lifespan: Nature vs. Nurture

Note, however, that there are other factors which have a much greater impact on longevity.  For example, we’ve recently learned that fully 50% of one’s lifespan is determined by genetics.⁷  This is good news for those who come from long lived families, because they are half way to their longest life the moment they are born.  Congratulations, you won the genetic lottery.

But for those who did less well in the genetic lottery the news isn’t all bad.  Within the constraints of genetics, choices in diet, exercise, and sleep control most of the other 50% of lifespan variability, and optimizing these three areas can in concert lengthen lifespan by as much as 10 years.  To fix ideas, on average every minute spent running extends one’s life by 7 minutes.  Depending on how you feel about running this may or may not be a bargain.  But Tai Chi, or even walking have similar effects.  Optimizing one’s diet has about the same effect on lifespan.⁸

Importantly, genetics and lifestyle operate independently rather than interactively, meaning that lifestyle interventions confer substantial benefits regardless of genetic risk.  And, in a turnabout that seems only fair, the highest absolute risk reduction observed in those with the most extreme genetic disadvantage.⁹  So, some good news for those who didn’t do so well in the genetic lottery: you can claw back your losses by simply paying attention to diet, exercise and sleep.  By the same token, those who won the genetic longevity lottery can throw away their winnings with a poor diet, lack of exercise and poor sleeping habits.

 

The Bottomline: 

Here’s the takeaway:  don’t stress too much about modest increases in your BMI and blood pressure as you age, because these changes are not only not harmful but are actually associated with modestly increased lifespan.  But do pay attention to diet, exercise, and sleep, because these choices can add as much as ten years to your lifespan.  And, perhaps as importantly, can make those years healthier and more enjoyable.  By embracing a more physiological and philosophical understanding of aging that recognizes both its modifiable and inevitable components a more compassionate approach to aging emerges:  It’s OK that you’re not 20 anymore.  Because you aren’t. 

 

¹ Tanaka, H., Monahan, K. D., & Seals, D. R. (2001). Age-predicted maximal heart rate revisited. Journal of the American College of Cardiology, 37(1), 153–156. https://doi.org/10.1016/s0735-1097(00)01054-8

² Bhaskaran, K., Dos-Santos-Silva, I., Leon, D. A., Douglas, I. J., & Smeeth, L. (2018). Association of BMI with overall and cause-specific mortality: A population-based cohort study of 3·6 million adults in the UK. The Lancet Diabetes & Endocrinology, 6(12), 944–953. https://doi.org/10.1016/S2213-8587(18)30288-2

³ Cheng, F. W., Gao, X., Mitchell, D. C., Wood, C., Still, C. D., Rolston, D., & Jensen, G. L. (2016). Body mass index and all-cause mortality among older adults. Obesity, 24(10), 2232–2239. https://doi.org/10.1002/oby.21612

⁴ Stamatakis, E., Koemel, N. A., Biswas, R. K., Ahmadi, M. N., Allman-Farinelli, M., Trost, S. G., Inan-Eroglu, E., Del Pozo Cruz, B., Bin, Y. S., Postnova, S., Duncan, M. J., Dumuid, D., Brown, H., Maher, C., Fontana, L., Simpson, S., & Cistulli, P. A. (2025). Minimum and optimal combined variations in sleep, physical activity, and nutrition in relation to all-cause mortality risk. BMC Medicine, 23(1), Article 111. https://doi.org/10.1186/s12916-024-03833-x

⁵ Setters, B., & Holmes, H. M. (2017). Hypertension in the older adult. Primary Care, 44(3), 529–539. https://doi.org/10.1016/j.pop.2017.05.002

⁶ Scott, I. A., Hilmer, S. N., Reeve, E., Potter, K., Le Couteur, D., Rigby, D., Gnjidic, D., Del Mar, C. B., Roughead, E. E., Page, A., Jansen, J., & Martin, J. H. (2015). Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Internal Medicine, 175(5), 827–834. https://doi.org/10.1001/jamainternmed.2015.0324

⁷ Shenhar, B., Pridham, G., De Oliveira, T. L., Raz, N., Yang, Y., Deelen, J., Hägg, S., & Alon, U. (2026). Heritability of intrinsic human life span is about 50% when confounding factors are addressed. Science, 391(6784), 504–510. https://doi.org/10.1126/science.adz1187

⁸ Fadnes, L. T., Celis-Morales, C., Økland, J. M., Parra-Soto, S., Livingstone, K. M., Ho, F. K., Pell, J. P., Balakrishna, R., Javadi Arjmand, E., Johansson, K. A., Haaland, Ø. A., & Mathers, J. C. (2023). Life expectancy can increase by up to 10 years following sustained shifts towards healthier diets in the United Kingdom. Nature Food, 4(11), 961–965. https://doi.org/10.1038/s43016-023-00868-w

⁹ Bian, Z., Wang, L., Fan, R., Sun, J., Yu, L., Xu, M., Timmers, P. R. H. J., Shen, X., Wilson, J. F., Theodoratou, E., Wu, X., & Li, X. (2024). Genetic predisposition, modifiable lifestyles, and their joint effects on human lifespan: Evidence from multiple cohort studies. BMJ Evidence-Based Medicine, 29(4), 255–263. https://doi.org/10.1136/bmjebm-2023-112583