Introduction

As the global population ages, the prevalence of chronic conditions, including multi-morbidity, is increasing, posing significant challenges to healthcare systems [1,2]. In Great Britain, 36% of adults report having a disability, and 20% experience other long-term limiting conditions [3]. Obesity is a significant contributor to morbidity and mortality, responsible for more than 3.4 million deaths worldwide, 4% of life years lost, and at least 4% of disability-adjusted life years (DALYs) [4]. Socioeconomic disparities further exacerbate the issue, with obesity prevalence nearly double in the most deprived areas compared to the least, at 36% and 20%, respectively [5].

Despite growing concerns over obesity’s impact on health, its influence on social care needs among older adults remains underexplored [6,7]. Older adults with obesity often experience functional impairments that increase their dependence on personal care assistance [8]. Research has shown that morbidly obese older women require significantly more support with daily living activities than their normal-weight counterparts [9]. Beyond physical challenges, obesity in older adults is frequently associated with social discrimination, stigma, and body image concerns, all of which can negatively impact mental wellbeing, self-esteem, and overall health behaviours [10–13]. Such experiences may further compound the complexity of social care needs for this population. Wharton et al. [11] identified weight bias in healthcare settings as a key factor contributing to delayed medical care, which can exacerbate health conditions and increase dependence on social support services. Furthermore, internalised weight stigma among older adults has been linked to poorer psychological wellbeing and reduced engagement in health-promoting behaviours [12].

Social care encompasses a broad range of support services that help individuals maintain independence and quality of life. These needs are typically met through formal state-funded services, private care arrangements, or informal family support [14,15]. However, unmet social care needs remain a persistent issue among older adults, particularly those with chronic health conditions. The Health Survey for England (HSE) reported that a significant proportion of older adults require more care than they currently receive, with unmet needs affecting daily activities such as washing, dressing, and mobility [16,17]. Studies indicate that approximately 47% of care recipients believe they require additional services to adequately meet their needs [18,19]. Additionally, NHS England (NHSE) data suggests that 19% of men and 28% of women over the age of 65 struggle with at least one activity of daily living (ADL), with 12% of men and 15% of women reporting unmet needs for at least one instrumental ADL (IADL) [20,21].

In England, access to formal state social care is contingent on specific eligibility criteria, including financial means, physical and mental health status, and the availability of informal caregivers [22,23]. Budgetary constraints and policy changes have further restricted access to state-funded support, leading to an increasing reliance on informal family carers and private services [16,24]. This reliance places a growing burden on unpaid carers, who may themselves experience physical, emotional, and financial strain. As a result, gaps in care provision can contribute to increased hospital admissions and poor health outcomes for older adults with unmet needs [25].

The Care Act [26] highlights the importance of identifying and addressing unmet social care needs through preventive strategies that delay or reduce the need for intensive care support. These include primary prevention measures aimed at individuals without existing social care needs, as well as secondary and tertiary prevention efforts focused on those already receiving care. Moreover, the Care Act Guidance on Secondary Prevention [27] emphasises the need to address “low-level” care needs early to prevent the escalation of long-term support requirements.

Given the rising prevalence of obesity among older adults and the growing challenges within the social care system, this study aims to explore and understand the social care experiences and needs of older adults in England who are overweight or obese. By investigating their unmet social care needs, the study seeks to identify the hidden burden of disease, the associated healthcare costs, and potential strategies to enhance quality of life. A report by Local Government Association (LGA) [2] informed that the Equality Act of 2010, is yet to be safeguarded by a person’s weight category. However, helping a person to overcome societal impairments have an association with significant cost implications and workforce. Hence it demands an improvised public health policy and planning. Addressing these gaps is critical for optimising the effectiveness of formal and informal social care support and ensuring that older adults receive the necessary assistance to maintain their independence and wellbeing.

Methods

This study applies a qualitative methodology to explore older adults’ perspectives on unmet social care needs, generating insights into the types and levels of support required rather than estimating the prevalence of unmet needs within the population. Therefore, the study has undertaken a purposive sampling strategy, using semi-structured, one-to-one interviews to explore the experiences of participants who met the study’s inclusion and exclusion criteria. Each participant received an information sheet and consent form prior to the interview. Sampling was done to the point of redundancy. A single NHS General Practitioner (GP) surgery was selected through convenience sampling, providing a private and accessible setting conducive to in-depth discussions. A loosely structured interview guide, based on a validated English Longitudinal Study of Ageing (ELSA) questionnaire (freely available), was used to ensure effective use of time. Open-ended and probing questions adapted to participants’ responses explored weight-related barriers in disability, health, wellbeing, and social care support. The interview protocol was pilot tested with the first two participants to assess clarity, accuracy, and effectiveness. This process evaluated recruitment, consent, interview questions, and recording procedures. The pilot also helped determine pacing and interview duration, leading to refinements in the final questions. All participants were debriefed after the completion of the interviews.

Defining the key phenomena

Obesity.

To determine unmet care needs, weight was categorised into five groups: normal weight, overweight, moderate or class I obesity, severe or class II obesity, and morbid or class III obesity. This was based on the three categories of obesity developed by World Health Organisation (WHO): obesity class I (BMI =  30-34.9 kg/m2), obesity class II (BMI =  35-39.9 kg/m2) and obesity class III (BMI ≥  40 kg/m2) [34].

Unmet care needs for social care and support.

This study defines unmet care needs as any identified needs, whether related to functional or mobility impairments or broader social and emotional aspects, that are not adequately supported by existing social care services. Unlike narrower definitions that focus primarily on ADLs and IADLs, this study expands the concept to encompass social contact, safety, loneliness, and a sense of purpose, thereby capturing hidden unmet needs.

Vlachantoni et al. [16] describe unmet care needs as the gap between demand (such as mobility impairments or difficulties in performing ADL/IADL tasks) and the supply of care, whether informal (family), formal (public/state services), or private (paid care). Dunatchik et al. [20] caution that a purely task-based assessment may overlook critical aspects of wellbeing, such as social engagement and emotional fulfilment. The Care Act [26] reinforces this preventive approach, advocating for proactive measures to mitigate unmet needs before they result in greater dependency on social care services.

Conceptual model of unmet care needs.

To achieve the study’s objectives, a conceptual model (see Fig 1) was developed to identify gaps in social care provision, particularly among individuals who either do not meet formal eligibility criteria or are unaware of their own unmet needs. By predicting a range of required support services, the model aims to inform policy decisions and resource allocation for more inclusive care planning. While this approach may lead to an overestimation of unmet needs, identifying potential care gaps at an early stage allows for strategic intervention, ultimately reducing long-term health and social care costs.

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Fig 1. Conceptualised model on unmet care needs for social care and support.

Constructed by Ghosh [45].

https://doi.org/10.1371/journal.pone.0320253.g001

In this model (Fig 1), the Y-axis denotes social care support (S), and the X-axis refers to social care needs (N). According to the model, from the centre (0,0), social care support increases along the Y-axis, and social care needs increase along the X-axis. Therefore, according to the need and support received, the population are divided into five groups. Group A represents older adults who do not have any need (in terms of functional and mobility impairments and any other individual felt needs), but they receive support (whether informal family, formal state or formal private paid-for care or a combination). Group B represents the older adults who do not have any needs and are not receiving any social care. Group C1 represents older adults who have at least one need (either social care service-defined or individual-felt), and their needs are fulfilled by the social care they receive. Group C2 represents older adults who are not satisfied with the support they are receiving according to their felt needs. Hence, they have existing unmet felt needs and unmet needs for social care. Group D represents older adults who have at least one need but are not receiving any social care. Therefore, this group of people has unmet felt needs and unmet needs for social care. The present study’s focus is to collect primary data about two groups of older adults in the mode, groups C2 and D, and explore the association between unmet felt needs and unmet needs for social care by the degree of BMI in older adults.

Results

Research findings are discussed under three headings: participant background profile, a summary of the narrative discussion, and interpretation of the narrative. Specific cases are purposefully selected for narratives according to the study objective. The interviews that answered the research question and provided the maximum information related to the study objective were chosen. The discussion of ‘unmet care need’ is framed around the framework (Fig 1); a detailed description of the framework is presented above.

Participant’s profile

Table 1 outlines each participant’s demographic and background information and anthropometric height and weight measurements, calculated BMI, and assigned weight category. Participants’ weight category is assigned according to the WHO BMI classification, as discussed above.

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Table 1. Anonymised demographic details of participants.

https://doi.org/10.1371/journal.pone.0320253.t001

The main outcome of narrative analysis

A summary of 10 older adults (aged 50+ years), where each of them experienced an ‘unmet care need’, is presented below in Table 2. All names in the narratives are pseudonyms. The unmet care needs of each participant are in bold. In the narratives, symbols like: (.) represent pauses and […] represents omitted materials in the conversation, and italic words indicate the direct quotes from participants’ talk, the exact way they told their narratives.

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Table 2. Narrative analysis findings.

https://doi.org/10.1371/journal.pone.0320253.t002

According to the conceptual framework (Fig 1), all the participants in the narratives in Table 2 either had ‘unexpressed needs’ (D) or ‘expressed needs that were sub-optimally satisfied’ (C2). The ‘unexpressed needs’, where participants either had care needs in terms of ADLs, IADLs, and mobility but did not perceive their difficulties (case numbers- 19, 14) or participants were reluctant to request help and support (case numbers- 19, 27, 21, 14, 32). The ‘expressed needs that were sub-optimally satisfied’, where participants either not qualified to meet the eligibility criteria to access the local authority social care support (case number- 10, 7, 14) or had inadequate existing social care (case number- 2, 27, 30, 32, 19) and support. Some participants also had both unexpressed needs and expressed sub-optimally satisfying needs (case numbers- 27, 14, 32, 19).

The participants with impaired mobility or problems in daily living faced the following challenges of unmet needs: ill health, loneliness, lack of socialisation, lack of emotional support (felt frustrated, depressed, burdened, guilty, embarrassed and anxious), felt vulnerable due to lack of carers’ time (unpaid carers), lack of carers’ knowledge, lack of housing adaptations, lack of support with everyday activities, lack of self-confidence obtaining existing social care services, lack of safety in one’s own house and lack of financial aid (individual raised).

From the above narratives, it is discerned that most of the participants mentioned their painful back and joints resulting from different types of arthritis (case number- 2, 27, 53, 57), as the main reason for their disability, or the pain due to cancer, kidney dysfunction and previous surgery.

Participants with higher obesity levels reported unmet needs primarily linked to emotional distress, including stress, frustration, social discrimination, isolation, feeling like a burden, lack of housing adaptations and safety, boredom, inability to continue hobbies, and limited access to support. In contrast, normal-weight and overweight participants (cases 3, 19) identified gaps in service provision, such as insufficient carer time and knowledge.

Narratives also highlight that past health conditions (cases 21, 14), mobility challenges (cases 3, 7, 19, 32, 30, 27, 2), or significant life events like bereavement and divorce (case 10) contribute to unmet needs. Older adults living with a spouse, partner, or children generally receive more care than those living alone. It also shows how the sense of frustration, social discrimination, lack of life purpose, depression, being a burden, guilt, embarrassment, anxiety, boredom, and being unable to do things they used to do diminish participants’ self-worth and self-confidence. In addition, the narratives reveal that despite having a sound support system in terms of money, housing adaptations, mobility aids and unpaid care support (case number- 27) or not having any difficulty in daily living (case number- 21, 14) the older adult participants can still experience low self-esteem.

It is also noted that loneliness and social isolation are more critical issues for many older adults (case number- 2, 10, 32, 21) than actual physical needs regardless of their disability and health status.

Some older adults feared social discrimination (cases 27, 32), judgment (cases 27, 32), and anxiety and panic (case 30) along with other contributing factors, leading to isolation and reduced wellbeing. For many older adults, relying on a spouse for care and support (culturally unacceptable in some cases, e.g., case 3) is a key factor contributing to poor well-being (cases 27, 30, 32). Narratives suggest that those with lower life satisfaction are more likely to experience poor wellbeing and unmet needs, regardless of the support they receive (cases 2, 30, 10, 32, 7). Daniel (case 14) feels frustrated over not losing weight and hesitates to acknowledge unmet needs, though his lack of emotional support emerges as a concern. His sleep apnoea, linked to a high BMI [2,35], also contributes to fatigue and low energy.

Conversely, some older adults report life satisfaction despite unstable care support. Those engaged in hobbies (case 32, though Alison struggles due to the pandemic), helping others (cases 19, 21), working part/full-time (cases 21, 2; though Sunita feels isolated after losing work due to the pandemic), maintaining social connections (even via phone, case 21), or having a positive cohabitation relationship (case 14) tend to experience better wellbeing.

It is also noted that financial hardship is another unmet need that older adults are having. For example, Ali (case number 3) was in full-time employment, but he lost his job due to his painful back, and joints resulting from his obesity. However, older adults who put a high value on their independence to protect their self-esteem and hold a positive outlook are deemed to have higher wellbeing regardless of their increasing weight and also seem to have fewer unmet care needs than others (case number- 21, 27). The above narratives, also reveal that in many cases, minimal support like few adaptations or aids or just providing a counselling service (case number- 10) and/or providing a social network may help older adults to meet their needs.

Discussion

The narrative analyses of the qualitative semi-structured interview indicate that participants face challenges in their everyday lives regardless of their weight categories. Moreover, the stories reveal that older adults with disabilities concerning difficulties in either ADLs, IADLs and/or mobilities struggle to meet a range of compound needs than other older adult participants. The findings are supported by Age UK [13] that found living with a single ‘need’ can be as stressful as living with compound needs and that if they remain unmet, then individuals are often struggling with a combination of unmet needs. Several past studies have found that various types of arthritis, cancer, and kidney disease can be directly or indirectly associated with individuals’ high BMI level [36–38]. This is also reflected in the narrative stories of the study participants that the main reason for their disability is either due to their painful back and joints or the pain due to cancer, kidney dysfunction and previous surgery.

Moreover, the narratives of the present study explore that loneliness and social isolation are critical issues for many older adults regardless of their disability and health status. Yet loneliness is a key predictor of poor self-esteem and lack of self-confidence [39]. A longitudinal study on English older adults by Shankar et al [40] explored that loneliness and social isolation are associated with an individual’s poor wellbeing. These findings are also in line with a NatCen study by Dunatchik et al [41] from a primary interview dataset of older adults that “older people raised unmet need for social contact and mobility as being as important, if not more important as meeting basic needs of daily living”. Furthermore, several studies support the finding that high BMI increases the risks/likelihood of loneliness, social discrimination, being socially judged and social anxiety [2,42,43].

Furthermore, it is noted from the interview narratives that some older adults are more satisfied in their lives overall, despite their unstable care and support system. Age UK [13] states that “wellbeing for older people is multi-faceted and includes health, care and support, money, housing and social contact. It follows that people living with disadvantage in these areas, and even with a single need, are more likely to have lower wellbeing”. A longitudinal study on the secondary ELSA dataset [20] found that older adults’ level of wellbeing is not a significant predictor of their future unmet care needs. Another report [41] on a primary interview dataset of older adults showed that there are some areas of unmet care need that have a stronger association with wellbeing than others, these are “lack of mobility and isolation and lack of access to hobbies and interests and the associated loss of independence”. However, both studies considered the study participants included older adults that may be underweight and malnourished and so may not wholly apply to overweight and older adults with obesity. At the same time, the study by Dunatchik et al [41] found that an easily accessible helpline or community centres can be an intervention that reduces the risk of negative wellbeing. This is in line with this present study’s findings that many older adults are frustrated and upset due to a lack of easily accessible support or helpline (case number- 2, 10). It is also evident that implementing effective interventions, such as home modifications and assistive technologies, can help older adults maintain independence and reduce future demand for social care services [20].

Financial hardship is found to be another crucial issue for many older adults in the present study since there is an association between obesity and unemployment [2], and older adults experiencing major transitional phases of life, like retirement [1]. As such, a cross-sectional study by Conklin et al. [44] established obesity demands financial hardship regardless of social class, education, and housing tenure. However, older adults who put a high value on their independence to protect their self-esteem and hold a positive outlook are deemed to have higher wellbeing. Although, this finding needs to be treated with caution as according to Dunatchik et al [41], “managing to cope, but with impacts on exhaustion and pain, or by limiting expectations is an indication of unmet need”.

It is, however, important to state that qualitative interviews reveal people’s perspectives to see their lives rather than quantify the number of people holding those outlooks [41].

Conclusion

The study conceptualises unmet care needs as gaps in service provision, including activity-based needs (e.g., ADLs, IADLs) and broader psychosocial factors such as loneliness, safety concerns, and social support. Unmet care needs were classified as either unexpressed (participants unaware of their needs or reluctant to seek support) or expressed but sub-optimally met due to eligibility criteria or service limitations. The findings contribute to the broader discourse on care provision, emphasising the necessity of addressing both practical and psychosocial dimensions of support for older adults. Many participants living alone or lacking strong social networks experienced heightened feelings of vulnerability and isolation. The key emerging themes included: the impact of chronic pain and disability on daily functioning, social isolation as a predictor of low self-esteem and emotional distress, financial hardship as a barrier to accessing necessary care, the role of informal caregivers and its cultural implications and the significance of minimal social support interventions in improving wellbeing. Policymakers and healthcare providers should consider these insights to develop integrated obesity management strategies that encompass both medical and social care dimensions in a more holistic way. Future research should further explore targeted interventions that empower older adults and enhance their quality of life.

Supporting information

Acknowledgments

This research is an outcome of the first author’s PhD study at the University of West London, UK.