Obesity within the Elderly by Roxana Aminbakhsh, as presented within the GWEP 2018 January Conference

1. Obesity in
Elderly
Roxana Aminbakhsh, MD.
Geriatrition

2. Introduction
 Obesity is defined as an unhealthy excess
of body fat which enhances the risk of
morbidity and untimely mortality.

3. Introduction
 It is accompanied by ;
Burden of chronic diseases,
Metabolic complications,
Worsening of quality of life.
 More importantly:
Obesity exacerbates the age related decline in
physical function  Frailty & Disability.

4. Measurement
 BMI (Body Mass Index):
weight(kg)/height Squared (m)
BMI <18.5  underweight
BMI 18.5- 24.9  Normal
BMI 25-29.9  Overweight (I)
BMI 30-39.9  Obesity (II)
BMI >40 Extreme obesity (III)
 Waist circumference:
Men > 40 in; Women > 35 in

5. Measurement
 However, height may be reduced due to
degenerative bone disease or kyphoscoliosis,
contributing errors to BMI computation in the
elderly. Frailty also poses difficulty in obtaining
weight and height.
 Increasingly, WC has been used as an index of
adiposity in adults. The advantage of WC over
BMI is that it correlates highly with both total and
intra-abdominal fat.

6. Prevalence
 More than one-third of older adults aged 65
and over were obese in 2007–2010.
 Obesity prevalence was higher among those
aged 65‒74 compared with those aged 75
and over in both men and women.

7. Prevalence
 By 2050, the number of U.S. older adults,
defined as persons aged 65 and over, is
expected to more than double, rising from
40.2 million to 88.5 million. Both aging and
obesity contribute to increased health care
service use. Consequently, an increase in the
proportion of older adults who are obese may
compound health care spending.

8. Prevalence of obesity among adults aged 65 and over, by sex:
United States, 2007–2010 . (SOURCE: CDC/NCHS, National
Health and Nutrition Examination Survey, 2007‒2010.)

9. Prevalence
 IS there any differences in the prevalence
of obesity among older adults by race and
ethnicity?

10. Prevalence of obesity among adults aged 65 and over, by sex and
race and ethnicity: United States, 2007–2010
(SOURCE: CDC/NCHS, National Health and Nutrition Examination
Survey, 2007‒2010.)

11. Prevalence
 Is there any differences in the prevalence
of obesity among older adults by race and
ethnicity?
 There were no significant differences in
obesity prevalence by race and ethnicity
among men. However, the prevalence of
obesity differed by race and ethnicity among
women.

12. Prevalence
 Is there any differences in the prevalence
of obesity among older adults by
educational attainment?

13. Prevalence of obesity among adults aged 65 and over, by sex and
education: United States, 2007–2010
(SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey,
2007‒2010.)

14. Prevalence
 Is there any differences in the prevalence
of obesity among older adults by
educational attainment? There were no
significant linear trends in the prevalence of
obesity among men aged 65–74 by
educational attainment. There was a linear
trend among women aged 65‒74: There was
a decrease in obesity prevalence with
increasing education.

15. Body composition & aging
 After the age of 30 years, There is a
progressive decrease in fat-free mass (FFM),
such as muscles and bone and an increase in
fat mass.
 Aging is also associated with the redistribution
of body fat (Central obesity).

16. Body composition & aging
Reduced production of anabolic hormones:
No Decline in Catabolic hormone,

17. Causes of Obesity in Elderly
 Obesity results when:
Total energy intake >energy out put
What happens to energy intake in elderly?

18. Causes of Obesity in Elderly
 Obesity results when:
Total energy intake >energy out put
What happens to energy intake in elderly?
Energy intake neither changes nor declines with
advancing age. Hence, the decrease in total
energy output (EO) is an important contributor
to obesity in elderly.

19. Causes of Obesity in Elderly
 Energy Out Put (EO) :
1- Basal metabolic rate (70%)
2- Thermal effect of food (10%)
3- Physical activity (20%)

20. Causes of Obesity in Elderly
 What happens to basal metabolic rate?

21. Causes of Obesity in Elderly
 What happens to basal metabolic rate?
It decreases because of decrease in FFM.

22. Causes of Obesity in Elderly
 What happens to basal metabolic rate?
It decreases because of decrease in FFM.
 What is the thermic effect of food (TEF)
and what happens to it?

23. Causes of Obesity in Elderly
 What happens to basal metabolic rate?
It decreases because of decrease in FFM.
 What is the thermic effect of food (TEF)
and what happens to it?

24. Causes of Obesity in Elderly
 Thermic effect of food (TEF) is simply the
energy used in digestion, absorption and
distribution of nutrients.
 Thermic effect of food (TEF) also declines
with ageing.

25. Causes of Obesity in Elderly
 What about the physical activity
component?

26. Causes of Obesity in Elderly
 What about the physical activity
component?
Actually the declines in physical activity with
ageing contributes to almost 50% of the
reduction in EO that occurs with ageing.

27. Mortality
 Obesity is associated with a higher relative
risk of death for younger adults than for older
ones.
 An elevated BMI  increase in absolute
mortality and health risk linearly up to 75
years of age.
 One explanation for this demographic shift is
selective mortality.

28. Comorbid conditions
 Insulin resistance & type II DM
 Dyslipidemia (high TG, Low HDL)
 HTN
 CAD
 Increase in joint immobility and arthritis
 Obstructive sleep apnea
 Neoplasia
 Urinary incontinence

29. Comorbid conditions
 Higher rate of Nursing home admission.
 Frailty syndrome (96% of community- living
obese (BMI >30) elderly (65-80 years old) are
frail.
 Relative sarcopenia,
 Functional dependence and poor quality of
life.

30. Beneficial effects of Obesity
 Decrease in osteoporosis- related fractures:
1- Increased adipose tissue conversion of
androstenedione to estrone.
2- Extra cushioning provided by body fat.

31. Mechanisms by which obesity
increases mortality & morbidity
 Adipose tissue is recognized as a source of
inflammatory mediators by producing
cytokines such as:


 It is postulated that visceral fat ( Intra-
abdominal fat) is most responsible for
producing these cytokines.

32. Effects of intentional weight loss
in older adults
 Weight loss results in decrease in both fat
mass (75%) and FFM (25%), it is possible
that weight loss in obese older persons could
worsen the age related loss in muscle mass.

33. Physical function- quality of life
 It is well known that weight loss improves or
normalizes metabolic abnormalities
associated with obesity in young and middle
aged persons. Clinical trials shows similar
results in elderly.
 Weight loss in combination with exercise
training showed beneficial effect on muscle
strength.

34. Physical function- quality of life
 One study demonstrated that diet- induced
weight loss programs can indeed improve
both endurance capacity and exercise
tolerance in obese older adults despite loss
of FFM.

35. Bone mineral density
 A clinical trial conducted in young and
middle- aged persons showed that diet-
induced weight loss, but not exercise –
induced weight loss, is associated with
decrease in bone mineral density (BMD).
 However, one study showed that moderate
weight loss even when combined with
exercise decreases BMD in elderly.

36. Mortality
 In epidemiologic studies, it has been
observed that older adults who lost weight, or
who experienced weight recycling, had an
increased relative mortality risk compared
to those who were weight- stable.

37. Effects of intentional weight loss
in older adults
 SHOULD OBESE ELDERLY LOSE WEIGHT
OR NOT?

38. Weight Loss

.

39. Weight Loss
 HOW?

40. Lifestyle interventions
 HOW?
 Life- style intervention is just in
older subjects as in younger ones.

41. Diet Therapy
 A successful Diet- induced weight loss
program should have a goal:
 8% to 10% reduction in initial body weight
by 6 months.
 Following a calorie- reduced ( calorie deficit –
500 to 1000 kcal/d), but balance diet that
provides 1 to 2 pounds weight loss a week.

42. Exercise Therapy
 Exercise should be started gradually and
must be customized individually.
 It should be started at low to moderate
intensity.
 A multicomponent program including:
stretching, Aerobic activity and strength
exercises is the most appropriate.
 Very old & frail should not be excluded.

43. Exercise Therapy
 HHS 2008 guidelines describes the range of
relative intensity using a scale from 0 to 10:
 Sitting = 0
 All-out effort = 10
 Moderate intensity is 5,produces noticeable
increase in HR and breathing.
 Vigorous –intensity activity is 7-8 produces
large increase in HR & breathing.

44. Exercise Therapy
Talk Test
 During moderate intensity exercise patient
should be able to talk without pauses, but not
sing.
 During vigorous activity, a person cannot say
more than few words without pausing for
breath.

45. Pharmacotherapy
 Limited data are available.
 Can increase in likelihood of noncompliance
and errors.
 All medications should be carefully reviewed
for interactions.
 Antipsychotics, antidepressants,
anticonvulsants, steroids can cause weight
gain.

46. Bariatric Surgery
 The available evidence for safety and
effectiveness is insufficient.
 It should be considered for selective older adults
who have disabling obesity that can be
ameliorated with weight loss and have failed
multiple weight loss attempts in the past.
 The multidisciplinary team should evaluate the
case carefully prior to surgery.

47. References
 Brocklehurst’s Textbook of Geriatric Medicine
and Gerontology, 7th Edition,
 Geriatrics Review Syllabus, 8th edition
 British Medical Bulletin, Volume 97, Issue Pp.
169-196,
 The American Journal of Clinical Nutrition,
 CDC/NCHS, National Health and Nutrition
Examination Survey, 2007‒2010.