Obesity paradox in elderly patients with cardiovascular diseases

Obesity paradox of cardiovascular mortality in older adults in the United States: A cohort study using 1997-2018 National Health Interview Survey data linked with the National Death Index

BACKGROUND

Large-scale, population-based investigations primarily investigating the association between body mass index (BMI) and cardiovascular disease (CVD) mortality among older and younger adults in the United States (U.S.) are lacking.

OBJECTIVE

To evaluate the relationship between BMI and CVD mortality in older (≥65 years) and younger (<65 years) adults and to identify the nadir for CVD mortality.

DESIGN

This cohort study used serial cross-sectional data from the 1997 to 2018 National Health Interview Survey (NHIS) linked with the National Death Index. NHIS is an annual nationally representative household interview survey of the civilian noninstitutionalized U.S.

POPULATION

SETTING

Residential units of the civilian noninstitutionalized population in the U.S.

PARTICIPANTS

The target population for the NHIS is the civilian noninstitutionalized U.S. population at the time of the interview. We included all adults who had BMI data collected at 18 years and older and with mortality data being available. To minimize the risk of reverse causality, we excluded adults whose survival time was ≤2 years of follow-up after their initial BMI was recorded and those with prevalent cancer and/or CVD at baseline.

METHODS

We used the BMI record obtained in the year of the NHIS survey. Total CVD mortality used the NHIS data linked to the latest National Death Index data from the survey inception to December 31, 2019. We performed multivariable Cox proportional hazards regression models to estimate adjusted hazard ratios (aHRs) and 95 % confidence intervals (CIs).

RESULTS

The study included 425,394 adults; the mean (SD) age was 44 (16.7) years. During a median follow-up period of 11 years, 12,089 CVD-related deaths occurred. In older adults, having overweight was associated with a lower risk of CVD mortality (aHR 0.92 [95 % CI, 0.87-0.97]); having class I obesity (1.04 [0.97-1.12]) and class II obesity (1.12 [1.00-1.26]) was not significantly associated with an increased CVD mortality; and having class III obesity was associated with an increased risk of CVD mortality (1.63 [1.35-1.98]), in comparison with adults who had a normal BMI. Yet, in younger adults, having overweight, class I, II, and III obesity was associated with a progressively higher risk of CVD mortality. The nadir for CVD mortality is 28.2 kg/m2 in older adults and 23.6 kg/m2 in younger adults.

CONCLUSION

This U.S. population-based cohort study highlights the significance of considering age as a crucial factor when providing recommendations and delivering self-care educational initiatives for weight loss to reduce CVD mortality.

Examining Age-Adjusted Associations between BMI and Comorbidities in Mongolia: Cross-Sectional Prevalence

(1) Background: This study investigated the association between body mass index (BMI) categories and comorbidities in the context of a developing country, utilizing data from a nationwide health screening in Mongolia. (2) Methods: The study included 181,080 individuals (mean age 47.0 ± 15.3, 42.0% male) from the population-based general health screening. We counted the number of diseases from participants' medical records based on ICD-10 codes, excluding those categorized under Z00-Z99 and codes indicating acute disorders, as well as individuals classified as underweight. (3) Results: Among study participants, the prevalence of two or more comorbidities was 4.2%. The weight distribution comprised 40.4% normal weight; 37.1% overweight; and 16.9%, 4.4%, and 1.2% in the Class I, II, and III obesity categories, respectively. Comorbidities increased with BMI: normal weight (0.222); overweight (0.255); and Class I (0.290), Class II (0.302), and Class III obesity (0.303), suggesting a dose-dependent likelihood of having multiple diseases. Adjusted linear regression (beta coefficients, 95% CIs) showed increased comorbidity risks in overweight (0.017, 0.013-0.021) and obesity (0.034, 0.030-0.039). Interaction analysis with age revealed a significant effect (p < 0.001). While comorbidities tend to increase with higher BMI categories in all age-tertile groups, this association was notably stronger among younger individuals. (4) Conclusions: Obesity is associated with a twofold increase in the prevalence of multiple comorbidities compared to normal weight. Our findings also highlight the critical role of age in the development of multiple diseases, with BMI remaining a significant factor across various age groups, encompassing both younger and older adults.

Obesity pharmacotherapy in older adults: a narrative review of evidence

The prevalence of obesity in older adults (people aged >60 years) is increasing in line with the demographic shift in global populations. Despite knowledge of obesity-related complications in younger adults (increased risk of type 2 diabetes, liver and cardiovascular disease and malignancy), these considerations may be outweighed, in older adults, by concerns regarding weight-loss induced reduction in skeletal muscle and bone mass, and the awareness of the 'obesity paradox'. Obesity in the elderly contributes to various obesity-related complications from cardiometabolic disease and cancer, to functional decline, worsening cognition, and quality of life, that will have already suffered an age-related decline. Lifestyle interventions remain the cornerstone of obesity management in older adults, with emphasis on resistance training for muscle strength and bone mineral density preservation. However, in older adults with obesity refractory to lifestyle strategies, pharmacotherapy, using anti-obesity medicines (AOMs), can be a useful adjunct. Recent evidence suggests that intentional weight loss in older adults with overweight and obesity is effective and safe, hence a diminishing reluctance to use AOMs in this more vulnerable population. Despite nine AOMs being currently approved for the treatment of obesity, limited clinical trial evidence in older adults predominantly focuses on incretin therapy with glucagon-like peptide-1 receptor agonists (liraglutide, semaglutide, and tirzepatide). AOMs enhance weight loss and reduce cardiometabolic events, while maintaining muscle mass. Future randomised controlled trials should specifically evaluate the effectiveness of novel AOMs for long-term weight management in older adults with obesity, carefully considering the impact on body composition and functional ability, as well as health economics.

Obesity paradox in older sarcopenic adults - a delay in aging: A systematic review and meta-analysis

The prognostic significance of obesity in sarcopenic adults is controversial. This systematic review and meta-analysis aimed to investigate the effect of additional obesity on health outcomes in sarcopenia. MEDLINE, EMBASE, Scopus and CENTRAL were systematically searched for studies to compare health outcomes of adults with sarcopenic obesity (SO) to those of sarcopenic non-obese (SNO) adults. We also considered the methods of assessing obesity. Of 15060 records screened, 65 papers were included (100612 participants). Older community-dwelling SO adults had 15% lower mortality risk than the SNO group (hazard ratio, HR: 0.85, 95% confidence interval 0.76, 0.94) even when obesity was assessed by measurement of body composition. Additionally, meta-regression analysis revealed a significant negative linear correlation between the age and the HR of all-cause mortality in SO vs. SNO community-dwelling adults, but not in severely ill patients. Compared with SNO, SO patients presented lower physical performance, higher risk for metabolic syndrome, but similar cognitive function, risk of falls and cardiovascular diseases. Age-related obesity, SO and later fat loss leading to SNO represent consecutive phases of biological aging. Additional obesity could worsen the health state in sarcopenia, but above 65 years SO represents a biologically earlier phase with longer life expectancy than SNO.

Monitoring body composition change for intervention studies with advancing 3D optical imaging technology in comparison to dual-energy X-ray absorptiometry

BACKGROUND

Recent 3-dimensional optical (3DO) imaging advancements have provided more accessible, affordable, and self-operating opportunities for assessing body composition. 3DO is accurate and precise in clinical measures made by DXA. However, the sensitivity for monitoring body composition change over time with 3DO body shape imaging is unknown.

OBJECTIVES

This study aimed to evaluate the ability of 3DO in monitoring body composition changes across multiple intervention studies.

METHODS

A retrospective analysis was performed using intervention studies on healthy adults that were complimentary to the cross-sectional study, Shape Up! Adults. Each participant received a DXA (Hologic Discovery/A system) and 3DO (Fit3D ProScanner) scan at the baseline and follow-up. 3DO meshes were digitally registered and reposed using Meshcapade to standardize the vertices and pose. Using an established statistical shape model, each 3DO mesh was transformed into principal components, which were used to predict whole-body and regional body composition values using published equations. Body composition changes (follow-up minus the baseline) were compared with those of DXA using a linear regression analysis.

RESULTS

The analysis included 133 participants (45 females) in 6 studies. The mean (SD) length of follow-up was 13 (5) wk (range: 3-23 wk). Agreement between 3DO and DXA (R2) for changes in total FM, total FFM, and appendicular lean mass were 0.86, 0.73, and 0.70, with root mean squared errors (RMSEs) of 1.98 kg, 1.58 kg, and 0.37 kg, in females and 0.75, 0.75, and 0.52 with RMSEs of 2.31 kg, 1.77 kg, and 0.52 kg, in males, respectively. Further adjustment with demographic descriptors improved the 3DO change agreement to changes observed with DXA.

CONCLUSIONS

Compared with DXA, 3DO was highly sensitive in detecting body shape changes over time. The 3DO method was sensitive enough to detect even small changes in body composition during intervention studies. The safety and accessibility of 3DO allows users to self-monitor on a frequent basis throughout interventions. This trial was registered at clinicaltrials.gov as NCT03637855 (Shape Up! Adults; https://clinicaltrials.gov/ct2/show/NCT03637855); NCT03394664 (Macronutrients and Body Fat Accumulation: A Mechanistic Feeding Study; https://clinicaltrials.gov/ct2/show/NCT03394664); NCT03771417 (Resistance Exercise and Low-Intensity Physical Activity Breaks in Sedentary Time to Improve Muscle and Cardiometabolic Health; https://clinicaltrials.gov/ct2/show/NCT03771417); NCT03393195 (Time Restricted Eating on Weight Loss; https://clinicaltrials.gov/ct2/show/NCT03393195), and NCT04120363 (Trial of Testosterone Undecanoate for Optimizing Performance During Military Operations; https://clinicaltrials.gov/ct2/show/NCT04120363).

Sociodemographic and behavioural risk factors for obesity among community-dwelling older adults in Ghana and Nigeria: A secondary analysis of data from the SIREN study

OBJECTIVES

To explore the prevalence and risk factors of obesity among older adults from low- and middle-income countries (LMICs).

METHODS

This is a secondary analysis of data obtained from the SIREN study through in-person interviews and measurements from healthy stroke-free older adults (≥60 years). Overweight/obesity was defined as body mass index ≥25 kg/m². Abdominal obesity was defined as waist-to-hip ratio (WHR) of >0.90 for males and >0.85/females or waist circumference (WC) of >102 cm for males/>88 cm for females. Adjusted odds ratio (aORs) with 95% confidence interval (CIs) of the relationship between obesity and sociodemographic factors were assessed at P < 0.05.

RESULTS

Overall, 47.5% of participants were overweight/obese, 76.6% had a larger than recommended WHR, and 54.4% had a larger than recommended WC. Abdominal obesity (WC; aOR: 9.43, CI: 6.99-12.50), being a Nigerian (aOR: 0.55; CI: 0.42-0.72), living in an urban setting (aOR: 1.92; CI: 1.49-2.46), earning >$100/month (aOR: 1.53; CI: 1.19-1.96), and having formal education (aOR: 1.42; CI: 1.08-1.87) were associated with overweight/obesity.

CONCLUSION

Living in urban settings, earning a higher income, and having a formal education were associated with a higher odds of obesity among older adults from LMICs.

Association of social capital with obesity among older adults in China: a cross-sectional analysis

Background

Under the global aging trend, health issues of the elderly have received more and more attention. Among them, older adults’ obesity is one of the common health problems of the elderly. The association between social capital and obesity in the older adults has been analysed and discussed in previous studies but remains controversial. There are few studies on the association between social capital and obesity in the older adults in China. We examined whether social capital was associated with obesity in Chinese older adults.

Methods

The data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) —wave 8 (2017–2018) was used in this study. Totally, 10,164 respondents were included in the final analysis. Generalized trust, social participation (informal social interaction and participation of organized social activities), and social support was used as measures of social capital. Obesity status was defined by body mass index (BMI). Logistic regression analyses were used to assess associations between the social capital and obesity, adjusting for confounders.

Results

We found that the older adults who did not trust people around had greater odds of being overweighted/obese compared to those who trust [Adjusted Odds Ratio (AOR) 1.155, 95% CI 1.045 to 1.265]. The older adults having formal participation (participating in organized social activities) registered considerably higher BMI (AOR 1.155, 95% CI 1.041 to 1.269). The older adults who did not trust people around them had greater odds of being overweighted/obese both in males (AOR 1.172, 95% CI 1.012–1.333) and in females (AOR 1.155, 95% CI 1.004–1.306). Males having formal social participation were more likely to be overweighted/obese (AOR 1.181, 95% CI 1.024 to 1.337), but not in females.

Conclusions

Generalized trust and formal social participation was associated with overweight/obesity among older adults in China. Targeted obesity interventions for older adults are needed by developing public health policies for social capital optimization.

Relationship of body mass index with frailty and all-cause mortality among middle-aged and older adults

BACKGROUND

Parallel to growth of aging and obese populations, the prevalence of metabolic diseases is rising. How body mass index (BMI) relates to frailty and mortality across frailty levels is controversial. We examined the associations of high BMI with frailty and mortality and explored the effects of percent body fat on these associations.

METHODS

We included 29,937 participants aged ≥50 years from the 2001-2006 National Health and Nutrition Examination Survey (NHANES) cohorts (N=6062; 53.7% females) and from wave 1 (2004) of Survey of Health, Ageing and Retirement in Europe (SHARE) (N=23,875; 54% females). BMI levels were categorized as: normal: 18.5-24.9 kg/m², overweight: 25.0-29.9, obese grade 1: 30.0-34.9, and obese grade 2 or 3: >35.0. A frailty index (FI) was constructed excluding nutrition-related items: 36 items for NHANES and 57 items for SHARE. We categorized the FI using 0.1-point increments: FI ≤ 0.1 (non-frail), 0.1 < FI ≤ 0.2 (very mildly frail), 0.2 < FI ≤ 0.3 (mildly frail), and FI > 0.3 (moderately/severely frail). Percent body fat was measured using DXA for NHANES participants. All-cause mortality data were obtained until 2015 for NHANES and 2017 for SHARE to estimate 10-year mortality risk. All analyses were adjusted for age, sex, educational, marital, employment, and smoking statuses.

RESULTS

Mean age of participants was 63.3±10.2 years for NHANES and 65.0±10.0 years for SHARE. In both cohorts, BMI levels ≥25 kg/m² were associated with higher frailty, compared to normal BMI. In SHARE, having a BMI level greater than 35 kg/m² increased mortality risk in participants with FI≤0.1 (HR 1.31, 95%CI 1.02-1.69). Overweight participants with FI scores >0.3 were at lower risk for mortality compared to normal BMI [NHANES (0.79, 0.64-0.96); SHARE (0.71, 0.63-0.80)]. Higher percent body fat was associated with higher frailty. Percent body fat significantly mediated the relationship between BMI levels and frailty but did not mediate the relationship between BMI levels and mortality risk.

CONCLUSIONS

Being overweight or obese is associated with higher frailty levels. In this study, we found that being overweight is a protective factor of mortality in moderately/severely frail people and obesity grade 1 may be protective for mortality for people with at least a mild level of frailty. In contrast, obesity grades 2 and 3 may be associated with higher mortality risk in non-frail people. The relationship between BMI and frailty is partially explained by body fat.

Sex-different changes of body composition in aging: a systemic review

OBJECTIVE

Aging causes changes in body composition, in which differences in the distribution and amount of fat and muscle tissue affect the development of various diseases according to sex. We conducted a systemic review of the literature and examined the relationship between body composition differences and related health conditions or diseases in older men and women.

METHODS

Three different electronic databases (MEDLINE, Web of Science, and Embase) were used to find articles from 2000 until March 2022. Information on the study design characteristics, setting, measure of body composition, and health outcomes was extracted.

RESULTS

A total of 217 articles were retrieved, and 28 studies met the inclusion criteria. The included studies showed that older men have larger skeletal muscle mass (sMM) than women, while older women have larger fat mass (FM) than men. sMM has a favorable effect on physical performance, bone density, metabolism, cognitive function, and mortality in both men and women; however, the effects of sMM in women are less significant and even negligible compared to those in men. FM is significantly unfavorable for physical performance in women but sometimes favorable or unfavorable for glucose level and cognitive and lung function according to location. FM in men is usually less important for function, bone density, glucose level, and cognitive function than in women.

CONCLUSION

Changes in muscle and fat distribution according to aging and their correlation with health outcomes differ according to sex. Muscle mass may not always be favorable, and fat mass may not always be unfavorable in older adults.

Associations of BMI with all-cause mortality in normoglycemia, impaired fasting glucose and type 2 diabetes mellitus among an elderly Chinese population: a cohort study

Aim

To explore the associations of body mass index (BMI) and mortality among people with normal fasting glucose (NFG), impaired fasting glucose (IFG), and type 2 diabetes mellitus (T2DM) in an elderly Chinese population. 

Methods

A retrospective cohort study was conducted that included 59,874 elderly people who were aged 60 and older at baseline. Data for the study came from a health check-up program in China between 2011 and 2019. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using multivariable Cox proportional hazard models of BMI categories by glycemic status.

Results

During the median of 5.96 years of follow-up, 7928 participants died (6457/49057 with NFG, 712/5898 with IFG and 759/4919 with T2DM). In adjusted Cox models, risk of mortality showed a decreasing trend with BMI < 18.5 kg/m², 24 ≤ BMI < 28 kg/m², and BMI ≥ 28 kg/m² compared to 18.5 ≤ BMI < 24 kg/m²: HR (95% CI): 1.33 (1.18 to 1.49), 0.88 (0.83 to 0.93), and 0.90 (0.82 to 0.98), respectively, for NFG; 0.89 (0.55 to 1.46), 0.84 (0.71 to 0.99), and 0.88 (0.70 to 1.11), respectively, for IFG; and 1.42 (0.88 to 2.29), 0.75 (0.64 to 0.89), and 0.76 (0.62 to 0.93), respectively, for T2DM. There were curvilinear-shaped associations between BMI and mortality in the NFG and T2DM groups (P overall < 0.001 and P overall < 0.001, respectively; P nonlinearity < 0.001 and P nonlinearity = 0.027, respectively) and no significantly association between BMI and all-cause mortality was observed in the IFG group (P overall = 0.170).

Conclusion

High BMI compared to normal BMI was associated with decreased mortality, especially in the old populations with NFG and T2DM. Future studies are needed to explain the obesity paradox in elderly patients with T2DM.

Relationship of body mass index to clinical outcomes after percutaneous coronary intervention

BACKGROUND

Elevated body mass index (BMI) demonstrates lower all-cause and cardiovascular mortalities compared with normal-weight or lean patients in chronic diseases. This study investigated relationships between BMI and clinical outcomes following percutaneous coronary intervention (PCI) in coronary artery disease (CAD) patients, together with the sex-specific impacts of BMI on mortality.

METHODS

We reviewed 1104 CAD patients who underwent PCI between 2006 and 2015. Patients were divided by BMI into three groups: lean, <18.5 kg/m² ; normal, 18.5-24.9 kg/m² ; and overweight/obese, ≥25 kg/m² . The primary endpoint was all-cause mortality, and the secondary endpoint was 3-point major adverse cardiovascular events (MACE).

RESULTS

Kaplan-Meier survival analysis demonstrated risks of all-cause death, and 3-point MACE were higher in lean patients compared with normal-weight and overweight/obese subjects (log-rank p < .001). Cox proportional hazard modelling showed overweight/obese was significantly associated with all-cause death (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.48-0.95; p = .03), and lean was significantly associated with 3-point MACE (HR 2.02, 95% CI 1.15-3.53; p = .01). Cox proportional hazard analysis with restricted cubic spline showed non-linear associations between BMI and both all-cause mortality and 3-point MACE (p for effect = .002 and = .003, respectively). No significant interaction was evident between sex and BMI for all-cause mortality (p for interaction = .104) or 3-point MACE (p for interaction =0.122).

CONCLUSIONS

Lean category was associated with adverse outcomes among CAD patients. An obesity paradox regarding the independent association of elevated BMI with reduced mortality after PCI is evident in both males and females.

Frailty in older adults with heart disease

BACKGROUND

Heart failure prevalence will double in the next 40 years and affects more than 10% of persons over the age of 70 years in an age-dependent manner. Frailty is an age-associated clinical syndrome defined as a decrease in physiological reserve in situations of stress, such as operations, infections and acute illness based on a state of higher vulnerability. The prevalence is up to 74% in older individuals over the age of 80 years or those over 70 years old with a high burden of comorbidities and chronic diseases. This geriatric syndrome is associated with a worse clinical outcome and higher morbidity and mortality in acute and chronic disease than in age-matched cohorts without this syndrome.

METHODS

In this brief review, the scientific evidence of appropriate tools for diagnosis of frailty in heart failure patients is addressed. Heart failure management in this special group of patients requires a holistic care planning presented here in accordance with pathophysiologic particularities. A literature search in PubMed using the terms "heart failure" and "frailty" was carried out and a further search in the references based on the findings.

CONCLUSION

The diagnosis of frailty should influence the intensity of further diagnostic investigations and medical treatment based on the personal wishes of the patient, reduced organ reserves and general prognosis. The prognosis of heart failure patients remains poor, partially due to the intertwining with frailty. A clear statement for the use of an appropriate diagnostic tool for frailty and heart failure and specific therapeutic recommendations are presented based on clinical evidence.

Does the "obesity paradox" exist after transcatheter aortic valve implantation?

Background

Transcatheter aortic valve implantation (TAVI) for symptomatic aortic stenosis is considered a minimally invasive procedure. Body mass index (BMI) has been rarely evaluated for pulmonary complications after TAVI. This study aimed to assess the influence of BMI on pulmonary complications and other related outcomes after TAVI.

Methods

The clinical data of 109 patients who underwent TAVI in our hospital from May 2018 to April 2021 were retrospectively analyzed. Patients were divided into three groups according to BMI: low weight (BMI < 21.9 kg/m², n = 27), middle weight (BMI 21.9–27.0 kg/m², n = 55), and high weight (BMI > 27.0 kg/m², n = 27); and two groups according to vascular access: through the femoral artery (TF-TAVI, n = 94) and through the transapical route (TA-TAVI, n = 15). Procedure endpoints, procedure success, and adverse outcomes were evaluated according to the Valve Academic Research Consortium (VARC)-2 definitions.

Results

High-weight patients had a higher proportion of older (p < 0.001) and previous percutaneous coronary interventions (p = 0.026), a higher percentage of diabetes mellitus (p = 0.026) and frailty (p = 0.032), and lower glomerular filtration rate (p = 0.024). Procedure success was similar among the three groups. The 30-day all-cause mortality of patients with low-, middle-, and high weights was 3.7% (1/27), 5.5% (3/55), and 3.7% (1/27), respectively. In the multivariable analysis, middle- and high-weight patients exhibited similar overall mortality (middle weight vs. low weight, p = 0.500; high weight vs. low weight, p = 0.738) and similar intubation time compared with low-weight patients (9.1 ± 7.3 h vs. 8.9 ± 6.0 h vs. 8.7 ± 4.2 h in high-, middle-, and low-weight patients, respectively, p = 0.872). Although high-weight patients had a lower PaO₂/FiO₂ ratio than low-weight patients at baseline, transitional extubation, and post extubation 12th hour (p = 0.038, 0.030, 0.043, respectively), there were no differences for post extubation 24th hour, post extubation 48th hour, and post extubation 72nd hour (p = 0.856, 0.896, 0.873, respectively). Chronic lung disease [odds ratio (OR) 8.038, p = 0.001] rather than high weight (OR 2.768, p = 0.235) or middle weight (OR 2.226, p = 0.157) affected postoperative PaO₂/FiO₂ after TAVI.

Conclusions

We did not find the existence of an obesity paradox after TAVI. BMI had no effect on postoperative intubation time. Patients with a higher BMI should be treated similarly without the need to deliberately extend the intubation time for TAVI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01910-x.

Abdominal Visceral Adipose Tissue and All-Cause Mortality: A Systematic Review

INTRODUCTION

Increased abdominal visceral adipose tissue (VAT) implies an adverse cardio-metabolic profile. We examined the association of abdominal VAT parameters and all-cause mortality risk.

METHODS

We systematically searched four databases. We performed citations/articles screening, data abstraction, and quality assessment in duplicate and independently (CRD42020205021).

RESULTS

We included 12 cohorts, the majority used computed tomography to assess abdominal VAT area. Six cohorts with a mean age ≤ 65 years, examining all-cause mortality risk per increment in VAT area (cm²) or volume (cm³), showed a 11-98% relative risk increase with higher VAT parameters. However, the association lost significance after adjusting for glycemic indices, body mass index, or other fat parameters. In 4 cohorts with a mean age >65 years, the findings on mortality were inconsistent. Conversely, in two cohorts (mean age 73-77 years), a higher VAT density, was inversely proportional to VAT area, and implied a higher mortality risk.

CONCLUSION

A high abdominal VAT area seems to be associated with increased all-cause mortality in individuals ≤ 65 years, possibly mediated by metabolic complications, and not through an independent effect. This relationship is weaker and may reverse in older individuals, most likely secondary to confounding bias and reverse causality. An individual participant data meta-analysis is needed to confirm our findings, and to define an abdominal VAT area cutoff implying increased mortality risk.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=205021, identifier CRD42020205021.

The Relationship Between Obesity and Amputation-free Survival in Patients Undergoing Lower-limb Revascularisation for Chronic Limb-threatening Ischaemia: A Retrospective Cohort Study

BACKGROUND

The obesity paradox is a well-documented phenomenon in cardiovascular disease, however it remains poorly understood. We aimed to investigate the relationship between body mass (as measured by body mass index [BMI]) and 1-year amputation-free survival (AFS) for patients undergoing lower limb revascularisation for chronic limb-threatening ischaemia (CLTI).

METHODS

A retrospective analysis was undertaken of all consecutive patients undergoing lower limb revascularisation for CLTI at the Leicester Vascular Institute between February 2018-19. Baseline demographics and outcomes were collected using electronic records. BMI was stratified using the World Health Organization criteria. One-year AFS (composite of major amputation/death) was the primary outcome. Kaplan-Meier survival analysis and adjusted Cox's proportional hazard models were used to compare groups to patients of normal mass.

RESULTS

One-hundred and ninety patients were included. Overall, no difference was identified in 1-year AFS across all groups (pooled P = 0.335). Compared to patients with normal BMI (n = 66), obese patients (n = 43) had a significantly lower adjusted combined risk of amputation/death (aHR 0.39, 95% CI 0.16-0.92, P = 0.032), however no significant differences were observed for overweight (aHR 0.89, 95% CI 0.47-1.70, P = 0.741), morbidly obese (aHR 1.15, 95% CI 0.41-3.20, P = 0.797) and underweight individuals (aHR 1.86, 95% CI 0.56-6.20, P = 0.314).

CONCLUSIONS

In the context of CLTI, obesity is potentially associated with favourable amputation-free survival at 1 year, compared to normal body mass. The results of this study support the notion of an obesity paradox existing within CLTI and question whether current guidance on weight management requires a more patient-specific approach.

Obesity May Not Be a Risk of Non-Target Lesion Revascularization in the Elderly Patients

Obesity is assumed to be one of the robust risk factors for coronary artery disease. However, the effects of obesity on the progression of atherosclerosis in patients in different age groups after percutaneous coronary intervention (PCI) remain unclear. This study aimed to examine the effect of obesity on prognosis in different age groups.Consecutive patients who underwent urgent or elective PCI were surveyed for this study and were then divided into the elderly group and middle-aged group with a cut-off age of 70 years. All patients underwent coronary angiography or coronary computed tomography angiography 1 year after PCI to examine the progression of atherosclerosis. The primary endpoint was revascularization for a new lesion within 2 years after PCI. In addition, the main effects and correlations between obesity and age were examined. Multivariate logistic regression analysis was conducted to identify independent predictors of non-target lesion revascularization (non-TLR).Of the 711 patients who met the criteria and were available for follow-up analysis, the incidence of non-TLR within 2 years was 97/711 (13.6%). The higher incidence of non-TLR in patients with obesity was observed only in the middle-aged group. Furthermore, in the multivariate analysis, obesity was independently associated with non-TLR only in the middle-aged group.The findings of the present study would enable us to construct the hypothesis that obesity in elderly patients may not be an independent predictor of the incidence of non-TLR, indicating that the management to prevent non-TLR may vary depending on the age of the patient.

Association of Body Composition with Arterial Stiffness in Long-lived People

Fundamento

Pouco se conhece sobre a relação entre sarcopenia e hemodinâmica central em idosos longevos.

Objetivo

Estudar a relação da rigidez arterial com a composição corporal em idosos longevos.

Métodos

A composição corporal foi avaliada por meio da absortometria de Raio X de dupla energia (DEXA) e dos parâmetros de circulação central (PCC) obtidos por método oscilométrico não invasivo, com o Mobil-O-Graph 24h PWA Monitor®. Os parâmetros centrais avaliados foram: velocidade da onda de pulso (VOP), augmentation index (AIx), índice de amplificação da pressão de pulso (iAPP) e pressão de pulso central (PPc). Estes foram correlacionados com massa magra total (MM) e apendicular (MA), percentual de gordura corporal e índice de Baumgartner (IB). Aceitou-se nível de significância de 5%.

Resultados

Participaram 124 longevos, com idade média de 87,1 anos (DP±4,3 anos), sendo 74,2% mulheres e 57,3% brancos. Houve correlação inversa do AIx com as variáveis MM (r = - 0,391, p < 0,001), MA (r= -0,378, p< 0,001) e IB (r = -0,258, p 0,004). A PPc apresentou associação inversa com MM (r= -0,268, p =0,003), MA (r=-0,288, p= 0,001) e IB (r= -0,265, p = 0,003). Houve relação direta apenas entre AIx e percentual de gordura corporal (r= 0,197, p= 0,029).

Conclusão

Em idosos longevos, o percentual de gordura corporal se associa diretamente com a rigidez arterial e tem associação inversa com a quantidade de MM. Esses achados podem estar associados ao maior risco cardiovascular.

Associations between low body mass index and mortality in patients with sepsis: A retrospective analysis of a cohort study in Japan

Background

The distribution of body mass in populations of Western countries differs from that of populations of East Asian countries. In East Asian countries, fewer people have a high body mass index than those in Western countries. In Japan, the country with the highest number of older adults worldwide, many people have a low body mass index. Therefore, this study aimed to determine the association between a low body mass index and mortality in patients with sepsis in Japan.

Methods

We conducted this retrospective analysis of 548 patients with severe sepsis from a multicenter prospective observational study. Multivariate logistic regression analyses determined the association between body mass index and 28-day mortality adjusted for age, sex, pre-existing conditions, the occurrence of septic shock, Acute Physiology and Chronic Health Evaluation II scores, and Sequential Organ Failure Assessment scores. Furthermore, the association between a low body mass index and 28-day mortality was analyzed.

Results

The low body mass index group represented 18.8% of the study population (103/548); the normal body mass index group, 57.3% (314/548); and the high body mass index group, 23.9% (131/548), with the 28-day mortality rates being 21.4% (22/103), 11.2% (35/314), and 14.5% (19/131), respectively. In the low body mass index group, the crude and adjusted odds ratios (95% confidence intervals) for 28-day mortality relative to the non-low body mass index (normal and high body mass index groups combined) group were 2.0 (1.1–3.4) and 2.3 (1.2–4.2), respectively.

Conclusion

A low body mass index was found to be associated with a higher 28-day mortality than the non-low body mass index in patients with sepsis in Japan. Given that older adults often have a low body mass index, these patients should be monitored closely to reduce the occurrence of negative outcomes.

Nutritional Status of Non-Institutionalized Adults Aged over 65. Study of Weight and Health in Older Adults (PYSMA)

BACKGROUND

A significant increase in the prevalence of malnourishment, obesity, and sarcopenic obesity has been observed in developed countries over the last few decades. In Spain, this especially happens in populations over 65 who are not institutionalized. Differences in lifestyle, medication, and economic capacity partially explain this increase.

OBJECTIVE

To study the nutritional status of a population of 65 year-olds and subjects who are not institutionalized, in the Cádiz region (Spain).

METHODS

Observational, transversal study carried out on 2621 subjects who are 65 years old and over, with a direct weight and height measurement, in 150 pharmacy offices from 44 locations. A mobile application was designed for homogeneous data collection in all the pharmacy offices. The data required from all subjects was gender, age, postal code, social security contribution regime, if the patient lives alone, type of food consumed as the main meals, level of physical activity, polypharmacy, weight, and height.

RESULTS

The prevalence of overweight and obesity amounts to 82.2% of the population (43.2% overweight and 39% obese). We found an inverse relationship between the prevalence of overweight and obesity with carrying out physical activity and having full dinners.

CONCLUSION

We identify the need to reinforce the messages to the elderly aimed at maintaining adequate physical activity and assessing the quality and quantity of dinners, as well as reducing, as much as possible, the treatments that may lead to weight gain.

Identification of Mortality Risks in the Advancement of Old Age: Application of Proportional Hazard Models Based on the Stepwise Variable Selection and the Bayesian Model Averaging Approach

Identifying factors that affect mortality requires a robust statistical approach. This study’s objective is to assess an optimal set of variables that are independently associated with the mortality risk of 433 older comorbid adults that have been discharged from the geriatric ward. We used both the stepwise backward variable selection and the iterative Bayesian model averaging (BMA) approaches to the Cox proportional hazards models. Potential predictors of the mortality rate were based on a broad range of clinical data; functional and laboratory tests, including geriatric nutritional risk index (GNRI); lymphocyte count; vitamin D, and the age-weighted Charlson comorbidity index. The results of the multivariable analysis identified seven explanatory variables that are independently associated with the length of survival. The mortality rate was higher in males than in females; it increased with the comorbidity level and C-reactive proteins plasma level but was negatively affected by a person’s mobility, GNRI and lymphocyte count, as well as the vitamin D plasma level.

Digital Predictors of Morbidity, Hospitalization, and Mortality Among Older Adults: A Systematic Review and Meta-Analysis

The widespread adoption of digital health technologies such as smartphone-based mobile applications, wearable activity trackers and Internet of Things systems has rapidly enabled new opportunities for predictive health monitoring. Leveraging digital health tools to track parameters relevant to human health is particularly important for the older segments of the population as old age is associated with multimorbidity and higher care needs. In order to assess the potential of these digital health technologies to improve health outcomes, it is paramount to investigate which digitally measurable parameters can effectively improve health outcomes among the elderly population. Currently, there is a lack of systematic evidence on this topic due to the inherent heterogeneity of the digital health domain and the lack of clinical validation of both novel prototypes and marketed devices. For this reason, the aim of the current study is to synthesize and systematically analyse which digitally measurable data may be effectively collected through digital health devices to improve health outcomes for older people. Using a modified PICO process and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, we provide the results of a systematic review and subsequent meta-analysis of digitally measurable predictors of morbidity, hospitalization, and mortality among older adults aged 65 or older. These findings can inform both technology developers and clinicians involved in the design, development and clinical implementation of digital health technologies for elderly citizens.

Effect of Metabolic Health and Obesity Phenotype on the Risk of Pancreatic Cancer: A Nationwide Population-Based Cohort Study

BACKGROUND

Recently, a few studies have reported different results regarding the relationship between metabolic health and obesity phenotype and several cancers. We examined the effects of metabolic health and obesity phenotype on pancreatic cancer using a nationwide population-based cohort database.

METHODS

Using the Korean National Health Insurance Service-Health Screening Cohort, we enrolled 347,434 Korean adults who underwent a health examination between 2009 and 2010 and were followed until 2015. This population was divided into four groups based on metabolically healthy status and body mass index (BMI): metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO).

RESULTS

Over a median follow-up of 6.1 (5.5-6.5) years, 886 individuals were diagnosed with pancreatic cancer. The adjusted HRs for incident pancreatic cancer were 1.52 [95% confidence interval (CI) 1.27-1.81] and 1.34 (95% CI, 1.12-1.61) for the MUNW and MUO phenotypes (compared with the MHNW phenotype) after adjusting for various confounding factors. However, compared with the MHNW phenotype, the MHO phenotype did not show an elevated risk of pancreatic cancer. Moreover, the HR for pancreatic cancer gradually increased with an increase in number of metabolically unhealthy components, even after adjusting for BMI (P _trend < 0.001).

CONCLUSIONS

Regardless of BMI, metabolically unhealthy phenotype demonstrated significantly increased risk of pancreatic cancer, whereas obese individuals with metabolically healthy phenotype did not.

IMPACT

These findings suggest that metabolically unhealthy phenotype might represent a potential risk factor for pancreatic cancer occurrence independent of obesity.

Association between low muscle mass and metabolic syndrome in elderly Japanese women

Metabolic syndrome (MetS) is an important predictor of mortality in older adulthood, but it is not reliably related to measures of body composition such as body mass index in older adults, as opposed to those in earlier life stages. Previous research suggests that skeletal muscle mass is related to cardiovascular risk in older adulthood, but it is difficult to measure muscle mass accurately and independently of body fat. This study aimed to examine the relationship between body composition and cardiovascular risk factors among women in older adulthood. A cross-sectional observational clinical study was conducted at a single medical clinic in Tokyo, Japan. Participants included 90 healthy Japanese women aged 65 years and older. MetS risk factors were assessed. Appendicular skeletal muscle mass (ASM) was assessed using dual-emission X-ray absorptiometry. Visceral fat area (VFA) was measured using computed tomography. VFA positively correlated with ASM and MetS, whereas ASM and MetS did not correlate with each other. Using VFA and ASM data in a MetS multiple linear regression model, the association between VFA and MetS remained positive, whereas a significant negative relationship emerged between ASM and MetS. Lower muscle mass was independently associated with higher cardiovascular risk after controlling for VFA. Clinical interventions to reduce muscle loss in older adulthood may be beneficial for reducing the risk of MetS and improving cardiovascular health.

Healthcare provider counselling for weight management behaviours among adults with overweight or obesity: a cross-sectional analysis of National Health and Nutrition Examination Survey, 2011-2018

OBJECTIVES

To determine if adults with overweight or obesity received counselling from their healthcare providers (HCPs) to lose weight and/or adopt healthful behaviours associated with weight loss, and whether they took action on their HCPs' recommendations.

DESIGN

Cross-sectional analysis of 2011-2018 National Health and Nutrition Examination Survey (NHANES) data.

SAMPLE

NHANES respondents aged 18+ who were overweight/obese and had seen an HCP in the previous 12 months (n=13 158).

METHODS

Respondents reported if their HCPs recommended they control/lose weight, increase exercise/physical activity (PA) and/or reduce fat/calorie intake, and if they adopted the offered recommendation(s). Weighted logistic regression models examined receipt of HCP counselling by sex, age, race/ethnicity, and weight status accounting for demographic characteristics and complex sampling. Similar analyses examined reported adoption of HCPs' recommendations.

RESULTS

The sample was 53.1% women, 45.0% were overweight and 55.0% had obesity. In total, 40.4% received counselling to control/lose weight, 49.5% to increase exercise/PA and 38.9% to reduce fat/calorie intake. The following groups were less likely (p<0.001) to receive counselling: men; younger adults (aged 18-39) versus middle-aged (aged 40-64) and older adults (aged 65+); White versus Black and Hispanic respondents; overweight respondents versus respondents with obesity. Approximately half of those advised to make changes reported doing so (53.6% controlled/lost weight, 57.3% increased exercise/PA, 51.8% reduced fat/calorie intake). Differences in the adoption of recommendations were identified by sex, age group, race/ethnicity and weight status (all p<0.05); women, middle-aged and older adults, Black and Hispanic respondents and individuals with obesity were more likely to adopt one or more recommendations.

CONCLUSION

Most respondents did not receive HCP counselling, and approximately half of those who received counselling reported taking action. HCPs may need training to provide counselling and to offer recommendations tailored to the social contexts of populations less likely to adopt weight control related recommendations.

Association of obesity with cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease: Insights from TECOS

BACKGROUND

Obesity is a risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). Whether obesity affects outcomes among those with T2D and atherosclerotic CVD (ASCVD) remains uncertain. Our objective was to investigate the relationship between body mass index (BMI) and ASCVD outcomes among TECOS participants with T2D and ASCVD.

METHODS

BMI categories were defined as underweight/normal weight (BMI <25 kg/m²), overweight (25-29.9 kg/m²), obese class I (30-34.9 kg/m²), obese class II (35-39.9 kg/m²), and obese class III (≥ 40 kg/m²). Asian-specific BMI categories were applied to Asian participants. Kaplan-Meier survival analysis and Cox proportional hazards models were used to examine associations between baseline BMI and a composite CV outcome (CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina).

RESULTS

For 14,534 TECOS patients with available BMI, mean age was 65.5 years; 29.3% were female, 32.0% non-White, and 23.1% insulin-treated, with median 3 years' follow-up. At baseline, 11.6% (n = 1686) were underweight/normal weight, 38.1% (n = 5532) overweight, 32.2% (n = 4683) obese class I, 12.4% (n = 1806) obese class II, and 5.7% (n = 827) obese class III. The composite CV outcome occurred in 11.4% (n = 1663) of participants; the outcome risk was lower, compared with under/normal weight, in overweight (HR 0.83, 95% CI 0.71-0.98) and obese class I (HR 0.79, 95% CI 0.67-0.93) individuals. Obesity was not associated with worse glycemic control.

CONCLUSIONS

The majority of TECOS participants with ASCVD and T2D were overweight or obese, yet overweight or obese class I individuals had lower CV risk than those who were under/normal weight. These results suggest the presence of an obesity paradox, but this paradox may reflect an epidemiological artifact rather than a true negative association between normal weight and clinical outcomes.

Health Care Providers' Advice on Lifestyle Modification for Older Adults

OBJECTIVES

To describe the pattern of health care providers' advice on lifestyle modification to older adults, and identify correlates of receiving such advice.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Data from the National Health and Nutrition Examination Survey study from 2007-2016 on adults ≥65 years (n = 3758) were analyzed.

METHODS

We estimated the weighted prevalence and correlates of receiving advice on the following lifestyle modifications: (1) increase physical activity, (2) reduce fat/calories, (3) control/lose weight, and (4) a combination of control/lose weight and physical activity. Data were analyzed according to level of comorbidity (number of chronic conditions including high blood pressure, high blood cholesterol, type 2 diabetes mellitus, coronary heart disease, and arthritis) and body mass index (BMI).

RESULTS

Physical activity was the most widely prescribed lifestyle modification, reported by 15.7% of older adults free of chronic conditions and 28.9%, 35.4%, and 52.6% of older adults with 1, 2, and ≥3 comorbidities. Advice on reducing fat/calories was reported by 9.2%, 18.5%, 26.3%, and 40.9% of older adults with 0, 1, 2, and ≥3 comorbidities, respectively, and advice on weight loss/control was reported by 6.5%, 19.1%, 20.8%, and 37.5%, respectively. The combination of advice on weight loss/control and physical activity was least commonly reported: 5.1%, 13.5%, 16.6%, and 32.0%, respectively. Overall, lifestyle modifications were more frequently advised to older adults who were overweight, obese, or Hispanic.

CONCLUSIONS AND IMPLICATIONS

In the United States, lifestyle modifications are not routinely recommended to older adults, particularly those free of chronic conditions, presenting a missed opportunity for chronic disease prevention and management. Among those advised to lose or manage weight, concurrent advice to increase physical activity is not consistently provided.

Changes in Visceral Adipose Tissue Plasma Membrane Lipid Composition in Old Rats Are Associated With Adipocyte Hypertrophy With Aging

Increased adiposity, through adipocyte hypertrophy, and/or hyperplasia, characterizes aging and obesity. Both are leptin-resistant states, associated with disturbed lipid metabolism, reduced insulin sensitivity and inflammation. Nevertheless, fat tissue dysfunction appears earlier in obesity than in normal aging. In contrast, lipodystrophy is accompanied by diabetes, and improving the fat cell capacity to expand rescues the diabetic phenotype. Fat tissue dysfunction is extensively studied in the diet-induced obesity, but remains relatively neglected in the aging-associated obesity. In the Wistar rat, as occurs in humans, early or middle aging is accompanied by an increase in adiposity. Using this experimental model, we describe the molecular mechanisms contributing to the white adipose tissue (WAT) hypertrophy. WAT from middle-old age rats is characterized by decreased basal lipogenesis and lipolysis, increased esterification, as demonstrated by the higher TAG and cholesterol content in visceral WAT, and the maintenance of total ceramide levels within normal values. In addition, we describe alterations in the adipose tissue plasma membrane lipid composition, as increased total ether-phosphatidylcholine, sphingomyelin, and free cholesterol levels that favor an enlarged fat cell size with aging. All these metabolic changes may be regarded as a survival advantage that prevents the aged rats from becoming overtly diabetic.

Association between fulfilling the recommendations for health-enhancing physical activity with (instrumental) activities of daily living in older Austrians

Aim

The aim of the study was to describe the association between fulfilling the recommendation for health-enhancing physical activity (PA), and deficits in activities of daily living (ADL) and instrumental activities of daily living (IADL) in 3308 subjects aged 65+ years from the Austrian Health Interview Survey 2014.

Methods

The proportion of subjects who fulfilled the minimal recommendations for health-enhancing PA was assessed with the Physical Activity Questionnaire of the European Health Interview Survey (EHIS-PAQ). The ADLs were assessed based on the Barthel index, and IADLs by the IADL scale of Lawton and Brody. Additionally, various sociodemographic and health-related factors were assessed.

Results

Of the participants 54.7% did not fulfil the minimal requirements for aerobic PA, and 67.1% not for muscle strengthening PA, 16.4% reported ADL deficits, and 47.1% IADL deficits. Adjusted for sociodemographic and health-related parameters, not fulfilling the recommendations for aerobe PA was associated with a higher chance for ADL deficits (odds ratio, OR 1.73, 95%-confidence interval 1.36–2.21), and IADL deficits (1.57; 1.34–1.84). Not fulfilling the recommendations for muscle strengthening PA also increased the chance for ADL and IADLs deficits (1.34; 1.04–1.72, and 1.29; 1.09–1.53, respectively).

Conclusion

The number of participants who did not fulfil the minimal requirements for aerobic or strengthening PA was very high, and these participants showed significantly more problems in ADLs and IADLs. Therefore, all future efforts should focus on increasing participation and adherence in exercise programs for older people with the intention to improve their performance status and functions in daily life.

Body mass index and all-cause mortality in patients with atrial fibrillation: insights from the China atrial fibrillation registry study

BACKGROUND

Impact of body mass index (BMI) on all-cause mortality in atrial fibrillation (AF) patients remains controversial.

METHODS

A total of 10,942 AF patients were prospectively enrolled and categorized into four BMI groups: underweight (BMI < 18.5 kg/m²), normal weight (BMI 18.5-24 kg/m²), overweight (BMI 24-28 kg/m²) and obesity (BMI ≥ 28 kg/m²). The primary outcome was all-cause mortality. Different Cox proportional hazards models were performed to evaluate the association between BMI and all-cause mortality.

RESULTS

During a median follow-up of 30 months (IQR 18-48 months), 862 deaths events occurred. Compared to normal BMI, higher BMI was associated with a lower mortality risk (overweight: HR 0.70; 95% CI 0.61-0.81, P < 0.0001 and obesity: HR 0.54; 95% CI 0.44-0.67, P < 0.0001) and lower BMI was associated with a higher mortality risk (HR 2.23, 95% CI 1.67-2.97, P < 0.0001).

CONCLUSION

A reversed relationship between BMI and all-cause mortality in AF patients was found. Higher risk of mortality was observed in underweight patients compared to patients with a normal BMI, while overweight and obese patients had a lower risk of all-cause mortality.

CLINICAL TRIAL REGISTRATION

URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729.

Does Body Mass Index and Height Influence the Incident Risk of Ischemic Stroke in Newly Diagnosed Type 2 Diabetes Subjects?

OBJECTIVE

To estimate the incident risk of ischemic stroke (IS) in newly diagnosed type 2 diabetes (T2D) subjects according to different body mass index (BMI) and height categories.

METHODS

A total of 25,130 newly diagnosed T2D subjects were included in this study. All T2D subjects were enrolled consecutively from the Chronic Disease Surveillance System (CDSS) of Ningbo. Standardized incidence ratio (SIR) and its 95% confidence interval (95% CI) stratified by BMI categories and height quartiles were used to estimate the incident risk of IS in T2D subjects.

RESULTS

In total, 22,795 subjects completed the follow-up. Among them, 1268 newly diagnosed IS cases were identified, with 149,675 person-years. The SIRs of normal BMI (18.5-24.0 kg/m²), overweight (24.0-28.0 kg/m²), and obese (≥28.0 kg/m²) in overall subjects were 2.56 (95% CI 1.90-3.13), 2.13 (95% CI 1.90-3.13), and 1.87 (95% CI 1.29-2.43), respectively (P _trend < 0.01), comparing to the general population of Ningbo. For each 1 kg/m² increment in BMI, the SIR was 0.948 (95% CI 0.903-0.999). For height quartiles, the SIRs of male subjects in quartile 1 (<160 cm), quartile 2 (161-165 cm), quartile 3 (165-170 cm), and quartile 4 (≥171 cm) were 2.27 (95% CI 1.99-2.56), 2.01 (95% CI 1.67-2.45), 1.37 (95% CI 1.05-1.68), and 0.91 (95% CI 0.40-1.32), respectively (P _trend < 0.01). While for female subjects, the SIRs in quartile 1 (<155 cm), quartile 2 (156-160 cm), quartile 3 (161-165 cm), and quartile 4 (≥166 cm) were 3.57 (95% CI 3.11-3.49), 2.96 (95% CI 2.61-3.31), 1.94 (95% CI 1.51-2.36), and 1.71 (95% CI 0.95-2.47), respectively (P _trend < 0.01).

CONCLUSION

Compared to the general population of Ningbo, T2D subjects had a higher incident risk of IS. Furthermore, the IS incident risk was not only higher in newly diagnosed T2D subjects with normal BMI but also lower in taller newly diagnosed T2D subjects.

Body Mass Index and Mortality in Elderly Subjects from the Moli-Sani Study: A Possible Mediation by Low-Grade Inflammation?

The association between obesity and mortality in the elderly remains controversial. To test the association between BMI and mortality, with the hypothesis of a mediation by low-grade inflammation (LGI), a prospective study design (median follow-up 7.8 years) was used on a sample of 4,970 elderly subjects (age ≥ 65 years) from the Moli-sani Study cohort. The association between BMI categories and overall or cause-specific mortality (hazard ratio, HR) was calculated by multivariable Cox regression. Dose-response relationship was tested using restricted cubic splines. Interaction between BMI and LGI, assessed through high-sensitivity C-reactive protein (hs-CRP) and INFLA-score, was also tested. In comparison with normal-weight, overweight was significantly associated with a 20% (adjusted HR = 0.80; 95%CI 0.67-0.95) reduced risk of total mortality, while severe obesity (BMI > 40) with an increased risk (HR = 1.81; 95%CI 1.13-2.93). Cubic spline curves showed a U-shaped relationship between BMI and total mortality (p value for nonlinear relationship = 0.001). Similar results were found for cardio-cerebrovascular and other causes mortality. Hs-CRP and INFLA-score were associated with an increased risk of total mortality in adjusted analyses. Mediation analysis did not show any effect of LGI on the association between BMI and mortality. However, after stratification for LGI under or below the population median, greater LGI increased the risk of mortality in obese elderly more than expected (p for interaction = 0.04). A U-shaped association between BMI and mortality was observed in Italian elderly subjects. While the association was independent of LGI levels, there was a significant interaction between BMI and LGI in increasing mortality risk in obese elderly individuals.

Perspective on Diagnostic Criteria for Obesity and Abdominal Obesity in Korean Adults

Excessive body weight is associated with increased health risks in humans. In general, the risk of mortality increases with greater obesity. The 2018 guideline for the management of obesity by the Korean Society for the Study of Obesity proposed the body mass index (BMI) cut-off levels of 25 kg/m2 and 23 kg/m2 as diagnostic criteria for obesity and overweight (pre-obese) in Korean adults, respectively. Abdominal obesity has been defined as waist circumference (WC) ≥90 cm in men and WC ≥85 cm in women. In this review, the validity of these criteria for Korean adults was examined based on the evidence regarding the associations of obesity index with mortality and morbidity. The American Association of Clinical Endocrinologists/American College of Endocrinology algorithm and American Diabetes Association guideline for the medical care of obese and overweight patients support a BMI of 25 kg/m2 and 23 kg/m2, respectively, as the cut-off levels for Asians (and some ethnicities) corresponding to the BMI values of 30 kg/m2 and 25 kg/m2, respectively, for Caucasians. In the future, the optimal cut-off levels for obesity and abdominal obesity may require adjustment as the demographic characteristics of the Korean population change. In addition, development of more valid indicators that better reflect health risks of obesity is needed.

Obesity Paradox in Aging: From Prevalence to Pathophysiology

Recent advances in medical technology and health care have greatly improved the management for chronic diseases and prolonged human lifespan. Unfortunately, increased lifespan and the aging population impose a major challenge on the ever-rising prevalence of chronic diseases, in particular cardiometabolic stress associated with the pandemic obesity in our modern society. Although overweight and obesity are associated with incident cardiovascular diseases (CVD), including heart failure (HF), it paradoxically leads to a more favorable prognosis in patients with chronic HF, a phenomenon commonly defined as "obesity paradox". Numerous population-based and clinical studies have suggested possible explanations such as better metabolic reserve, smoking and disease-associated weight loss for obesity paradox. Recent evidence noticed a shift in obesity paradox with aging. While some studies have reported a more pronounced "obesity paradox" in the older patients, others have seen diminished cardiac benefits with overweight and obesity in the elderly patients with CVD. These findings suggested that a complex relationship among aging, metabolism, and HF severity/chronicity, which may explain the shift in obesity paradox in the elderly. Aging negatively affects body metabolism and cardiac function although its precise impact on obesity paradox remains elusive. To develop new strategies for cardiovascular health in the elderly, it is imperative to understand the precise role for aging on obesity-related CVD.

Elderly Obesity: Is It Harmful or Beneficial?

The prevalence of obesity among elderly populations is a matter of increasing concern. Elderly obesity is a pathophysiologically complex issue, and predictions regarding obesity-related comorbidity and weight management are challenging. As individuals age, changes in the body composition, such as increase in fat mass and decrease in muscle mass, are observed even in the absence of changes in body weight and body mass index. Hence, body mass index and other indices of obesity should be cautiously interpreted in the elderly, and weight loss should be recommended for obese elderly individuals with functional limitations or metabolic complications that may improve with weight loss. By the year 2026, more than 20% of the Korean population will be aged 65 years or older, and this along with the obesity epidemic is expected to pose an increasingly serious financial problem for the Korean healthcare system. This review summarizes the epidemiology of obesity in Korea, the clinical implications of elderly obesity, and considerations regarding weight management. Understanding the complexity of elderly obesity could facilitate the design of preventative and therapeutic strategies that would have a positive impact on the overall health of the Korean population.

Adiposity, body composition and ventricular-arterial stiffness in the elderly: the Atherosclerosis Risk in Communities Study

AIM

Weight gain appears to accelerate age-related ventricular-arterial stiffening, which has been implicated in the development of heart failure (HF), but it is unclear whether body fat accumulation underpins this association. We evaluated the relationship of adiposity, using measures of body composition, with ventricular-arterial stiffness among the elderly in the community.

METHODS AND RESULTS

Adiposity was accessed through body mass index (BMI), waist circumference, and body fat percentage. We studied the association of these measures with carotid-femoral pulse wave velocity (cfPWV), arterial elastance index (EaI), left ventricular (LV) end-systolic elastance index (EesI) and LV end-diastolic elastance index (EedI) in 5520 community-based, elderly Atherosclerosis Risk in Communities (ARIC) Study participants, who underwent echocardiography between 2011 and 2013. BMI and waist circumference were directly associated with EaI, EedI and EesI even after adjusting for age, sex, race, hypertension, diabetes mellitus, heart rate, prevalent coronary heart disease and HF. After further adjustment for BMI, body fat percentage demonstrated significant independent linear relationships with EaI [standardized beta coefficient (β)=0.17, P<0.001], EesI (β=0.08, P=0.003) and EedI (β=0.20, P<0.001), and significant non-linear relationships with cfPWV (P=0.033).

CONCLUSION

In this biracial community-based cohort, increased adiposity was associated with increased ventricular-arterial stiffness among the elderly and suggests a potential mechanism by which obesity might contribute to the development of HF.

Oxidative stress is increased in sarcopenia and associated with cardiovascular disease risk in sarcopenic obesity

OBJECTIVES

To define whether circulating markers of oxidative stress correlate with sarcopenia in terms of glutathione balance and oxidative protein damage, and whether these biomarkers are associated with risk of cardiovascular disease (CVD).

STUDY DESIGN

Population-based cross-sectional study. 115 out of 347 elderly subjects were classified as non-sarcopenic non-obese (NS-NO), sarcopenic non-obese (S-NO), non-sarcopenic obese (NS-O), and sarcopenic obese (S-O).

MAIN OUTCOME MEASUREMENTS

Sarcopenia was defined as a relative skeletal muscle mass index (RASM) <7.25kg/m² for men or <5.67kg/m² for women, while obesity was diagnosed in those presenting with% fat >27 for men or >38 for women. The CVD risk was estimated by the carotid intima-media thickness (IMT) and the Framingham score. Blood reduced glutathione (GSH), oxidized glutathione (GSSG), plasma malondialdehyde-(MDA) and 4-hydroxy-2,3-nonenal-(HNE) protein adducts were analyzed.

RESULTS

Significantly greater blood GSSG/GSH ratio and plasma MDA/HNE protein adducts were observed in sarcopenic than in non-sarcopenic patients. A logistic regression model showed a close relationship between serum HNE and MDA adducts and sarcopenia (OR=1.133, 95% CI 1.057-1.215, and OR=1.592, 95% CI 1.015-1.991, respectively). Linear and logistic regression analysis evidenced strong associations between the IMT or the Framingham CVD risk category and blood GSSG/GSH or serum HNE protein adducts in the S-O group.

CONCLUSION

Circulating markers of oxidative stress are increased in sarcopenia and related to CVD risk in sarcopenic obesity, suggesting that redox balance analysis would be a useful part of a multidimensional evaluation in aging. Further research is encouraged to support interventional strategies to correct redox imbalance, which might contribute to the prevention or at least limitation of sarcopenia and its co-morbidities.

Complex relationship of obesity and obesity paradox in heart failure - higher risk of developing heart failure and better outcomes in established heart failure

Heart failure (HF) and obesity are major public health problems. Studies have shown that obesity may increase the risk of developing new HF but after patients have developed HF, obesity may be associated with improved outcomes. This paradoxical association of obesity with HF remains poorly understood. It is believed that the obesity paradox may in part be due to the inherent limitations of body mass index (BMI) as a measure of obesity. BMI may not appropriately measure important components of body mass like body fat, fat distribution, lean body mass, and body fluid content and may not be ideal for examining the relationship of body composition with health outcomes. Differentiating between body fat and lean body mass may explain some of the paradoxical association between higher BMI and better prognosis in patients with HF. Paradoxical outcomes in HF may also be due to phenotypes of obesity. Future studies need to develop and test metrics that may better measure body composition and may serve as a better tool for the estimation of the true association of obesity and outcomes in HF and determine whether the association may vary by obesity phenotypes. KEY MESSAGES Obesity predisposes to heart failure in all age groups. But obesity in heart failure is an area of controversy, because of obesity paradox, the apparent protective effect of overweight and mild obesity on mortality after development of heart failure. Traditional markers of obesity do not measure different components of body weight like muscle mass, fat, water, and skeletal weight. Body Mass Index in heart failure subjects does not measure accurately body fat or fluid retention. So new markers of obesity like visceral adiposity index, body composition analysis, sarcopenic status assessment may be helpful in the assessment of heart failure outcomes. Different phenotypes of obesity may be responsible for the different morbidity, mortality as well as therapeutic outcomes in heart failure.

Long-term consumption of an obesogenic high fat diet prior to ischemia-reperfusion mediates cardioprotection via Epac1-dependent signaling

BACKGROUND

Obesity is still considered a risk factor for cardiovascular disease, although more recent knowledge also suggests obesity to be associated with reduced morbidity and mortality - the "obesity paradox". This study explores if long-term feeding of an obesogenic high fat diet renders the myocardium less susceptible to ischemic-reperfusion induced injury via Epac-dependent signaling.

METHODS

Wild type (wt), Epac1 (Epac1^-/-) and Epac2 (Epac2^-/-) deficient mice were fed a high fat (HFD) or normal chow diet (ND) for 33 ± 1 weeks. Six experimental groups were included: (1) control wt ND (wt ND), (2) control wt HFD (wt HFD), (3) Epac1^-/- mice on ND (Epac1^-/-ND), (4) Epac1^-/- mice on HFD (Epac1^-/-HFD), (5) Epac2^-/- mice on ND (Epac2^-/-ND), and (6) Epac2^-/- mice on HFD (Epac2^-/-HFD). Isolated ex vivo mice hearts were perfused in a constant pressure Langendorff mode, and exposed to 30min of global ischemia (GI) and 60min of reperfusion. Endpoints were infarct size and functional recovery.

RESULTS

All groups fed a HFD presented with significantly enhanced body weight, visceral fat content and reduced glucose clearance compared to corresponding ND groups. Although the HFD cohorts presented with an overall comparable systemic capability to clear glucose, the Epac1^-/- HFD group presented with glucose levels slightly above the human diabetes criteria at the end of the intraperitoneal glucose tolerance test (ipGTT). Moreover, the HFD significantly reduced infarct size in both wild type (wt HFD 41.3 ± 5.5% vs. wt ND 58.0 ± 9.8%, p < 0.05) and Epac2^-/- cohorts (Epac2^-/-HFD 34.4 ± 7.2% vs. Epac2^-/-ND 56.5 ± 3.8%, p < 0.05). Interestingly, however, the HFD did not reduce infarct size in Epac1^-/- deficient mice hearts (Epac1^-/-HFD 65.1 ± 5.1% vs. Epac1^-/-ND 56.1 ± 3.5%, ns.).

CONCLUSION

Epac1-dependent signaling is involved in mediating the cardioprotection afforded by long-term feeding of an obesogenic high fat diet in mice hearts.

Is Alzheimer's disease a Type 3 Diabetes? A critical appraisal

Recently researchers proposed the term 'Type-3-Diabetes' for Alzheimer's disease (ad) because of the shared molecular and cellular features among Type-1-Diabetes, Type-2-Diabetes and insulin resistance associated with memory deficits and cognitive decline in elderly individuals. Recent clinical and basic studies on patients with diabetes and AD revealed previously unreported cellular and pathological among diabetes, insulin resistance and AD. These studies are also strengthened by various basic biological studies that decipher the effects of insulin in the pathology of AD through cellular and molecular mechanisms. For instance, insulin is involved in the activation of glycogen synthase kinase 3β, which in turn causes phosphorylation of tau, which involved in the formation of neurofibrillary tangles. Interestingly, insulin also plays a crucial role in the formation amyloid plaques. In this review, we discussed significant shared mechanisms between AD and diabetes and we also provided therapeutic avenues for diabetes and AD. This article is part of a Special Issue entitled: Oxidative Stress and Mitochondrial Quality in Diabetes/Obesity and Critical Illness Spectrum of Diseases - edited by P. Hemachandra Reddy.

'Adipaging': ageing and obesity share biological hallmarks related to a dysfunctional adipose tissue

The increasing ageing of our societies is accompanied by a pandemic of obesity and related cardiometabolic disorders. Progressive dysfunction of the white adipose tissue is increasingly recognized as an important hallmark of the ageing process, which in turn contributes to metabolic alterations, multi-organ damage and a systemic pro-inflammatory state ('inflammageing'). On the other hand, obesity, the paradigm of adipose tissue dysfunction, shares numerous biological similarities with the normal ageing process such as chronic inflammation and multi-system alterations. Accordingly, understanding the interplay between accelerated ageing related to obesity and adipose tissue dysfunction is critical to gain insight into the ageing process in general as well as into the pathophysiology of obesity and other related conditions. Here we postulate the concept of 'adipaging' to illustrate the common links between ageing and obesity and the fact that, to a great extent, obese adults are prematurely aged individuals.

Obesity and Aging in Humans and Nonhuman Primates: A Mini-Review

The prevalence of obesity in the US is increasing exponentially across gender, age and ethnic groups. Obesity and a long-term hypercaloric diet result in what appears to be accelerated aging, often leading to a multi-systemic deterioration known as the metabolic syndrome. Due to their physiological similarity to humans as well as comparable rates of spontaneous obesity and diabetes mellitus, nonhuman primates provide a useful translational model for the human condition. They allow for an in vivo study of disease progression, interaction of comorbidities, and novel interventions. However, defining obesity in aged humans and nonhuman primates is difficult as the physiological changes that occur with aging are not accounted for using our current systems (BMI - body mass index and BCS - body condition score). Nonetheless, nonhuman primate studies have greatly contributed to our understanding of obesity and metabolic dysfunction and should continue to play a large role in translational research. Here, methods for defining obesity and metabolic syndrome in humans and nonhuman primates are described along with the prevalence and effects of these conditions.

The FTO gene is associated with a paradoxically favorable cardiometabolic risk profile in frail, obese older adults

OBJECTIVE

Fat mass and obesity-associated (FTO) gene polymorphisms have been reported to be associated with differences in BMI, obesity, and type 2 diabetes. However, previous studies have been predominantly conducted in younger individuals across a spectrum of body weights, whereas little information is available on the older population. We examined the association of FTO gene polymorphisms with cardiometabolic risks among adults who were both obese (BMI≥30 kg/m) and older (age≥65 years).

METHODS

A total of 165 frail, obese older adults were genotyped for FTO (rs9939609 and rs8050136) single nucleotide polymorphisms and studied for associations with body weight and body composition, components and prevalence of the metabolic syndrome, insulin response to an oral glucose tolerance test, and levels of adipocytokines (e.g. leptin) and vitamin D.

RESULTS

Carriers of the A allele (CA/AA) of the FTO single nucleotide polymorphism rs8050136 had lower body weight, BMI, body fat, and trunk fat than those without the A allele (CC genotype; all P's<0.05). Moreover, genotype CA/AA was associated with lower levels of triglycerides and higher levels of high-density lipoprotein-cholesterol and carriers of this genotype showed a trend toward a lower waist circumference, resulting in a lower prevalence of metabolic syndrome than in CC genotype carriers. The insulin area under the curve during the oral glucose tolerance test was lower for genotype CA/AA. Despite the lower insulin levels, the glucose area under the curve was unchanged, resulting in a higher insulin sensitivity index. Leptin levels were also lower and adiponectin and 25-hydroxyvitamin levels tended to be higher for genotype CA/AA than for genotype CC. No differences were observed for rs9939609.

CONCLUSION

Unlike the results from studies in younger individuals, the risk A allele may confer a favorable cardiometabolic risk profile in obese older adults, suggesting selective survival of obese adults into old age. If confirmed in a larger sample of surviving obese older adults, these findings may have implications in the clinical approach to obesity in this population.

Effect of major lifestyle risk factors, independent and jointly, on life expectancy with and without cardiovascular disease: results from the Consortium on Health and Ageing Network of Cohorts in Europe and the United States (CHANCES)

Seldom have studies taken account of changes in lifestyle habits in the elderly, or investigated their impact on disease-free life expectancy (LE) and LE with cardiovascular disease (CVD). Using data on subjects aged 50+ years from three European cohorts (RCPH, ESTHER and Tromsø), we used multi-state Markov models to calculate the independent and joint effects of smoking, physical activity, obesity and alcohol consumption on LE with and without CVD. Men and women aged 50 years who have a favourable lifestyle (overweight but not obese, light/moderate drinker, non-smoker and participates in vigorous physical activity) lived between 7.4 (in Tromsø men) and 15.7 (in ESTHER women) years longer than those with an unfavourable lifestyle (overweight but not obese, light/moderate drinker, smoker and does not participate in physical activity). The greater part of the extra life years was in terms of “disease-free” years, though a healthy lifestyle was also associated with extra years lived after a CVD event. There are sizeable benefits to LE without CVD and also for survival after CVD onset when people favour a lifestyle characterized by salutary behaviours. Remaining a non-smoker yielded the greatest extra years in overall LE, when compared to the effects of routinely taking physical activity, being overweight but not obese, and drinking in moderation. The majority of the overall LE benefit is in disease free years. Therefore, it is important for policy makers and the public to know that prevention through maintaining a favourable lifestyle is “never too late”.