Obesity in the elderly--a future matter of concern?

A Neuroscience Primer for Integrating Geroscience With the Neurobiology of Aging

Neuroscience has a rich history of studies focusing on neurobiology of aging. However, much of the aging studies in neuroscience occur outside of the gerosciences. The goal of this primer is 2-fold: first, to briefly highlight some of the history of aging neurobiology and second, to introduce to geroscientists the broad spectrum of methodological approaches neuroscientists use to study the neurobiology of aging. This primer is accompanied by a corresponding geroscience primer, as well as a perspective on the current challenges and triumphs of the current divide across these 2 fields. This series of manuscripts is intended to foster enhanced collaborations between neuroscientists and geroscientists with the intent of strengthening the field of cognitive aging through inclusion of parameters from both areas of expertise.

Relationship of Multimorbidity, Obesity Status, and Grip Strength among Older Adults in Taiwan

Background: The combination of multiple disease statuses, muscle weakness, and sarcopenia among older adults is an important public health concern, and a health burden worldwide. This study evaluates the association between chronic disease statuses, obesity, and grip strength (GS) among older adults in Taiwan. Methods: A community-based survey was conducted every 3 years among older adults over age 65, living in Chiayi County, Taiwan. Demographic data and several diseases statuses, such as diabetes mellitus, hypertension, cerebrovascular disease, cardiovascular disease, and certain cancers, were collected using a questionnaire. Anthropometric characteristics were measured using standard methods. Grip strength was measured using a digital dynamometer (TKK5101) method. Results: A total of 3739 older individuals were recruited (1600 males and 2139 females) with the mean age of 72.9 years. The mean GS was 32.8 ± 7.1 kg for males and 21.6 ± 4.8 kg for females. GS significantly decreased most in males with cerebrovascular disease (from 33.0—29.5 kg, p < 0.001) and in females with diabetes mellitus (from 21.8—21.0 kg, p < 0.01). GS was highest in older adults with obesity (body mass index ≥ 27 kg/m²); however, there was no significant change of GS as the disease number increased. Conclusion: Older adults who have two, rather than one or greater than three chronic diseases, have significantly lower GSs than those who are healthy. Stroke and CKD for males, and hypertension and diabetes for females, are important chronic diseases that are significantly associated with GS. Furthermore, being overweight may be a protective factor for GS in older adults of both sexes.

Impact of age on morbidity and mortality following bariatric surgery

BACKGROUND

Bariatric surgery is the most effective modality to treat obesity and obesity-related comorbidities. This study sought to utilize the MBASQIP® Data Registry to analyze the impact of age at time of surgery on outcomes following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) procedures.

METHODS

The MBSAQIP® Data Registry for patients undergoing SG or RYGB procedures between 2015 and 2016 was reviewed. Patients were divided into 4 age groups [18-44; 45-54; 55-64; > 65 years]. Minimal exclusions for revisional and/or emergency surgery were selected and combination variables created to classify complications as major or minor. A comorbidity index was constructed to include diabetes, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and prior cardiac surgery. Univariate and multivariate logistic regression analyses were performed to compare age stratifications to the young adult (18-45 years) cohort.

RESULTS

Of 301,605 cases, 279,419 cases (71.2% SG) remained after applying exclusion criteria (79.2% female, mean BMI 45.5 ± 8.1 kg/m², 8.9% insulin-dependent diabetics). Mean age was 44.7 ± 12.0 years (51.3% 18-44 years; 26.9% 45-54 years; 16.3% 55-64 years; 5.5% > 65 years). A univariate analysis demonstrated preoperative differences of lower BMI with increasing age concomitant with increasing frequency of RYGB and a higher comorbidity index (p < 0.0001 vs. 18-45 years). At age > 45 years, major complications and 30-day mortality increased independent of procedure type (p < 0.0001). A multivariate analysis controlling for comorbidity indices demonstrated increasing age (> 45 years) increased risk for major complications and mortality.

CONCLUSION

Overall, bariatric surgery (SG or RYGB) remains a low mortality risk procedure for all age groups. However, all age group classifications > 45 years had higher incidence of major complications and mortality compared to patients 18-45 years (despite older individuals having lower preoperative BMI) indicating delaying surgery is detrimental.

Association of basal metabolic rate and fuel oxidation in basal conditions and during exercise, with plasma S-klotho: the FIT-AGEING study

S-klotho, the shed form of α-klotho, is thought to be an ageing suppressor with functions related to the physiology of energy metabolism. However, it remains unknown whether ageing biomarkers such as S-klotho and/or chronological ageing are associated in any way with basal metabolic rate (BMR) and fuel oxidation in basal conditions and during exercise. The present work investigates the association of BMR and fuel oxidation in basal conditions and during exercise, with plasma S-klotho in middle-aged, sedentary adults. BMR was measured by indirect calorimetry in 74 such subjects (53% women; age 53.7±5.1 years) following standard procedures, and their fuel oxidation estimated via stoichiometric equations. The maximal fat oxidation during exercise (MFO) and the intensity of exercise that elicits MFO (Fat_max) were determined using a walking graded exercise test. No relationship was seen between BMR and plasma S-klotho (P>0.1), although both basal fat oxidation and MFO showed positive associations with this protein (both P<0.001); these relationships persisted after controlling for age, sex and fat mass. However, no significant associations were seen between BMR, basal fat oxidation or MFO and chronological age (all P>0.1). The present findings suggest that basal fat oxidation and MFO are strongly associated with plasma S-klotho in middle-aged sedentary adults. These results support the idea that metabolic flexibility is a powerful predictor of biological ageing.

Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes

In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups ( P < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% vs 9.1%; P < 0.0001) and major complications (2.2% vs 6.3%; P < 0.0001), and 30-day mortality (0.1% vs 0.5%; P = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.

The Effect of Age upon the Interrelationship of BMI and Inpatient Health Outcomes

OBJECTIVES

There is growing evidence that the relationship between body mass index (BMI - defined as weight in kilograms divided by height in metres squared) and patient outcomes is age-dependent; specifically, a raised BMI may have a protective effect in older adults. This has been demonstrated clearly in the community setting; less clear is the effect of age on this relationship in the inpatient setting.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Retrospective analysis of 22,903 electronic records for patients discharged from two large public hospitals in South Australia between January 2015 and September 2018 inclusively. Records were retained if the patient's height and weight had been recorded during the admission, BMI was between 10-99 kg/m2 and it was the patient's first admission during that time. Patients were grouped by BMI (<18.5 kg/m2 ("underweight"), 18.5-24.9 kg/m2 ("normal weight"), 25-29.9 kg/m2 ("overweight"), >30 kg/m2 ("obese")) and age (18-59 years, 60-79 years, > 80 years); for each group we measured the relative stay index (RSI) (actual length of stay divided by predicted length of stay), death in hospital and composite adverse outcome after discharge (unplanned readmission within 30 days and/or death within 30 days).

RESULTS

Underweight patients across all age groups generally experienced significantly poorer outcomes compared to those not underweight. In those aged 18-59 years there were no significant differences in outcomes between the normal weight, overweight and obese groups. In those aged 60-79 years overweight patients had a significantly reduced risk of RSI > 2 compared to those of normal weight (p=0.014), and both overweight and obese patients had a significantly reduced risk of adverse outcome after discharge when compared to those of normal weight (p=0.028 and p=0.009 respectively). In those aged 80 years or older, both overweight and obese patients had a significantly reduced risk of adverse outcome after discharge when compared to those of normal weight (p=0.028 and p=0.013 respectively), and obese patients had a significantly reduced risk of inpatient mortality and RSI >2 when compared to those of normal weight (p=0.027 and p=0.037 respectively).

CONCLUSION

A BMI > 25 kg/m2 in older patients is associated with reduced risk of prolonged admission, inpatient mortality and adverse outcomes following discharge. This adds to growing evidence that age-specific BMI guidelines are required for adults because the healthiest BMI in the older hospital patient is seemingly not in the range 18.5-24.9 kg/m2.

Roux-en-Y gastric bypass is safe in elderly patients: a propensity-score matched analysis

BACKGROUND

Numerous studies have established the effectiveness of Roux-en-Y gastric bypass (RYGB) for weight loss and co-morbidity amelioration. However, its safety and efficacy in elderly patients remains controversial.

OBJECTIVES

To evaluate outcomes in patients aged ≥60 years who underwent RYGB compared with nonsurgical controls with the hypothesis that RYGB provides weight loss benefits without differences in survival.

SETTING

University-affiliated tertiary center.

METHODS

All patients who underwent RYGB from 1985 to 2015 were identified and divided into elderly (age ≥60) and nonelderly (age <60) groups. A nonsurgical elderly control population was identified using a clinical data repository of outpatient visits to propensity match elderly patients 4:1 on demographic characteristics, co-morbidities, and relevant preoperative substance/medication use. Unpaired appropriate univariate analyses compared each stratified group. Kaplan-Meier survival curves were fitted based on social security death data.

RESULTS

A total of 2306 patients underwent RYGB. The 107 elderly patients had lower median body mass index (47.0 versus 49.9; P = .007) and higher rates of co-morbidities. Rates of complications did not differ between elderly and nonelderly patients. Elderly surgical patients were propensity matched 4:1 (10,044 controls) yielding 428 well-matched nonsurgical controls. The elderly group demonstrated significant percent reduction in excess body mass index compared with the control group (81.8% versus 10.3%; P < .001). Kaplan-Meier survival analysis with log-rank test demonstrated no difference in midterm survival (P = .63).

CONCLUSIONS

A significant weight reduction benefit was identified after RYGB in elderly patients without a difference in midterm survival compared with propensity-matched controls, suggesting RYGB is a safe and efficacious weight loss strategy in the elderly.

Dynapenic Abdominal Obesity Increases Mortality Risk among English and Brazilian Older Adults: A 10-Year Follow-Up of the ELSA and SABE Studies

BACKGROUND/OBJECTIVE

There is little epidemiological evidence demonstrating that dynapenic abdominal obesity has higher mortality risk than dynapenia and abdominal obesity alone. Our main aim was to investigate whether dynapenia combined with abdominal obesity increases mortality risk among English and Brazilian older adults over ten-year follow-up.

DESIGN

Cohort study.

SETTING

United Kingdom and Brazil.

PARTICIPANTS

Data came from 4,683 individuals from the English Longitudinal Study of Ageing (ELSA) and 1,490 from the Brazilian Health, Well-being and Aging study (SABE), hence the final sample of this study was 6,173 older adults.

MEASUREMENTS

The study population was categorized into the following groups: non-dynapenic/non-abdominal obese, abdominal obese, dynapenic, and dynapenic abdominal obese according to their handgrip strength (< 26 kg for men and < 16 kg for women) and waist circumference (> 102 cm for men and > 88 cm for women). The outcome was all-cause mortality over a ten-year follow-up. Adjusted hazard ratios by sociodemographic, behavioural and clinical characteristics were estimated using Cox proportional hazards models.

RESULTS

The fully adjusted model showed that dynapenic abdominal obesity has a higher mortality risk among the groups. The hazard ratios (HR) were 1.37 for dynapenic abdominal obesity (95% CI = 1.12 - 1.68), 1.15 for abdominal obesity (95% CI = 0.98 - 1.35), and 1.23 for dynapenia (95% CI = 1.04 - 1.45).

CONCLUSIONS

Dynapenia is an important risk factor for mortality but dynapenic abdominal obesity has the highest mortality risk among English and Brazilian older adults.

Are Obese Residents More Likely to Be Admitted to Nursing Homes That Have More Deficiencies in Care?

OBJECTIVES

To determine whether obese older adults who qualify for nursing home (NH) placement are as likely as nonobese adults to be admitted to NHs that provide adequate quality of care.

DESIGN

Retrospective study.

SETTING

NHs in New York State.

PARTICIPANTS

Individuals aged 65 and older newly admitted to a NH in New York State in 2006-07.

MEASUREMENTS

Total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses were used to assess the association between obesity (body mass index (BMI) 30.0-39.9 kg/m(2) ) and morbid obesity (BMI ≥ 40.0 kg/m(2) ) separately and admission to facilities with more deficiencies.

RESULTS

NHs that admitted a higher proportion of morbidly obese residents were more likely to have more deficiencies, whether total or healthcare related. These NHs also had greater odds of having severe deficiencies, or falling in the top quartile ranking of total deficiencies. After sequentially controlling for the choice of facilities within the inspection region, resident characteristics, and facility covariates, the association between morbid obesity and admission to higher-deficiency NHs persisted.

CONCLUSION

Residents with morbid obesity were more likely to be admitted to NHs of poorer quality based on deficiency citations. The factors driving these disparities and their impact on the care of obese NH residents require further elucidation.

BARIATRIC SURGERY IN THE ELDERLY: RESULTS OF A MEAN FOLLOW-UP OF FIVE YEARS

BACKGROUND

Surgical treatment of obesity in the elderly, particularly over 65, remains controversial; it is explained by the increased surgical risk or the lack of data demonstrating its long-term benefit. Few studies have evaluated the clinical effects of bariatric surgery in this population.

AIM

To evaluate the results of surgical treatment of obesity in patients over 60 years, followed for an average period of five years.

METHOD

This was a retrospective study evaluating 46 patients, 60 years or older, who underwent surgical treatment of obesity, by conventional gastric bypass technique (laparotomy). The average age was 64 years (60-71), mean BMI of 49.6 kg/m2 (38-66), mean follow-up of 5.9 years; 91% of patients were hypertensive, 56% diabetics and 39% had dyslipidemia.

RESULTS

The incidence of complications (major and minor) in patients under 65 years was 26% and over 65 years 37% (p=0.002). There were no deaths in the group with less than 65 years and there were two deaths (12.5%) over 65 years. The average loss of overweight over 65 years or less was 72% vs 68% (p=0.56). There was total control of the diabetes mellitus in 77% and partial in 23%, with no difference between groups. There was improvement in arterial hypertension in 56% of patients, also no difference between groups. The average LDL levels did not differ between the pre and postoperative (106 mg/dl to 102 mg/dl), an increase of HDL (56 mg/dl to 68 mg/dL) and reduced triglyceride levels (136 mg/dl to 109 mg/dl). There was no statistical difference in the variation of the cholesterol fractions and triglycerides between the groups. Two patients in the group with less than 65 years died in late follow-up, of brain tumor and pneumonia, three and five years after bariatric surgery, respectively.

CONCLUSIONS

Surgical morbidity and mortality were higher in patients over 65 years, and this group had the same benefits observed in patients lower 65 years for weight loss and comorbidities control.

Functional assessment of older obese patients candidates for bariatric surgery

CONTEXT

Obesity in the elderly is associated with exacerbation of functional decline (dependency), that occurs with aging, because of decreased muscle mass and strength, and increased joint dysfunction. Consequently, there is progressive loss of independence, autonomy, chronic pain and impaired quality of life. The weight loss can bring benefits in all these aspects, especially when accompanied by exercises. Elderly patients with morbid obesity may be submitted to surgical treatment, taking into account that the massive weight loss, eventually caused by bariatric surgery, may exacerbate the loss of muscle mass and nutritional complications that may bring harm to the overall health and quality of life of these patients. The functional assessment of elderly patients, candidates for bariatric surgery and the extent to which surgery can bring benefits to the patients, in the field of functionality, has still to be determined.

OBJECTIVE

To describe profile functionality in obese elderly referred to a bariatric surgery program.

METHODS

Patients with age ≥ 60 and BMI ≥ 35 underwent comprehensive geriatric assessment that evaluates co morbidities, medication use, ability to perform basic activities of daily living and instrumental activities of daily living, and the "Timedupandgo" test to evaluate mobility, whose cut-off point was ≤ 10 seconds. Statistical analysis was performed in order to see if there is a positive correlation of dependency with BMI and age (over or under 65 years). Results Forty subjects have completed evaluation. The mean age was 64.1 years (60-72) and 75% were women. They had an average weight of 121.1 kg (72.7-204) and a mean BMI of 47.2 kg/m2 (35.8-68.9). 16 patients (40%) have shown dependency for activities of daily living, 19 (47,5%) for instrumental activities of daily living and 20 patients (50%) had a "Timedupandgo" test over 10 seconds. Statistical analysis (t-Student, Mann-Whitney, Binary Logistic Regression) has shown positive correlation of dependency in activities of daily living for BMI >49 kg/m2, dependency in instrumental activities of daily living for BMI >46,5 kg/m2, and "Timedupandgo" test greater than 10 seconds for BMI >51 kg/m2 (P<0,05). No dependency difference was observed for patients over or under 65 years age.

CONCLUSIONS

Functional decline is observed in almost half of the morbid obese patients over 60 years old. It is related to increasing BMI (BMI >46,5 kg/m2) but not related to age (60 to 65 years or over 65 years). Functional decline should be considered a co-morbidity in the elderly obese patients and should be assessed before bariatric surgery in this population.

The effect of age on the shape of the BMI-mortality relation and BMI associated with minimum all-cause mortality in a large Austrian cohort

BACKGROUND

It is unclear if the body mass index (BMI) associated with minimum all-cause mortality is constant throughout adult life or increasing with age.

METHODS

We applied multivariable fractional polynomials to the data of the Vorarlberg Health Monitoring and Prevention Program to quantify the BMI associated with minimum mortality over age. The analysis included data of 129,904 never-smoking women and men (mean age: 45.4 years) who were followed for a median of 18.6 years.

RESULTS

Optimum BMI in women increased with age, lying within the normal BMI category (according to the World Health Organization definition) from the age of 20 years (23.3 kg m(-2), 95% confidence interval (CI): 22.2-24.3) to the age of 54 years and in the lower half of the overweight category from the age of 55 years onwards, reaching 26.2 kg m(-2) (95% CI: 25.1-27.3) at the age of 69 years. In men, optimum BMI increased slightly from 23.7 kg m(-2) (95% CI: 22.1-25.2) at the age of 20 years until the age of 59 years, reaching a BMI of 25.4 kg m(-2) (95% CI: 24.8-26.0) and decreased afterwards to 22.7 kg m(-2) (95% CI: 20.9-24.6) at the age of 80 years.

CONCLUSIONS

Our results indicate that BMI associated with minimum all-cause mortality changes with age and that patterns differ by sex. Sex- and age-independent BMI recommendations might therefore be inappropriate. Further studies using flexible methods instead of predefined categories are necessary to revise BMI recommendations.

Complex Interaction between Obesity and Trauma

Trauma and obesity are large-scale epidemics that can be associated with significant morbidity and mortality. In few studies, it has noted that there is the ‘obesity paradox’ (obesity has been found to be protective against mortality) due to certain causes, i.e. heart failure or cardiovascular disease. Subcutaneous fat can show great variability between individuals and increased subcutaneous fat may be protective against injuries by cushioning the internal abdominal organs against injurious forces in road traffic accidents. Many factors including the body fat distribution, body shape, and center of gravity may play an important role in the different injury patterns and severity of injury between men and women. A better understanding of how obesity influences trauma related injuries not only will help to improve the outcome but also foster the development of interventions to address the most salient and modifiable risk factors to reduce obesity related morbidity and mortality. In present article, we review the relevant literature with special considerations to understand the interactions of obesity and trauma with their impact on patient management and outcomes.

How to cite this article

Agrawal A. Complex Interaction between Obesity and Trauma. Panam J Trauma Crit Care Emerg Surg 2014;3(3):109-113.

The impact of obesity and exercise on cognitive aging

Obesity is a major concern in the aging population and degrades health, motor functions and cognition in older adults. The effects of obesity are pervasive and challenging to health-care systems, making this a widespread and critically important public health dilemma. In this review, we examine the relationship between obesity, cognitive aging, and related dysfunctions. Potential neural mechanisms underlying such relationship are described. We propose that cost-effective exercises can be employed to cope with obesity and cognitive declines in older adults. Finally, we discuss implications and future research directions.

Weight reduction and maintenance in a specialized outpatient health care center

SUMMARY

OBJECTIVE

To prospectively evaluate the amount of weight loss and subsequent maintenance and to identify correlates of successful weight reduction in overweight and obese outpatients treated in a specialized health care center.

TREATMENT

A treatment program involving diet, exercise and behavior modification was provided in an outpatient setting. Twenty-four treatment courses with a total of 177 participants (age: 45.5 ± 12.2 year; BMI: 36.7 ± 5.6 kg/m(2)) were run.

MEASUREMENTS

Weight and baseline characteristics were recorded at start of program; weight was re-assessed at the end of treatment and 1 year after the end of treatment.

RESULTS

Patients achieved a significant weight loss of 5.6 ± 7.9 kg (5.1 ± 6.4% of initial body weight) in the course of 1 year. An average of 80.8% or 4.8 kg of initial weight loss was maintained a year after treatment, representing a significant weight regain. A higher initial BMI, intake of venlafaxin, a higher percentage of course attendance, course completion and hypertension were associated with greater weight loss. The interaction of the specific treatment course and the percentage of attendance explained 25% of the variance of percental total weight loss.

CONCLUSION

Significant weight losses can be achieved by overweight and obese patients after a treatment program in specialized health care addressing diet, exercise and behavioral aspects. Weight loss maintenance remains difficult for patients. The specific treatment group itself and attendance of course sessions are critical for weight loss and should be considered in the design and evaluation of group-based treatment programs.

INSULIN RESISTANCE: GOOD OR BAD? DEVELOPMENT MECHANISMS AND THE ASSOCIATION WITH AGE-RELATED VASCULAR CHANGES

The authors discuss the mechanisms of insulin resistance (IR) development; the IR role in the development and progression of the major age-related vascular changes; IR and the transformation of vascular ageing into disease; and IR impact on life expectancy. 

Benefits and risks of weight-loss treatment for older, obese women

BACKGROUND

A key issue in the treatment of obesity in older adults is whether the health benefits of weight loss outweigh the potential risks with respect to musculoskeletal injury.

OBJECTIVE

To compare change in weight, improvements in metabolic risk factors, and reported musculoskeletal adverse events in middle-aged (50-59 years) and older (65-74 years), obese women.

MATERIALS AND METHODS

Participants completed an initial 6-month lifestyle intervention for weight loss, comprised of weekly group sessions, followed by 12 months of extended care with biweekly contacts. Weight and fasting blood samples were assessed at baseline, month 6, and month 18; data regarding adverse events were collected throughout the duration of the study.

RESULTS

Both middle-aged (n = 162) and older (n = 56) women achieved significant weight reductions from baseline to month 6 (10.1 ± 0.68 kg and 9.3 ± 0.76 kg, respectively) and maintained a large proportion of their losses at month 18 (7.6 ± 0.87 kg and 7.6 ± 1.3 kg, respectively); there were no significant differences between the two groups with respect to weight change. Older women further experienced significant reductions in systolic blood pressure, HbA(1c), and C-reactive protein from baseline to month 6 and maintained these improvements at month 18. Despite potential safety concerns, we found that older women were no more likely to experience musculoskeletal adverse events during the intervention as compared with their middle-aged counterparts.

CONCLUSION

These results suggest that older, obese women can experience significant health benefits from lifestyle treatment for obesity, including weight loss and improvements in disease risk factors. Further investigation of the impact of weight loss on additional health-related parameters and risks (eg, body composition, muscular strength, physical functioning, and injuries) in older adults is needed.

Weight loss in obese adults 65years and older: a review of the controversy

Obesity in older adults is ubiquitous in many developed countries and is related to various negative health outcomes, making it an important public health target for intervention. However, treatment approaches for obesity in older adults remain controversial due to concerns surrounding the difficulty of behavior change with advancing age, exacerbating the age-related loss of skeletal muscle and bone, and the feasibility of long-term weight maintenance and related health consequences. This review serves to systematically examine the evidence regarding weight loss interventions with a focus on obese (body mass index 30kg/m(2) and above) older adults (aged 65years and older) and some proposed mechanisms associated with exercise and caloric restriction (lifestyle intervention). Our findings indicate that healthy weight loss in this age group can be achieved through lifestyle interventions of up to a one-year period. Most interventions reviewed reported a loss of lean body mass and bone mineral density with weight loss. Paradoxically muscle quality and physical function improved. Inflammatory molecules and metabolic markers also improved, although the independent and additive effects of exercise and weight loss on these pathways are poorly understood. Using our review inclusion criteria, only one small pilot study investigating long-term weight maintenance and associated health implications was found in the literature. Future research on lifestyle interventions for obese older adults should address the loss of bone and lean body mass, inflammatory mechanisms, and include sufficient follow-up to assess long-term weight maintenance and health outcomes.

The Obesity Pandemic: Where Have We Been and Where Are We Going?

Obesity, a new pandemic, is associated with an increased risk of death, morbidity, and accelerated aging. The multiple therapeutic modalities used to promote weight loss are outlined with caution, especially for patients who are very young or old. Except for very rare single gene defects, the inheritance of obesity is complex and still poorly understood, despite active investigations. Recent advances that have shed light on the pathophysiology of obesity are the recognition that 1) excess fat is deposited in liver, muscle, and pancreatic islets; 2) fat tissue secretes a large number of active signaling molecules including leptin, adiponectin, and resistin, as well as free fatty acids; and 3) activated macrophages colonize the adipose tissue. Other candidates for key roles in the causes and consequences of obesity include 1) metabolic programming, where food acts as a developmental regulator; 2) the constellation of defects known as the "metabolic syndrome;" 3) cortisol overproduction in the adipose tissue; and especially, 4) insulin resistance. The possible etiologies of insulin resistance include cytokine excess, elevated free fatty acids, and hyperinsulinemia itself, as with transgenic overproduction of insulin in mice.

Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline

The prevalence of obesity is rising progressively, even among older age groups. By the year 2030-2035 over 20% of the adult US population and over 25% of the Europeans will be aged 65 years and older. The predicted prevalence of obesity in Americans, 60 years and older was 37% in 2010. The predicted prevalence of obesity in Europe in 2015 varies between 20 and 30% dependent on the model used. This means 20.9 million obese 60+ people in the USA in 2010 and 32 million obese elders in 2015 in the EU. Although cut-off values of BMI, waist circumference and percentages of fat mass have not been defined for the elderly (nor for the elderly of different ethnicity), it is clear from several meta-analyses that mortality and morbidity associated with overweight and obesity only increases at a BMI above 30 kg/m(2). Thus, treatment should only be offered to patients who are obese rather than overweight and who also have functional impairments, metabolic complications or obesity-related diseases, that can benefit from weight loss. The weight loss therapy should aim to minimize muscle and bone loss but also vigilance as regards the development of sarcopenic obesity - a combination of an unhealthy excess of body fat with a detrimental loss of muscle and fat-free mass including bone - is important in the elderly, who are vulnerable to this outcome. Life-style intervention should be the first step and consists of a diet with a 500 kcal (2.1 MJ) energy deficit and an adequate intake of protein of high biological quality together with calcium and vitamin D, behavioural therapy and multi-component exercise. Multi-component exercise includes flexibility training, balance training, aerobic exercise and resistance training. The adherence rate in most studies is around 75%. Knowledge of constraints and modulators of physical inactivity should be of help to engage the elderly in physical activity. The role of pharmacotherapy and bariatric surgery in the elderly is largely unknown as in most studies people aged 65 years and older have been excluded.

A systematic review of the literature concerning the relationship between obesity and mortality in the elderly

INTRODUCTION

Obesity is a risk factor for chronic diseases and premature mortality, but the extent of these associations among the elderly is under debate. The aim of this systematic literature review (SR) is to collate and critically assess the available information of the impact of obesity on mortality in the elderly.

METHODS

In PubMed, there are three-hundred twelve papers on the relationship between obesity and mortality among older adults. These papers were analysed on the basis of their abstracts, and sixteen studies were considered suitable for the purpose of the study. It was possible to perform a pooled estimate for aggregated data in three different studies.

CONCLUSION

The results of this SR document that an increased mortality in obese older adults. The limitation of BMI to index obesity and the noted protective action of a moderate increase in BMI on mortality are highlighted. Waist circumference is an indicator of central adiposity and potentially as good a risk factor for mortality as BMI in obese elderly adults.

Malalignment and subchondral bone turnover in contralateral knees of overweight/obese women with unilateral osteoarthritis: implications for bilateral disease

OBJECTIVE

To explore whether the risk of incident tibiofemoral (TF) osteoarthritis (OA) in the radiographically normal contralateral knee of overweight/obese women with unilateral knee OA is mediated by malalignment and/or preceded by increased turnover of subchondral bone.

METHODS

We used data of post hoc analyses from a randomized controlled trial. Cross-sectional analyses evaluated the baseline association between frontal plane alignment and bone turnover in the medial TF compartment in 78 radiographically normal contralateral knees. Longitudinal analyses ascertained whether incident radiographic OA (TF osteophyte formation within 30 months) was associated with malalignment and/or increased bone turnover at baseline. Alignment subcategories (varus/neutral/valgus) were based on the anatomic axis angle. (99m)Tc-methylene diphosphonate uptake in a late-phase bone scan was quantified in regions of interest in the medial tibia (MT) and medial femur (MF) and adjusted for uptake in a reference segment of the ipsilateral tibial shaft (TS).

RESULTS

MF and MT uptake in varus contralateral knees was 50-55% greater than in the TS. Adjusted MT uptake in varus contralateral knees was significantly greater than that in neutral and valgus contralateral knees (mean 1.55 versus 1.38 and 1.43, respectively; P < 0.05). Among 69 contralateral knees followed longitudinally, 22 (32%) developed TF OA. Varus angulation was associated with a marginally significant increase in the odds of incident OA (adjusted odds ratio 3.98, P = 0.067).

CONCLUSION

While the small sample size limited our ability to detect statistically significant risk factors, these data suggest that the risk of developing bilateral TF OA in overweight/obese women may be mediated by varus malalignment.

Is there a reversal in the effect of obesity on mortality in old age?

Studies of obesity and its relationship with mortality risk in older persons have yielded conflicting results. We aimed to examine the age-related associations between obesity and mortality in older persons. Data were drawn from the Cross-Sectional and Longitudinal Aging Study (CALAS), a national survey of a random sample of older Jewish persons in Israel conducted during 1989-1992. Analyses included 1369 self-respondent participants aged 75-94 from the Cross-Sectional and Longitudinal Aging Study (CALAS). Mortality data at 20-year followup were recorded from the Israeli National Population Registry. Obesity was significantly predictive of higher mortality for persons aged 75-84, but from age 85 onwards, obesity had a protective effect on mortality albeit at a nonsignificant level. Being underweight was consistently predictive of mortality. Findings suggest that the common emphasis on avoiding obesity may not apply to those advancing towards old-old age, at least as far as mortality is concerned.

What if we prevent obesity? Risk reduction in knee osteoarthritis estimated through a meta-analysis of observational studies

OBJECTIVE

To summarize the overall relative risk of knee osteoarthritis (OA) associated with body mass index, and to estimate the potential risk reduction due to the control of this risk factor.

METHODS

Six electronic databases were searched up to July 2010. Relative risk was estimated using odds ratio (OR). A random-effects model was used to pool the results. Risk reduction was estimated using population-attributable risk percentage (PAR%), i.e., the proportion of knee OA that would have been avoided if obesity had not been present in the population. The percentage of obesity in different populations was obtained from the International Obesity Task Force.

RESULTS

Forty-seven studies (446,219 subjects) were included in the meta-analysis, of which there were 14 cohort, 19 cross-sectional, and 14 case-control studies. The overall pooled ORs for overweight and obese individuals were 2.02 (95% confidence interval [95% CI] 1.84-2.22) and 3.91 (95% CI 3.32-4.56), respectively. Risk reduction in terms of PAR% for knee OA varied from 8% in China to 50% in the US, depending on the prevalence of overweight and obesity. The reduction was greater in severe symptomatic OA than in asymptomatic radiographic OA.

CONCLUSION

Obesity is a risk factor for many conditions, including knee OA. The benefit of modifying this risk factor may cause significant risk reduction of knee OA in the general population, especially in Western countries where obesity is prevalent.

Lifestyle change influences on GERD in Japan: a study of participants in a health examination program

BACKGROUND

Though gastroesophageal reflux disease (GERD) has been a prevalent disease in Western countries, the incidence of GERD has only just started to increase in Japan.

AIM

The aim of this study was to determine which lifestyle factors may be associated with GERD in Japan.

METHODS

A total of 2,853 participants who took part in a health examination program between July 2004 and March 2005 were enrolled. GERD symptoms were assessed using the Japanese version of the Carlsson-Dent self-administered questionnaire (QUEST). The GERD group consisted of participants with a QUEST score ≥6 and/or endoscopic findings. The GERD group was divided into asymptomatic ERD (erosive reflux disease with no symptoms), symptomatic ERD (erosive reflux disease with symptoms) and NERD (non-erosive reflux disease) groups. Associated factors for these diseases were analyzed by logistic regression analysis.

RESULTS

GERD was diagnosed in 667 (23.4%) participants. Among the subjects placed in the GERD group, asymptomatic ERD, symptomatic ERD and NERD were diagnosed in 232 (8.1%), 91 (3.2%) and 344 (12.1%) participants, respectively. Factors associated with GERD included a high BMI (body mass index), hiatus hernia, fewer hours of sleep, lack of exercise, and drinking green tea.

CONCLUSIONS

Relationships between lifestyle, gender and GERD were investigated in the present study. Both lifestyle improvements and consideration of gender differences can be used to help prevent GERD development.

Improving health for elderly people: an international health promotion and disease prevention agenda

Across the world, there are substantial but missed opportunities for promoting health of older persons and extending the healthy life span. Current approaches to health care rely on late detection and treatment of disease, and some of the most expensive systems of care have population health outcomes that are poor to mediocre. A majority of deaths and disability result from progression of preventable chronic diseases for which human behaviors are major contributing factors. An organized and aggressive agenda in health promotion and disease prevention emerges as an important part of the strategy to both promote health and control costs. After reviewing data on determinants of health and contribution of behavioral factors to morbidity and mortality, this paper presents the evidence for efficacy and effectiveness of specific behavioral and clinical interventions to reduce risk for many of the problems accounting for death and disability among elders. We address tobacco use, lack of exercise, inadequate nutrition, hypertension, delirium, obesity, falls, cancer screening, poor oral health, osteoporosis, immunizations and medication safety. Strategies for implementation of effective interventions present an international challenge.

Impact of Body Mass Index on the Effectiveness of a Disease Management—Health Promotion Intervention on Disability Status

Purpose.

To examine the impact of body mass index (BMI) on the effectiveness of a disease management—health promotion intervention among community-dwelling Medicare beneficiaries with disabilities.

Design.

Secondary data analyses of a randomized controlled trial.

Settings.

Nineteen counties in upstate New York and on the West Virginia—Ohio border.

Subjects.

Four hundred fifty-two Medicare beneficiaries who participated in the Medicare Primary and Consumer-Directed Care Demonstration between August 1998 and June 2002 and completed the 22-month follow-up.

Intervention.

Multicomponent disease management—health promotion intervention involving patient education, individualized health promotion coaching, medication management, and physician care management.

Measures.

Body mass index and dependence in Activies of Daily Living (ADLs).

Analysis.

Multivariate linear regression.

Results.

The intervention resulted in significantly less worsening in ADLs dependence among normal-weight participants (coefficient, − .42; p = .04). However, the intervention did not have a significant effect for underweight participants (F test p = .33 vs. underweight participants in the control group) or overweight or obese participants (F test p = .78 vs. overweight or obese participants in the control group).

Conclusions.

A positive effect of the intervention on disability was found among normal-weight participants but not among underweight or overweight or obese participants. Future health promotion interventions should take into consideration the influence of BMI categories on treatment effects.

[Association between homebound status and newly certified need of care among elderly in a rural community: the Iwate-Kenpoku cohort (Iwate-KENCO) study]

OBJECTIVE

The purpose of this study was to evaluate the association between homebound status and newly certified need of care among elderly in a rural community and to clarify the characteristics of those in homebound status.

METHODS

The Iwate-KENpoku COhort (Iwate-KENCO) study (26,469 participants) spanned the period from 2002 to 2004 and was conducted in northern Iwate Prefecture, Japan. In the present study, 12,056 elderly (men, 4,751; women, 7,305) participated after being screened for eligibility (> or =65 years of age; without certification for need of care; and without a history of stroke, cardiac heart failure, or ischemic heart disease). Being homebound was operationally defined as walking outdoors for less than 5 minutes per day. Cox's proportional hazard model was used to estimate the hazard risk (HR) for newly certified need of care and the 95% confidence interval (95% CI) after controlling for confounding factors by gender.

RESULTS

After a mean follow-up period of 2.65 years, 200 men (4.2%) and 412 women (5.6%) obtained certification for need of care. Homebound status was significantly associated with newly certified need of care in women (HR=1.64, 95%CI=1.29-2.09), but not in men (HR=1.07, 95%CI=0.76-1.52). Homebound status among elderly women was associated with nutritional status, missing teeth, and irregular daily rhythms.

CONCLUSION

These findings suggest that being homebound is a risk factor for elderly women receiving certification for need of care.

Fasting ghrelin is related to skeletal muscle mass in healthy adults

BACKGROUND/OBJECTIVES

The determinants of plasma ghrelin concentrations including the effects of aging, gender, and body composition, are unclear. Appetite and energy intake decrease with advancing age, and there is a corresponding decline in total body lean tissue, and an increase in fat mass.

METHODS

We measured fasting plasma ghrelin and insulin concentrations in 52 healthy subjects aged 22-82 years, and assessed body composition by dual energy X-ray absorptiometry. Energy intake was estimated from diet diaries.

RESULTS

Fasting ghrelin concentrations were not significantly correlated with age and energy intake (R = 0.07, P = 0.62; and R = -0.14, P = 0.34 respectively) on univariate regression analysis, and ghrelin concentrations were higher in females than males (2886.8 +/- 182.1 pg/ml vs 2082.5 +/- 121.2 pg/ml; P = 0.001). Ghrelin was inversely related to body mass index (R = -0.328, P = 0.018), fat-free body mass (R = -0.428, P = 0.002), and total skeletal muscle mass (R = -0.439, P = 0.001), but not related to body fat mass (R = 0.177, P = 0.208). On multiple regression analysis, total skeletal muscle mass (corrected for height) was the only significant negative predictor (P < 0.0001) of fasting ghrelin concentrations.

CONCLUSIONS

In conclusion, in healthy adults, plasma ghrelin concentrations are not significantly influenced by age or energy intake per se, but relate to skeletal muscle mass.

The danger of weight loss in the elderly

Aging is generally accompanied by weight loss made up of both fat mass and fat-free mass. As more people, including elderly, are overweight or obese, weight loss is recommended to improve health. Health risks are decreased in overweight children and adults by dieting and exercise, but the health benefits of weight loss in elderly, particularly by calorie restriction, are uncertain. Rapid unintentional weight loss in elderly is usually indicative of underlying disease and accelerates the muscle loss which normally occurs with aging. Intentional weight loss, even when excess fat mass is targeted also includes accelerated muscle loss which has been shown in older persons to correlate negatively with functional capacity for independent living. Sarcopenic obesity, the coexistence of diminished lean mass and increased fat mass, characterizes a population particularly at risk for functional impairment since both sarcopenia (relative deficiency of skeletal muscle mass and strength) and obesity have been shown to predict disability. However, indices of overweight and obesity such as body mass index (BMI) do not correlate as strongly with adverse health outcomes such as cardiovascular disease in elderly as compared to younger individuals. Further, weight loss and low BMI in older persons are associated with mortality in some studies. On the other hand, studies have shown improvement in risk factors after weight loss in overweight/obese elderly. The recent focus on pro-inflammatory factors related to adiposity suggest that fat loss could ameliorate some catabolic conditions of aging since some cytokines may directly impact muscle protein synthesis and breakdown. Simply decreasing weight may also ease mechanical burden on weak joints and muscle, thus improving mobility. However, until a strategy is proven whereby further loss of muscle mass can be prevented, weight loss by caloric restriction in individuals with sarcopenic obesity should likely be avoided.

Health Behaviors and Transitions of Physical Disability Among Community-Dwelling Older Adults

This study examined the transitions of disability over 5 years among older adults and the influences of health behaviors on these transitions. Data was obtained from the community cohort of the National Long-Term Care Survey in 1994 ( n = 5,089) and their follow-up data in 1999. Generalized logit regressions revealed that obesity increased the risk of disability. Light drinking decreased the risk of disability. Among disabled individuals, the risk of status decline was higher for those underweight or physically inactive, and those taking vitamin and/or mineral supplements regularly or working on a hobby were less likely to further decline in the disability statuses. In an older population, having more contacts with friends, having regular social activities, and having a body mass index ≥ 25 were beneficial to survival. These findings indicate that older adults may have greater personal control over their lives based on their choices about lifestyles and social connections.

Body mass index and nine-year mortality in disabled and nondisabled older U.S. individuals

OBJECTIVES

To investigate the relationship between body mass index (BMI) and 9-year mortality in older (> or = 65) Americans with and without disability.

DESIGN

Cohort study.

SETTING

The unique disability-focused National Long Term Care Survey (NLTCS) data that assessed the health and well-being of older individuals in 1994 were analyzed.

PARTICIPANTS

Four thousand seven hundred ninety-one individuals in the 1994 survey.

MEASUREMENTS

BMI (kg/m2) was calculated from self- or proxy reports of height and weight. The analysis was adjusted for 1-year change in BMI and demographic and health-related factors, as well as reports by proxies, and death occurring during the first 2 years after the interview.

RESULTS

The relative risk of death as a function of BMI formed a nonsymmetric U-shaped pattern, with larger risks associated with lower BMI (< 22.0) and minimal risks for BMI of 25.0 to 34.9. (BMI 22.0-24.9 was the reference.) Adjustments for demographic and health-related factors had little effect on this pattern. Nondisabled individuals exhibited a similar U-shaped pattern but with lower risks associated with lower BMI. For disabled individuals, the mortality-risk pattern was higher for lower BMI (< 22.0) and flat for higher BMI, thus exhibiting an inverse J shape. BMI patterns were age sensitive, with disability status affecting sensitivity.

CONCLUSION

Overweight or mild (grade 1) obesity was not a risk factor for 9-year mortality in older Americans participating in the 1994 NLTCS. A flatter BMI pattern of the relative risk of death for disabled than for nondisabled individuals suggests that optimal body weight can be sensitive to age and health and well-being.

Decreased muscle mass and increased central adiposity are independently related to mortality in older men

BACKGROUND

Aging is associated with significant changes in body composition. Body mass index (BMI; in kg/m(2)) is not an accurate indicator of overweight and obesity in the elderly.

OBJECTIVE

We examined the relation between other anthropometric indexes of body composition (both muscle mass and body fat) and all-cause mortality in men aged 60-79 y.

DESIGN

The study was a prospective study of 4107 men aged 60-79 y with no diagnosis of heart failure and who were followed for a mean period of 6 y, during which time there were 713 deaths.

RESULTS

Underweight men (BMI < 18.5) had exceptionally high mortality rates. After the exclusion of these men, increased adiposity [BMI, waist circumference (WC), and waist-to-hip ratio] showed little relation with mortality after adjustment for lifestyle characteristics. Muscle mass [indicated by midarm muscle circumference (MAMC)] was significantly and inversely associated with mortality. After adjustment for MAMC, obesity markers, particularly high WC (>102 cm) and waist-to-hip ratio (top quartile), were associated with increased mortality. A composite measure of MAMC and WC most effectively predicted mortality. Men with low WC (</=102 cm) and above-median muscle mass showed the lowest mortality risk. Men with WC > 102 cm and above-median muscle mass showed significantly increased mortality [age-adjusted relative risk: 1.36; 95% CI: 1.07, 1.74), and this increased to 1.55 (95% CI: 1.01, 2.39) in those with WC > 102 and low MAMC.

CONCLUSION

The findings suggest that the combined use of both WC and MAMC provides simple measures of body composition to assess mortality risk in older men.

Keeping the young-elderly healthy: is it too late to improve our health through nutrition?

Healthy older individuals can take several measures to preserve and improve their health. Even if past nutritional and lifestyle practices were not optimal, much can be done to reduce the risk of chronic disease and disability in future years. The first challenge is to recognize and address the profound changes in body composition that occur with aging. Older persons tend to accumulate relatively more body fat and less lean body mass, ie, muscle and bone. With a gain in body weight, which usually occurs, these changes are exaggerated. Because muscle tissue has a much higher metabolic rate than does fat tissue, older individuals generally develop lower metabolic rates. To avoid excess weight gain, older individuals must make major restrictions in caloric intake and increases in energy expenditure. Women experience changes in body composition similar to those in men, with changes becoming more prominent at menopause. Exercise improves body composition among healthy elderly, both by reducing fat mass and by increasing bone and muscle mass, thereby helping to restore higher metabolic rates. In men and women aged >/=65 y and taking calcium and vitamin D supplements for 3 y, the rate of bone loss slowed and the incidence of nonvertebral fractures was reduced. Several population studies of older persons show that following nutritional and lifestyle guidelines for cancer prevention reduces risk by one-third. Improving serum lipid concentrations in adults over 65 y of age with coronary artery disease decreases the risk of future cardiac events by as much as 45%. Furthermore, the greatest benefit from control of hypertension is in older individuals.

“Diabetes of the elderly” and type 2 diabetes in younger patients: Possible role of the biological clock

The increased prevalence of type 2 diabetes in the aged has been recognized for a long time. Within the last decades, a growing number of younger subjects and even children are prone to develop type 2 diabetes. In both groups, aged and young, the biological clock, located in the suprachiasmatic nucleus of the hypothalamus (SCN) is malfunctioning as evidenced by disturbed sleep cycles and altered circadian rhythms. While elderly patients have an impaired function of the SCN due to the degeneration of neurons, we propose that in younger subjects the clock loses its "feeling" for internal and external rhythms caused by the modern lifestyle. Sleeping late and less coupled with constant metabolic excess alter both internal and external environmental stimuli to the brain. In response to these alterations, the rhythm of the biological clock is disrupted which may lead to the metabolic syndrome and type 2 diabetes.

Increase of Plasma Fibrinogen Levels and Variability with Age in a Sample of Middle Aged Healthy Men

According to predictions from the current theoretical models for ageing the heterogeneity of the population is increasing with increasing age. Although the direct observation of such changes in humans is extremely difficult, supporting evidence should be identifiable in key biomarkers associated with health and mortality. Using data from the Northwick Park Heart Study II of 3052 healthy middle-aged men (mean 56 years of age, range 49-69 years), with 5 annual measures of CHD risk factors, ageing effects were tested for plasma fibrinogen, cholesterol and triglycerides. Fibrinogen levels increased with age (p < 0.0001), while cholesterol showed a decrease, and triglycerides did not show any change with age. There was a significant increase in the variance of fibrinogen with age (p < 0.0007) but not for cholesterol or triglycerides. The raising effect on fibrinogen levels associated with the A allele of the FIBB - 455G>A promoter variant also decreased with age (p = 0.005). The age-associated changes observed in the fibrinogen variability and the association of phenotype to genotype are discussed in light of the evolutionary theory, and their implications are considered.

The management of osteoarthritis in the obese patient: practical considerations and guidelines for therapy

Obesity and osteoarthritis (OA) co-exist in an increasing part of the population. The two diseases intertwine in several ways. The evolution in the population shows a tendency towards deterioration of both by increasing general age and weight. The two diseases share pathogenetic features and the development of one disease increases the risk of the other and may be the onset of a vicious circle. There is a link between treatments of these two diseases as well. There is now solid (gold) evidence that by treating effectively the obesity of patients with co-occurring OA, the functional status is dramatically ameliorated; the short-term results are equal to that of a joint replacement. The long-term efficacy of a weight loss remains to be shown. OA is definitely one of many diseases in which obesity must be taken seriously into account when planning a correct treatment of patients. The regimens used in the controlled studies of such patients are reviewed and it may be concluded that practical aspects of the dietary intervention in obese patients with OA are not different from general recommendations.

Exercise for overweight or obesity

BACKGROUND

Clinical trials have shown that exercise in adults with overweight or obesity can reduce bodyweight. There has been no quantitative systematic review of this in The Cochrane Library.

OBJECTIVES

To assess exercise as a means of achieving weight loss in people with overweight or obesity, using randomised controlled clinical trials.

SEARCH STRATEGY

Studies were obtained from computerised searches of multiple electronic bibliographic databases. The last search was conducted in January 2006.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials that examined body weight change using one or more physical activity intervention in adults with overweight or obesity at baseline and loss to follow-up of participants of less than 15%.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

The 43 studies included 3476 participants. Although significant heterogeneity in some of the main effects' analyses limited ability to pool effect sizes across some studies, a number of pooled effect sizes were calculated. When compared with no treatment, exercise resulted in small weight losses across studies. Exercise combined with diet resulted in a greater weight reduction than diet alone (WMD -1.1 kg; 95% confidence interval (CI) -1.5 to -0.6). Increasing exercise intensity increased the magnitude of weight loss (WMD -1.5 kg; 95% CI -2.3 to -0.7). There were significant differences in other outcome measures such as serum lipids, blood pressure and fasting plasma glucose. Exercise as a sole weight loss intervention resulted in significant reductions in diastolic blood pressure (WMD -2 mmHg; 95% CI -4 to -1), triglycerides (WMD -0.2 mmol/L; 95% CI -0.3 to -0.1) and fasting glucose (WMD -0.2 mmol/L; 95% CI -0.3 to -0.1). Higher intensity exercise resulted in greater reduction in fasting serum glucose than lower intensity exercise (WMD -0.3 mmol/L; 95% CI -0.5 to -0.2). No data were identified on adverse events, quality of life, morbidity, costs or on mortality.

AUTHORS' CONCLUSIONS

The results of this review support the use of exercise as a weight loss intervention, particularly when combined with dietary change. Exercise is associated with improved cardiovascular disease risk factors even if no weight is lost.

Abdominal fat distribution and functional limitations and disability in a biracial cohort: the Atherosclerosis Risk in Communities Study

OBJECTIVE

To examine the associations of abdominal fat and obesity with functional limitations and disability in late adulthood.

DESIGN

Longitudinal, cohort study.

PARTICIPANTS

African American and white men and women aged 45-64 y at baseline with measured waist circumference, waist-to-hip ratio (WHR), and body mass index (BMI) who participated in the Atherosclerosis Risk in Communities (ARIC) Study (n = 9416).

OUTCOME MEASURES

Self-reported functional limitations, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) at ages 52-75 y.

RESULTS

Waist circumference, WHR, and BMI were positively associated with functional limitations and ADL and IADL impairment approximately 9 y later among African American and white men and women. For example, in African American women the odds ratios (95% CI) associated with a one standard deviation (s.d.) increment in waist circumference (13.3 cm) for severe functional limitations and ADL and IADL impairment were 2.36 (2.00-2.79), 1.41 (1.25-1.58), and 1.49 (1.34-1.66), respectively. In white women, the odds ratios (95% CI) were 2.66 (2.39-2.96), 1.60 (1.47-1.74), and 1.42 (1.31-1.53), respectively. Similar associations were found in men. A 1 s.d. increment in WHR (0.08 U) and BMI (5.06 kg/m2) produced similar results. The associations of waist circumference and WHR with functional limitations and ADL and IADL impairment were attenuated but, in general, remained statistically significant when BMI was added to the models.

CONCLUSIONS

Maintaining a healthy body weight and avoiding increases in abdominal fat should be investigated for their potential to reduce the risk of functional limitations and disability in an aging population.

Prevalence and risk factors associated with obesity in the elderly in Barbados

This article's objective is to examine the epidemiology of obesity in the urban elderly population of Barbados. A random sample of adults >/= 60 years underwent comprehensive interviews and measurement of their weight, height, and waist circumference (WC). Outcomes of interest were obesity (body mass index [BMI] > 30 kg/m2), high-risk WC (men >/= 102 cm; women >/= 88 cm), and high risk of disease comorbidity (from BMI and WC criteria). Total, 1,508 persons participated (80% response). Women had higher rates of obesity (31% vs. 11.9%), high-risk WC (61.9% vs. 13.9%), and disease co-morbidity risk (51.1% vs. 17.5%) compared to men. Multivariate regression confirmed female gender as an independent predictor of outcomes (p < 0.001). Other predictors were less consistent: self-reported fair/poor health status and eating two (vs. three) meals daily were associated with obesity, whereas semiprofessional occupation and unmarried status predicted high-risk WC. Obesity is highly prevalent among elderly Barbadians. Public health interventions must target this group, particularly women.

Health consequences of obesity in the elderly: a review of four unresolved questions

Obesity prevalence is growing progressively even among older age groups. Controversy exists about the potential harms of obesity in the elderly. Debate persists about the relation between obesity in old age and total or disease-specific mortality, the definition of obesity in the elderly, its clinical relevance, and about the need for its treatment. Knowledge of age-related body composition and fat distribution changes will help us to better understand the relationships between obesity, morbidity and mortality in the elderly. Review of the literature supports that central fat and relative loss of fat-free mass may become relatively more important than BMI in determining the health risk associated with obesity in older ages. Weight gain or fat redistribution in older age may still confer adverse health risks (for earlier mortality, comorbidities conferring independent adverse health risks, or for functional decline). Evaluation of comorbidity and weight history should be performed in the elderly in order to generate a comprehensive assessment of the potential adverse health effects of overweight or obesity. The risks of obesity in the elderly have been underestimated by a number of confounders such as survival effect, competing mortalities, relatively shortened life expectancy in older persons, smoking, weight change and unintentional weight loss. Identification of elderly subjects with sarcopenic obesity is probably clinically relevant, but the definition of sarcopenic obesity, the benefits of its clinical identification, as well as its relation to clinical consequences require further study. Studies on the effect of voluntary weight loss in the elderly are scarce, but they suggest that even small amounts of weight loss (between 5-10% of initial body weight) may be beneficial. In older as well as in younger adults, voluntary weight loss may help to prevent the adverse health consequences of obesity.

Effectiveness of weight loss in the elderly with type 2 diabetes mellitus

We compared cardiovascular risk factors in younger and older patients with Type 2 diabetes mellitus and higher than normal body mass index (BMI) and percentage of body fat (% BF) after a 1-yr weight-reduction program in order to clarify the benefits of weight loss in the overweight elderly. Groups of 52 younger and 50 older patients consumed low-calorie diets and participated in a simple moderate-intensity aerobic exercise program for 1 yr. At three times during the program (start, 6 months, 12 months), 10 measures were taken for each participant: BMI, total cholesterol (TC), triglyceride (TG), % BF, waist circumference (WC), fasting plasma glucose, hemoglobulin A1c (HbA1c), leptin, high-sensitivity C-reactive protein (hs-CRP), and adiponectin levels. While changes in BMI, TC and TG were evidently the same in both age groups (p-value: 0.11, 0.33, 0.70, respectively), raw figures for change in % BF, WC, fasting plasma glucose, HbA1c, leptin, hs-CRP, and adiponectin values were significantly greater in the older group (p-value: 0.02, 0.01, 0.03, 0.04, 0.02, 0.01, 0.03 respectively). However, after adjusting for % BF and WC, these changes were no longer significant (p-values: 0.08, 0.07, 0.08, 0.06, 0.10, respectively), indicating that weight loss is equally beneficial for overweight patients with Type 2 diabetes in both age groups. Benefits were gained mainly through reduced body fat. Simple life-style modification of adding 20-min daily aerobic exercise and an adequate but restricted calorie diet is more effective in elderly diabetic patients.

Dietary Management for Older Subjects with Obesity

In recent years, obesity has been recognized as a form of malnutrition in older adults and a continuing risk factor for serious health problems. Weight reduction in older adults is not as reliable a recommendation as it is for younger adults; a decreased body mass index (BMI) seems to be associated with a higher incidence of stroke, and a normal or slightly elevated BMI has been linked to greater reserve capacity. Weight loss in older adults requires strategies that consider health status, functional ability, and rational targets. Strategies may include behavior modification, dietary alterations, exercise or physical activity, and reasonable goals that do not put the individual at nutritional risk. Studies that examine different approaches to weight reduction rarely include older subjects, so it is difficult to make judgments about various interventions (surgery, exercise, drugs, or diet) and their efficacy in this population. Fad diets may be lacking in essential nutrients and may prove to be risky for elderly people. Weight loss programs for older adults should focus on maintaining adequate intake of essential nutrients while reducing calories by controlling dietary fat intake.