Treatment of obesity in older persons-A systematic review

Nutrition for the older adult - Current concepts. Report from an ESPEN symposium

BACKGROUND & AIMS

In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge.

METHODS

Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report.

RESULTS

Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia.

CONCLUSIONS

In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults.

Bariatric Surgical Outcomes in the Elderly: A Comparison Study Between Primary and Revisional Procedures in the United Arab Emirates

PURPOSE

Data reported on comparing primary and revisional procedures in the elderly is still limited. The aim of this study was to compare the efficacy and safety between primary and revisional bariatric surgery in a cohort of older patients.

MATERIALS AND METHODS

All patients ≥ 60 years old were divided into two cohorts, primary surgery cohort (PSC) and revisional surgery cohort (RSC). Baseline and perioperative outcomes were analyzed.

RESULTS

Fifty-eight patients were included (34 PSC and 24 RSC) in the study. Forty-two (25 PSC and 17 RSC) 72.4% were female. The mean age was 64 (± 3.3 years) in the PSC and 65 (± 4.2 years) in the RSC, the median initial BMI was 46.7 and 47.4 kg/m2 (p < 0.848), respectively. The mean hospital stay was (3 PSC vs. 5 RSC, p < 0.022) days. Readmissions occurred in (1 PSC vs. 3 RSC, p = 0.158) patients within 30 days of discharge. Postoperative major complications included (1 PSC vs. 5 RSC, p < 0.0278) patients. Reoperations were reported in (0 PSC vs. 3 RSC, p < 0.034) patients. Patients who underwent surgery for weight management, the initial mean BMI was (46.7 PSC vs. 47.4 RSC kg/m2, p = 0.848). At 12-months post-procedure, the mean BMI was (34.3 PSC vs. 37.7 RSC kg/m2, p = 0.372) and (23.7 PSC vs. 19.1 RSC, p = 0.231) %TBWL. The mean overall follow-up was (12.4 PSC vs. 27.5 RSC, p < 0.004) months, and one unrelated death (cancer) was reported in the RSC.

CONCLUSION

PSC and RSC are effective in the elderly, however postoperative complications occurred more often in the RSC group.

Pharmacotherapy for older people with obesity

Rates of obesity continue to rise, including in older adults. Use of medication for obesity in the elderly has been considered controversial, due to concerns around potential progression of age-related sarcopenia and a general lack of evidence for its use in this age group. Within this review, we describe the general considerations when prescribing obesity pharmacotherapy for older adults living with obesity. We evaluate in detail the anti-obesity medications currently licenced in Europe, with emphasis on the available efficacy, safety and cardiovascular outcome data gathered from study of older people. Finally, we discuss future directions and avenues of research.

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.

Lifestyle and ADL Are Prioritized Factors Influencing All-Cause Mortality Risk Among Oldest Old: A Population-Based Cohort Study

To identify key factors affecting all-cause mortality in the elderly aged 80 years and above. Data from Chinese Longitudinal Healthy Longevity Survey (2011-2018) were utilized (N = 3993). A healthy lifestyle score was obtained by assigning 8 factors: smoking, drinking, exercise, sleep duration, social activity, waist circumference, BMI, and healthful plant-based diet index. Cox regression and decision tree model were used to identify factors influencing the mortality risk. Lifestyle and activities of daily living (ADL) were 2 of the most important modifiable factors influencing the mortality risk of the oldest seniors. A higher healthy lifestyle score was associated with lower mortality risk. The HR (95% CI) of death risk in Q2, Q3, and Q4 groups were 0.91 (0.81-1.01), 0.78 (0.71-0.86), and 0.64 (0.58-0.71), respectively, when compared with the Q1 group of healthy lifestyle score. Elderly with ADL disability had a higher mortality rate than those without ADL disability. When the elderly already have ADL disability, the healthier the lifestyle, the lower the mortality rate. Among individuals aged 80 to 89 years with ADL disability, the mortality rate was higher in the healthy lifestyle score Q1-Q2 groups (92.1%) than that in the Q3-Q4 groups (71.6%). Similar results were observed among subjects aged 90 to 99 years with ADL disability (Q1-Q2: 97.9%, Q3-Q4: 92.1%). For centenarians without ADL disability, maintaining a healthy lifestyle significantly reduced mortality (Q1-Q3: 90.5%, Q4: 75.5%). Caregivers should prioritize the consideration of lifestyle and ADL in their healthcare practices of the oldest old.

The Role of Lifestyle Modification with Second-Generation Anti-obesity Medications: Comparisons, Questions, and Clinical Opportunities

PURPOSE OF REVIEW

This review examines lifestyle modification for obesity management with the goal of identifying treatment components that could support the use of a new generation of anti-obesity medications (AOMs).

RECENT FINDINGS

Semaglutide reliably reduces baseline body weight by approximately 15% at 68 weeks, in contrast to 5-10% for lifestyle modification. Tirzepatide induces mean losses as great as 20.9%. Both medications reduce energy intake by markedly enhancing satiation and decreasing hunger, and they appear to lessen the need for traditional cognitive and behavioral strategies (e.g., monitoring food intake) to achieve calorie restriction. Little, however, is known about whether patients who lose weight with these AOMs adopt healthy diet and activity patterns needed to optimize body composition, cardiometabolic health, and quality of life. When used with the new AOMs, the focus of lifestyle modification is likely to change from inducing weight loss (through calorie restriction) to facilitating patients' adoption of dietary and activity patterns that will promote optimal changes in body composition and overall health.

Approach to obesity in the elderly population: a consensus report from the Diabetes, Obesity and Nutrition Working Group of SEMI (Spanish Society of Internal Medicine)

Obesity in the elderly not only impacts morbidity and mortality but their quality of life. This phenomenon has sparked extensive research and debate regarding treatment recommendations, primarly due to the lack evidence in this specific population. When addressing possible treatment recommendations for older adults with obesity, it is crucial to assess certain essential aspects such as functional status, sarcopenia, cognitive status, and others. Intentional weight loss in this population can be both effective and safe. The best weight loss plan for the elderly revolves around adopting a healthy lifestyle, which includes following a Mediterranean diet pattern and engaging in physical exercise, particularly strength training. Additionally, the use of weight loss medications, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RA) and novel glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists, can provide an additional stage of treatment. In selective candidates, bariatric surgery may also be considered. The objective of this document is to propose a comprehensive algorithm of recommendations for the management of obesity in the elderly (above the age of 65), based on scientific evidence and the expertise of members from the Diabetes, Obesity, and Nutrition Workgroup of the Spanish Society of Internal Medicine.

Factors affecting the effectiveness of the physical activity counselling intervention implemented in primary health care in adults with type 2 diabetes

BACKGROUND

Type 2 diabetes (T2D) has become a major public health threat; physical inactivity and obesity are both independent risk factors. Increasing daily physical activity (PA) significantly benefits treatment. Individual PA counselling is helpful for people with T2D, especially those with previous inactivity or with diabetes complications. This study evaluated factors contributing to effectiveness of PA counselling in primary health care (PHC) patients with T2D in a real-world setting and using data elicited from electronic health records (EHRs).

METHODS

All patients with T2D were offered the opportunity to participate in a PA program organized as part of basic PHC services in the Siun sote region in North Karelia, Finland, from October 2016 to December 2018. The study population consists of patients aged 19 to 87 years (n = 546). During the intervention information on possible other factors in addition to age and sex influencing the intervention effect such as amount of counselling sessions, changes in PA and patients´ motivation was gathered. Changes in the participants' PA activity was generated by following the predefined rules from patient records and by assessing the descriptive documentation of activity patterns. The patients' motivation level was assessed using a Likert scale.

RESULTS

Over 60% of participants who attended PA counselling more than three times increased their PA compared with 1% of participants with one counselling session. Of the whole intervention group, the participants experiencing the largest weight loss were those with an increased level of PA (-1.36 kg vs. -0.63 kg among those with no change in PA). Age, sex, and baseline motivation did not affect the change the PA nor the main intervention outcomes.

CONCLUSIONS

Patients' compliance with the intervention was reflected in the number of PA counselling sessions attended which in turn was seen as increased levels of PA as well as better treatment outcomes. In the implementation of lifestyle counselling interventions attention should be paid on sufficient amount and frequency of counselling sessions. The individually tailored PA counselling provided in PHC has similar effects regardless of sex and age.

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

Clinical Recommendations to Manage Gastrointestinal Adverse Events in Patients Treated with Glp-1 Receptor Agonists: A Multidisciplinary Expert Consensus

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are indicated in type 2 diabetes and obesity for their high efficacy in controlling glycaemia and inducing body weight loss, respectively. Patients may develop gastrointestinal adverse events (GI AEs), namely nausea, vomiting, diarrhoea and/or constipation. To minimize their severity and duration, healthcare providers (HCPs) and patients must be aware of appropriate measures to follow while undergoing treatment. An expert panel comprising endocrinologists, nephrologists, primary care physicians, cardiologists, internists and diabetes nurse educators convened across virtual meetings to reach a consensus regarding these compelling recommendations. Firstly, specific guidelines are provided about how to reach the maintenance dose and how to proceed if GI AEs develop during dose-escalation. Secondly, specific directions are set about how to avoid/minimize nausea, vomiting, diarrhoea and constipation symptoms. Clinical scenarios representing common situations in daily practice, and infographics useful to guide both HCPs and patients, are included. These recommendations may prevent people with T2D and/or obesity from withdrawing from GLP-1 RAs treatment, thus benefitting from their superior effect on glycaemic control and weight loss.

[What is confirmed in the treatment of obesity?]

Obesity is a chronic disease. Obesity and the associated sequelae not only lead to an increased morbidity and mortality but also to a reduced quality of life. People with obesity are often stigmatized and are not offered adequate professional treatment although evidence-based treatment options are available. According to current guidelines a multimodal, interdisciplinary and individualized obesity treatment must always be carried out. For most patients with advanced obesity structured multimodal therapy programs and/or bariatric surgery (with accompanying conservative measures) are the treatment of choice. The treatment spectrum is supplemented by pharmaceuticals, supportive fields and online offers. As obesity is a chronic disease any time-limited treatment is mostly futile. Treatment of obesity must therefore be organized in a professional and long-term manner.

Outcomes addressed in randomized controlled lifestyle intervention trials in community-dwelling older people with (sarcopenic) obesity-An evidence map

Obesity and sarcopenic obesity (SO) are characterized by excess body fat with or without low muscle mass affecting bio-psycho-social health, functioning, and subsequently quality of life in older adults. We mapped outcomes addressed in randomized controlled trials (RCTs) on lifestyle interventions in community-dwelling older people with (sarcopenic) obesity. Systematic searches in Medline, Embase, Cochrane Central, CINAHL, PsycInfo, Web of Science were conducted. Two reviewers independently performed screening and extracted data on outcomes, outcome domains, assessment methods, units, and measurement time. A bubble chart and heat maps were generated to visually display results. Fifty-four RCTs (7 in SO) reporting 464 outcomes in the outcome domains: physical function (n = 42), body composition/anthropometry (n = 120), biomarkers (n = 190), physiological (n = 30), psychological (n = 47), quality of life (n = 14), pain (n = 4), sleep (n = 2), medications (n = 3), and risk of adverse health events (n = 5) were included. Heterogeneity in terms of outcome definition, assessment methods, measurement units, and measurement times was found. Psychological and quality of life domains were investigated in a minority of studies. There is almost no information beyond 52 weeks. This evidence map is the first step of a harmonization process to improve comparability of RCTs in older people with (sarcopenic) obesity and facilitate the derivation of evidence-based clinical decisions.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Signaling pathways in obesity: mechanisms and therapeutic interventions

Obesity is a complex, chronic disease and global public health challenge. Characterized by excessive fat accumulation in the body, obesity sharply increases the risk of several diseases, such as type 2 diabetes, cardiovascular disease, and nonalcoholic fatty liver disease, and is linked to lower life expectancy. Although lifestyle intervention (diet and exercise) has remarkable effects on weight management, achieving long-term success at weight loss is extremely challenging, and the prevalence of obesity continues to rise worldwide. Over the past decades, the pathophysiology of obesity has been extensively investigated, and an increasing number of signal transduction pathways have been implicated in obesity, making it possible to fight obesity in a more effective and precise way. In this review, we summarize recent advances in the pathogenesis of obesity from both experimental and clinical studies, focusing on signaling pathways and their roles in the regulation of food intake, glucose homeostasis, adipogenesis, thermogenesis, and chronic inflammation. We also discuss the current anti-obesity drugs, as well as weight loss compounds in clinical trials, that target these signals. The evolving knowledge of signaling transduction may shed light on the future direction of obesity research, as we move into a new era of precision medicine.

Age- and sex-specific effects of a long-term lifestyle intervention on body weight and cardiometabolic health markers in adults with prediabetes: results from the diabetes prevention study PREVIEW

AIMS/HYPOTHESIS

Lifestyle interventions are the first-line treatment option for body weight and cardiometabolic health management. However, whether age groups or women and men respond differently to lifestyle interventions is under debate. We aimed to examine age- and sex-specific effects of a low-energy diet (LED) followed by a long-term lifestyle intervention on body weight, body composition and cardiometabolic health markers in adults with prediabetes (i.e. impaired fasting glucose and/or impaired glucose tolerance).

METHODS

This observational study used longitudinal data from 2223 overweight participants with prediabetes in the multicentre diabetes prevention study PREVIEW. The participants underwent a LED-induced rapid weight loss (WL) period followed by a 3 year lifestyle-based weight maintenance (WM) intervention. Changes in outcomes of interest in prespecified age (younger: 25-45 years; middle-aged: 46-54 years; older: 55-70 years) or sex (women and men) groups were compared.

RESULTS

In total, 783 younger, 319 middle-aged and 1121 older adults and 1503 women and 720 men were included in the analysis. In the available case and complete case analyses, multivariable-adjusted linear mixed models showed that younger and older adults had similar weight loss after the LED, whereas older adults had greater sustained weight loss after the WM intervention (adjusted difference for older vs younger adults -1.25% [95% CI -1.92, -0.58], p<0.001). After the WM intervention, older adults lost more fat-free mass and bone mass and had smaller improvements in 2 h plasma glucose (adjusted difference for older vs younger adults 0.65 mmol/l [95% CI 0.50, 0.80], p<0.001) and systolic blood pressure (adjusted difference for older vs younger adults 2.57 mmHg [95% CI 1.37, 3.77], p<0.001) than younger adults. Older adults had smaller decreases in fasting and 2 h glucose, HbA1c and systolic blood pressure after the WM intervention than middle-aged adults. In the complete case analysis, the above-mentioned differences between middle-aged and older adults disappeared, but the direction of the effect size did not change. After the WL period, compared with men, women had less weight loss (adjusted difference for women vs men 1.78% [95% CI 1.12, 2.43], p<0.001) with greater fat-free mass and bone mass loss and smaller improvements in HbA1c, LDL-cholesterol and diastolic blood pressure. After the WM intervention, women had greater fat-free mass and bone mass loss and smaller improvements in HbA1c and LDL-cholesterol, while they had greater improvements in fasting glucose, triacylglycerol (adjusted difference for women vs men -0.08 mmol/l [-0.11, -0.04], p<0.001) and HDL-cholesterol.

CONCLUSIONS/INTERPRETATION

Older adults benefited less from a lifestyle intervention in relation to body composition and cardiometabolic health markers than younger adults, despite greater sustained weight loss. Women benefited less from a LED followed by a lifestyle intervention in relation to body weight and body composition than men. Future interventions targeting older adults or women should take prevention of fat-free mass and bone mass loss into consideration.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01777893.

Impact of bariatric surgery in elderly patients with obesity

INTRODUCTION

to evaluate the long-term impact of bariatric surgery in the elderly population.

METHODS

a retrospective study including all patients older than 60 years who underwent Roux-en-Y gastric bypass (RYGB) at our center and maintained a follow-up longer than 1 year. Clinical and laboratory variables were studied to assess remission of obesity and its comorbidities, as well as variables directly related to the surgical procedure itself, including early and late complications.

RESULTS

fifty-six patients were studied, mostly female (76,8%), with a mean age of 64.02 ± 3.34. A rate of complications of 37,5% was observed, with 10,7% requiring hospital admission and emergency surgery. The mean excess weight loss (%EWL) was 74.22% ± 26.76. The remission rates of hypertension and diabetes mellitus were 26.08% and 54.54%, respectively. There was significant difference in BMI reduction (12.25 ± 5.42, p<0.001), total cholesterol (31.37 ± 38.89 p<0,001), LDL cholesterol (23.45 ± 34.9, p=0.002), HDL cholesterol (5.14 ± 11.13, p=0,024), triglycerides (48.85 ± 56.15 p<0.001), HbA1C (1,81 ± 1,97, p<0,001) e PCR (1.43 ± 1.96, p<0.001).

CONCLUSION

bariatric surgery was effective in weight loss and remission of comorbidities in the elderly obese population within the long term.

How to talk with patients about weight? Viewpoints of 1697 individuals with overweight and obesity

OBJECTIVES

To evaluate the preferences of individuals with overweight and obesity regarding the optimal approach for discussing the excess weight during medical appointments.

METHODS

The cross-sectional study was conducted by distribution of an anonymous questionnaire in social media platforms during September 2020, aiming for respondents with body mass index over 25 kg/m².

RESULTS

The questionnaire was completed by 1697 participants, mostly female. Only 14.5% agreed that the weight issue should be brought up at medical appointments, while 69.3% preferred health practitioners to ask for a preliminary agreement to talk about the excess weight. The participants were frequently advised to lose weight without them wanting to talk about this (65.0%), when the reason for their appointment was irrelevant to the excess weight (60.4%), and without receiving any effective and practical tools on losing weight (60.1%).

CONCLUSIONS

Health practitioners should ask the patient for a preliminary permission to discuss the issue of excess weight during medical appointments.

PRACTICE IMPLICATIONS

Discussing the subject of weight during medical appointments should be done in a sensitive and respectful manner. Health practitioners should learn more about the numerous reasons for obesity, the adverse effects of weight stigmatization, and the practical tools to lose weight.

Impacto da cirurgia bariátrica em pacientes idosos portadores de obesidade

RESUMO Introdução: avaliar o impacto da cirurgia bariátrica na população idosa no longo prazo. Métodos: estudo retrospectivo que incluiu todos os pacientes com mais de 60 anos submetidos ao Bypass gástrico em Y de Roux (BGYR) em nosso centro e que mantiveram seguimento superior a 1 ano. Foram estudadas variáveis clínicas e laboratoriais para avaliação da remissão da obesidade e suas comorbidades, além de variáveis diretamente relacionados ao procedimento cirúrgico em si, incluindo complicações precoces e tardias. Resultados: foram estudados 56 pacientes, a maioria do sexo feminino (76,8%), com idade média de 64,02 ± 3,34. Foi observada uma taxa de complicações de 37,5%, com 10,7% requerendo internamento hospitalar e cirurgia de urgência. A média geral da perda do excesso de peso (%PEP) foi de 74,22% ± 26,76. As taxas de remissão de hipertensão e diabetes mellitus foram de 26,08% e 54,54%, respectivamente. Houve variação significativa no IMC (12,25 ± 5,42, p<0,001), colesterol total (31,37 ± 38,89 p<0,001), colesterol LDL (23,45 ± 34,9, p=0,002), colesterol HDL (5,14 ± 11,13, p=0,024), triglicerídeos (48,85 ± 56,15 p<0,001), HbA1C (1,81 ± 1,97, p<0,001) e PCR (1,43 ± 1,96, p<0,001). Conclusão: a cirurgia bariátrica se mostrou eficaz na perda de peso e na remissão de comorbidades na população de idosos com obesidade no longo prazo..

Racial disparities in bariatric perioperative outcomes among the elderly

BACKGROUND

Bariatric surgery outcomes in elderly patients have been shown to be safe, but with a higher rate of adverse outcomes compared with nonelderly patients. The impact of race on bariatric surgery outcomes continues to be explored, with recent studies showing higher rates of adverse outcomes in black patients. Perioperative outcomes in racial cohorts of elderly bariatric patients are largely unexplored.

OBJECTIVE

The goal of this study was to compare outcomes between elderly non-Hispanic black (NHB) and non-Hispanic white (NHW) bariatric surgery patients to determine whether outcomes are mediated by race.

SETTING

Academic hospital.

METHODS

Patients who had a primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) in the period 2015-2018 and were at least 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (MBSAQIP PUF). Selected cases were stratified by race. Outcomes were compared between matched racial cohorts. Multivariate regression analyses were performed to determine whether race independently predicted morbidity.

RESULTS

From 2015 to 2018, 29,394 elderly NHW (90.8%) and NHB (9.2%) patients underwent an RYGB or SG. At baseline, NHB elderly patients had a higher burden of co-morbid conditions, resulting in higher rates of overall (7.7% versus 6.4%, P = .009) and bariatric-related (5.4% versus 4.1%, P = .001) morbidity. All outcome measures were similar between propensity-score-matched racial elderly bariatric patient cohorts. On regression analysis, NHB race remained independently correlated with morbidity (odds ratio [OR] 1.3, 95% CI 1.08-1.47, P = .003).

CONCLUSION

RYGB and SG are safe in elderly patient cohorts, with no differences in adverse outcomes between NHB and NHW patients, accounting for confounding factors. While race does not appear to impact outcomes in the elderly cohorts, NHB race may play a role in access.

Approach to Obesity in the Older Population

Until recently, weight loss in older obese people was feared because of ensuing muscle loss and frailty. Facing overall increasing longevity, high rates of obesity in older individuals (age ≥ 65 years) and a growing recognition of the health and functional cost of the number of obesity years, abetted by evidence that intentional weight loss in older obese people is safe, this approach is gradually, but not unanimously, being replaced by more active principles. Lifestyle interventions that include reduced but sufficient energy intake, age-adequate protein and micronutrient intake, coupled with aerobic and resistance exercise tailored to personal limitations, can induce weight loss with improvement in frailty indices. Sustained weight loss at this age can prevent or ameliorate diabetes. More active steps are controversial. The use of weight loss medications, particularly glucagon-like peptide-1 analogs (liraglutide as the first example), provides an additional treatment tier. Its safety and cardiovascular health benefits have been convincingly shown in older obese patients with type 2 diabetes mellitus. In our opinion, this option should not be denied to obese individuals with prediabetes or other obesity-related comorbidities based on age. Finally, many reports now provide evidence that bariatric surgery can be safely performed in older people as the last treatment tier. Risk-benefit issues should be considered with extreme care and disclosed to candidates. The selection process requires good presurgical functional status, individualized consideration of the sequels of obesity, and reliance on centers that are highly experienced in the surgical procedure as well as short-term and long-term subsequent comprehensive care and support.

Does the Impact of Intensive Lifestyle Intervention on Cardiovascular Disease Risk Vary According to Frailty as Measured via Deficit Accumulation?

BACKGROUND

Individuals are often counseled to use behavioral weight loss strategies to reduce risk for cardiovascular disease (CVD). We examined whether any benefits for CVD risk from weight loss intervention extend uniformly to individuals across a range of underlying health states.

METHODS

The time until first occurrence of a composite of fatal and nonfatal myocardial infarction and stroke, hospitalized angina, or CVD death was analyzed from 8 to 11 years of follow-up of 4,859 adults who were overweight or obese, aged 45-76 years with Type 2 diabetes. Individuals had been randomly assigned to either an intensive lifestyle intervention (ILI) or diabetes support and education (DSE). Participants were grouped by intervention assignment and a frailty index (FI) based on deficit accumulation, ordered from fewer (first tertile) to more (third tertile) deficits.

RESULTS

Baseline FI scores were unrelated to intervention-induced weight losses and increased physical activity. The relative effectiveness of ILI on CVD incidence was inversely related to baseline FI in a graded fashion (p = .01), with relative benefit (hazard ratio = 0.73 [95% CI 0.55,0.98]) for individuals in the first FI tertile to no benefit (hazard ratio = 1.15 [0.94,1.42]) among those in the third FI tertile. This graded relationship was not seen for individuals ordered by age tertile (p = .52), and was stronger among participants aged 45-59 years (three-way interaction p = .04).

CONCLUSIONS

In overweight/obese adults with diabetes, multidomain lifestyle interventions may be most effective in reducing CVD if administered before individuals have accrued many age-related health deficits. However, these exploratory analyses require confirmation by other studies.

CLINICAL TRIAL REGISTRATION

NCT00017953.

Bariatric surgery in over 60 years old patients: is it worth it?

The high prevalence of obesity in the elderly and the increase in life expectancy pushed up the age limit as an indication to bariatric surgery. Nevertheless, results on safety and effectiveness of these procedures in over 60 years old population are still controversial. Objectives of the study were to evaluate the safety and effectiveness of bariatric surgery in the elderly. A prospectively collected database was queried for patients older than 60 years who underwent laparoscopic bariatric procedures between 2010 and 2017 at a single institution. These patients were matched with a group of younger patients who had the same procedure in the same period of time. Basal characteristic, intra- and post-operative data were compared. Patients were followed up at 36 months reporting the percentage of excess weight loss (%EWL) and comorbidities remission rate. A total of 100 patients ≥ 60 years old were included (Group 1) and matched with a control group of 96 patients < 60 years (Group 2). Post-operative complications rate was similar (15.0% versus 10.4% p = 0.395). %EWL at 36 months was significantly higher in Group 2 (44.6% versus 68.2% p < 0.001), while remission of medical morbidities was similar in both groups, with a higher rate for type 2 diabetes (T2D) remission among older people (p = 0.017). Patients older than 60 years have post-operative outcomes comparable to younger population. Long-term results are inferior in terms of %EWL, but similar regarding morbidities remission rates, with particular benefits on T2D.

Development and application of an ethical framework for pediatric metabolic and bariatric surgery evaluation

BACKGROUND

As severe obesity continues to rise among youth, metabolic and bariatric surgery (MBS) will increasingly be used as a treatment of choice for durable weight loss and improvement of obesity-related complications. MBS for youth with intellectual and developmental disabilities (IDD) and for preadolescents has raised ethical questions.

OBJECTIVES

The purpose of this article is to present the creation and application of an ethical framework that supports why MBS should be considered in pediatrics based on the principle of justice without automatic exclusions. This framework also provides a guide for how to conduct a robust, ethically grounded evaluation of pediatric patients presenting for MBS in general, and among subpopulations including youth with IDD and preadolescents.

SETTING

Academic medical center, United States.

METHODS

An ethical framework was developed and applied through a collaboration between an MBS center at a children's hospital and the institution's ethics consult service.

RESULTS

Application of the ethical framework to address 4 core ethical questions is illustrated using 2 hypothetical cases: 1 that highlights an adolescent with IDD and 1 that highlights a preadolescent.

CONCLUSIONS

We have demonstrated the application of a novel, overarching framework to conduct the ethical evaluation of youth presenting for MBS. This framework resulted from a collaboration between MBS and ethics consult teams and has the potential to be used as a prototype for other youth-focused MBS programs. Next steps include prospective data collection to test the framework and determine its validity in the target population.

Is Laparoscopic Bariatric Surgery Safe and Effective in Patients over 60 Years of Age?" an Updated Systematic Review and Meta-Analysis

To evaluate, mid-term outcomes between elderly patients (EP, i.e., age > 60 years old) and young patients (YP, i.e., age < = 60 years old) who underwent laparoscopic bariatric surgery. Studies comparing EP versus YP for bariatric surgery published until April 2020 were selected and submitted to a systematic review and meta-analysis. After LSG, overall morbidity and specific post-operative complication rates (i.e., leak, abscess, hemorrhage, and reoperation) were significantly more frequent in EP compared with those in YP. Surgical outcomes were similar between EP and YP after LRYGB. Both procedures achieved weight loss, but it was statistically greater in YP compared with that in EP. In summary, this meta-analysis suggests that laparoscopic bariatric surgery is a safe and effective treatment in EP compared with that in YP.

Effective SLOPE: EffectS of Lifestyle interventions in Older PEople with obesity: a systematic review and network meta-analysis protocol

INTRODUCTION

Obesity is highly prevalent in older adults aged 65 years or older. Different lifestyle interventions (diet, exercise, self-management) are available but benefits and harms have not been fully quantified comparing all available health promotion interventions. Special consideration must be given to functional outcomes and possible adverse effects (loss of muscle and bone mass, hypoglycaemia) of weight loss interventions in this age group. The objective of this study is to synthesise the evidence regarding the effects of different types and modalities of lifestyle interventions, or their combinations, on physical function and obesity-related outcomes such as body composition in older adults with obesity.

METHODS AND ANALYSES

Six databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Psychinfo and Web of Science) and two trial registries (Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform) will be searched for randomised controlled trials of lifestyle interventions in older adults with obesity. Screening (title/abstract and full-text) and data extraction of references as well as assessment of risk of bias and rating of the certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluation for network meta-analyses) will be performed by two reviewers independently. Frequentist random-effects network meta-analyses will be conducted to determine the pooled effects from each intervention.

ETHICS AND DISSEMINATION

We will submit our findings to peer-reviewed journals and present at national and international conferences as well as in scientific medical societies. Patient-targeted dissemination will involve local and national advocate groups.

PROSPERO REGISTRATION NUMBER

CRD42019147286.

Addressing Obesity to Promote Healthy Aging

The population worldwide is aging and prevalence of obesity in this population is increasing. The range of consequences that effect these at-risk patients include increased risk of falls, fractures, reduced quality of life, and cognitive decline. This article describes the epidemiology of obesity, risks and benefits of weight loss, and importance of treating obesity to help promote healthy aging. Health care professionals should encourage older adults with obesity to implement healthy lifestyle behaviors including exercise and diet routine. Treating obesity in older adults mitigates the significant public health crisis, and reduces health care utilization and risk of long-term adverse events.

Dietary weight-loss interventions for the management of obesity in older adults

The obesity epidemic has reached old age in most industrialized countries, but trials elucidating the benefits and risks of weight reduction in older adults above 70 years of age with obesity remain scarce. While some findings demonstrate a reduced risk of mortality and other negative health outcomes in older individuals with overweight and mild obesity (i.e. body mass index (BMI) < 35 kg/m²), other recent research indicates that voluntary weight loss can positively affect diverse health outcomes in older individuals with overweight and obesity (BMI > 27 kg/m²), especially when combined with exercise. However, in this age group weight reduction is usually associated with a reduction of muscle mass and bone mineral density. Since uncertainty persists as to which level overweight or obesity might be tolerable (or even beneficial) for older persons, current recommendations are to consider weight reducing diets only for older persons that are obese (BMI ≥ 30 kg/m²) and have weight-related health problems. Precise treatment modalities (e.g. appropriate level of caloric restriction and indicated dietary composition, such as specific dietary patterns or optimal protein content) as well as the most effective and safest way of adding exercise are still under research. Moreover, the long-term effects of weight-reducing interventions in older individuals remain to be clarified, and dietary concepts that work for older adults who are unable or unwilling to exercise are required. In conclusion, further research is needed to elucidate which interventions are effective in reducing obesity-related health risks in older adults without causing relevant harm in this vulnerable population.

Recommendations Based on Evidence by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the Pre- and Postoperative Management of Patients Undergoing Obesity Surgery

In order to develop evidence-based recommendations and expert consensus for nutrition management of patients undergoing bariatric surgery and postoperative follow-up, we conducted a systematic literature search using PRISMA methodology plus critical appraisal following the SIGN and AGREE-II procedures. The results were discussed among all members of the GARIN group, and all members answered a Likert scale questionnaire to assess the degree of support for every recommendation. Patients undergoing bariatric surgery should be screened preoperatively for some micronutrient deficiencies and treated accordingly. A VLCD (Very Low-Calorie Diet) should be used for 4-8 weeks prior to surgery. Postoperatively, a liquid diet should be maintained for a month, followed by a semi-solid diet also for one month. Protein requirements (1-1.5 g/kg) should be estimated using adjusted weight. Systematic use of specific multivitamin supplements is encouraged. Calcium citrate and vitamin D supplements should be used at higher doses than are currently recommended. The use of proton-pump inhibitors should be individualised, and vitamin B12 and iron should be supplemented in case of deficit. All patients, especially pregnant women, teenagers, and elderly patients require a multidisciplinary approach and specialised follow-up. These recommendations and suggestions regarding nutrition management when undergoing bariatric surgery and postoperative follow-up have direct clinical applicability.

General and Central Adiposity in Older Adults in Palmas (TO): Prevalence and Associated Factors

Objectives: To evaluate the prevalence and associated factors with general and central adiposity in older adults in Palmas (TO).Methods: Cross-sectional study with older adults (≥60 years) of both sexes enrolled in the Family Health Strategy program in Palmas (TO). Sociodemographic aspects, health conditions, and functionality were evaluated as independent variables and Body Mass Index (BMI) for general adiposity and Waist Circumference (WC) for central adiposity as dependent variables. Descriptive analysis and hierarchical multiple Poisson regression with robust variance were performed.Results: A total of 449 seniors (50.6% women) from 60 to 92 years of age, average of 68.3 years, were evaluated. The prevalence of general adiposity was 46.8% (95% CI: 42.2%-51.4%) and central adiposity was 78.8% (95% CI: 74.7%-82.3%). The prevalence of both outcomes was significantly higher among women and the participants with a history of hypertension, diabetes, dyslipidemia, and rheumatic diseases and those dependent in activities of daily living (ADL) than among men. Lower frequency of adiposity (general and central) was found with increasing age. After adjustment, the prevalence of both outcomes was significantly higher in women aged 70-79 years and hypertensive.Conclusions: The results of this study confirm the need to establish nutritional status monitoring and direct obesity prevention and control interventions in programs to promote health and quality of life of older adults and those in the stages prior to old age.

Clinical and Metabolic Improvement after Bariatric Surgery in Older Adults: A 6-Year Follow-Up

AIM

Our aim in this study was to assess the clinical and metabolic impact of bariatric surgery in older adults.

METHODS

This analytical, observational, longitudinal study was carried out with individuals aged 60 years and older who underwent bariatric surgery after 55 years of age at a specialist center for obesity management located in the Federal District of Brazil. Post-surgery changes in the following parameters from baseline: total body weight, excess weight lost, body mass index (BMI), number of medications, number of comorbidities, and weight regain. Mean values of the variables of interest before and after surgery were compared using the nonparametric Wilcoxon test, Poisson regression and multiple linear regression to test the effect of different variables.

RESULTS

Overall, 74 subjects were assessed (78.3% female, mean age 65.8 ± 3.9 years). The mean time from bariatric surgery to assessment was 75.7 months. The mean weight and BMI in the overall sample at baseline was 101.9 ± 17.1 kg and 39.8 ± 4.9 kg/m², respectively. After the procedure, mean weight and BMI were reduced to 75.9 ± 12.9 kg and 29.4 ± 4.1 kg/m², respectively. Reductions were also achieved in mean number of medications used (P<0.001), number of comorbidities (P<0.001), triglyceride levels (P=0.007), and glycated hemoglobin (P=0.02). The mean HDL level increased significantly (P=0.008).

CONCLUSION

In this sample, bariatric surgery was not only useful to manage obesity, but also reduced the number of comorbidities and medications used, and was associated with improvement in clinical and laboratory parameters.

Bariatric surgery as a safe and effective intervention for the control of comorbidities in older adults

INTRODUCTION: In addition to being associated with worsening of diseases related to metabolic syndrome and musculoskeletal disorders, obesity in older adults increases the risk of falls, frailty syndrome, depression, and dementia, with consequent functional loss. Among all treatments available, bariatric surgery is an option for eligible patients. OBJECTIVES: To discuss aspects related to the safety and benefits of bariatric surgery for the control or remission of comorbidities in older adults. METHODS: This literature review was carried out in databases, using the following keywords: bariatric surgery and elderly or aged or older adult and comorbidities or safety. We included clinical trials, observational studies, comparative studies, and reviews that evaluated the effect of bariatric surgery on the control or remission of comorbidities in older adults. RESULTS: In recent years, several studies have evidenced not only control or remission of comorbidities, such as diabetes, hypertension, and sleep apnea syndrome, but also a low rate of complications, similar to those observed in young people. CONCLUSIONS: Based on the results of these studies, bariatric surgical procedures can be indicated for eligible older adults, without age restriction, taking into account functional and life expectancy aspects.

Benefit-to-Risk Balance of Weight Loss Interventions in Older Adults with Obesity

PURPOSE OF REVIEW

Obesity in the older adult is a burgeoning health epidemic that leads to increased morbidity, disability, and institutionalization. This review presents a brief overview of geriatric-specific consequences of obesity by highlighting the risks and benefits of intentional weight loss.

RECENT FINDINGS

Intentional weight loss reduces the extent of adiposity-related illnesses, yet the approach in older adults is fraught with challenges. Interventions combining caloric restriction and physical exercise (aerobic and resistance) maximize fat loss and minimize loss of muscle and bone. Interventions are also effective at improving physical function, reducing medication burden, and improving symptomatic osteoarthritis in this population. Approaches can mitigate the risks of isolated caloric restriction on muscle and bone in a safe and effective manner. Effective weight loss strategies should be considered in older adults. While there are potential risks, practical clinical approaches can minimize the potential harms while maximizing their benefits.