Management of Obesity in Older People

Introduction

Obesity is also termed as the abnormal growth of the adipose tissue, which can either be an enlargement of the fat cells (hypertrophic obesity) or an increase in the number of the fat cells (hyperplastic obesity), or a combination of both. According to a report from the World Health Organization, 2.8 million adults die each year as a result of being overweight or obese. In addition, 44 percent of diabetics, 23 percent of ischemic heart disease, and 7 to 41 percent of certain cancers are attributable to overweight and obesity. Elderly people are vulnerable to obesity as aging is usually associated with a decrease in physical activity and an increase in a sedentary lifestyle. Obesity is becoming a major health problem, being a predisposing factor for diabetes mellitus, cardiovascular disease, osteoarthritis, and sleep apnea.

What Are the Factors that Contribute to Obesity in Older People?

As the elderly are a particularly vulnerable group, obesity and its complications may lead to disability, so it is a major health concern in this age group. Further, the health risks of obesity in the elderly are mostly underestimated due to survivor bias seen in elderly people. Obesity has more functional implications as compared to lean people in the older population. The following are the reasons that predispose the elderly to obesity-

• The growth hormone secretion decreases with age which may result in the accumulation of fat, the reduction of fat-free mass, and energy balance.

• The decline in growth hormone and testosterone production with increasing age decreases fat-free mass and increases fat mass.

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• Resistance to leptin could result in a decreased ability to down-regulate the appetite.

• The metabolic syndrome (truncal obesity plus two low levels of high-density lipoprotein cholesterol, high levels of triglycerides, impaired fasting glucose/diabetes, and hypertension) is associated with raised inflammatory markers and sarcopenia, leading to a potentially vicious circle.

What Are the Consequences of Obesity in Older People?

Obesity causes serious health complications resulting in morbidity. The prevalence of various medical conditions, such as diabetes, hypertension, arthritis, cardiovascular disease, urinary incontinence, and various types of cancers, is associated with obesity in old age.

1. Cardiovascular Disease - Obesity is quantified as body mass index alone, which may potentially mask the association of abdominal fat and cardiovascular disease to events.

2. Pulmonary Abnormalities - Obesity, particularly abdominal obesity, is associated with pulmonary function abnormalities, obesity hypoventilation syndrome, and obstructive sleep apnea. Increased weight in the chest wall decreases respiratory compliance, increases the work of breathing, and restricts ventilation. Older obese men may be particularly predisposed to developing weight-related sleep apnea.

3. Cancer - Being overweight and obese is the most known avoidable cause of cancer after tobacco. Obesity is associated with an increased risk of several types of cancer, such as breast, colon, gallbladder, pancreas, renal, bladder, uterine, cervical, and prostate cancers.

4. Urinary Incontinence - This is a common and distressing problem for the elderly. Prevalence ranges from 5 to 25 percent in men and 7 to 42 percent in women. Obesity contributes to the increase in the prevalence of urinary incontinence in older persons, and the increase in urinary incontinence is directly associated with increased body mass index.

5. Cataracts - Being overweight and obese are associated with an increased prevalence of cataracts and cataract surgery.

6. Sarcopenia - The physical-related progression of sarcopenia and degenerative joint disease is increased due to obesity. A vicious cycle is established when such individuals become less physically mobile, progressing to the inability to perform the simple activities of their daily living. As a result, frailty develops impairment in function, and reduction in the physiological results is severe to bring in the disability.

7. Cognitive Functions - Obesity is importantly associated with impaired cognitive functions. Obesity in mid-life is linked to the development of vascular dementia and Alzheimer's disease. The decline in cognitive function has also been observed to be associated with vascular wrist factors, including wrist dyslipidemia (high plasma cholesterol levels) and hyperglycemia (high blood sugar), and metabolic syndrome (a group of conditions that increases the risk of heart disease, diabetes and stroke) in the presence of inflammation.

How to Manage Obesity in Older People?

The management of obesity in older adults should be individual-specific and aim to offset morbidity and disability. There are various means to manage obesity in older people, such as

1. Exercise - Multimodality exercises such as resistance, endurance, balance, and flexibility training improve physical function and frailty. Aging is associated with lean mass, loss of muscles, and weight loss, which can exacerbate this. Resistance exercise can help offset sarcopenia. Weight loss attempts in older obese adults should include multidisciplinary exercise.

2. Hypo-caloric Diet - It can be another management remedy. Most weight loss regimens described for people older than 65 years are designed with a 500 to 750 kilocalories deficit per day, which gives a weight loss of approximately 500 grams per week. The diet should contain adequate nutrients, serum iron, folate, vitamin D, calcium, and albumin, and then be implemented. Attention should be paid to protein intake, as increased protein intake offsets lean mass. An experienced dietitian can design a meal plan with the above requirements.

3. Very Low-Energy Diet - Very low-energy diets are meal replacement formulations that are used for weight loss. These are nutritionally complete for healthy younger adults as older adults have higher dietary requirements for certain nutrients like calcium and vitamin D; additionally, illnesses may give rise to higher nutrient requirements.

4. Bariatric Surgery - Bariatric surgery is the most effective method of intentional weight loss. Clinical benefits, including reduced need for medication and improvement of obesity-related conditions following bariatric surgery in older adults, have been demonstrated. Hospital stay for older patients is longer after procedures than for younger patients, but observed mortality rates are lower than expected.

5. Anti-obesity Medications - When choosing anti-obesity medications in older patients, there are two main considerations- appetite is often lower in older people, particularly in those with low lean mass; therefore, it is sensible to ask about hunger and appetite before starting them on appetite suppressants, and another reason is polypharmacy is a common problem in the elderly, if anti-obesity medications are deemed important, efforts could be made to minimize other medications.

Conclusion

Obesity is a common but increasing problem in the older population. The number of obese people is increasing because of the increased total number of older persons and the increase in the percentage of obesity among the elderly. Obesity has some important functional implications in older men and women because of their decline in physical activity and energy expenditure, which causes frailty or sarcopenic obesity. Among the elderly, many medical consequences, particularly obesity, are problematic, like diabetes, arthritis, cardiovascular diseases, metabolic syndrome, urinary incontinence, depression, and different types of cancer. The focus of the treatment is on the reduction of intra-abdominal fat initially with modest and conventional diet restriction and preservation of muscle mass and strength through physical activity.