John A. Batsis, MD, FACP

1
Overweight and Over 60 When is Overweight Really
a Problem

• John A. Batsis, MD, FACP
• Assistant Professor of Medicine
• The Geisel School of Medicine at Dartmouth
• Centers for Health Aging
• April 27th, 2012
• John.A.Batsis_at_hitchcock.org

2
Learning Objectives

• Describe the epidemiology of obesity in elderly
  and its clinical relevance
• Highlight the demographic trends observed in the
  elderly
• Indicate the specific geriatric syndromes and
  chronic conditions affected by obesity in elders
• Briefly discuss the challenges in classifying
  elders with obesity
• Outline the challenges and controversies of
  recommending weight loss in the elderly
• Illustrate the relationship between obesity,
  mortality and weight loss
• Clarify the importance of muscle mass in losing
  weight
• Discuss the current recommendations for
  intentional weight loss in elders

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Changing Demographics
4
What is obesity

• a medical condition in which excess body fat has
  accumulated to the extent that it may have an
  adverse effect on health, leading to reduced life
  expectancy and/or increased health problems

http//En.wilkipedia.org
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What measure do we use?

• Body Mass Index
• Weight (in kilograms)
• Height (in meters) 2

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Classification
BMI
Underweight lt18.5 kg/m2
Normal 18.5-24.9 kg/m2
Overweight 25 29.9kg/m2
Obesity gt30 kg/m2
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Change in BMI with ageBaltimore Longitudinal
Study of Aging
Sorkin JD Am J Epidemiol 1999150969-77
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Accuracy of BMI?

• Diagnostic performance of BMI using WHO values
• Males BFgt25
• Females gt35
• Sensitivity (true positives divided by all cases)
  drops, while specificity is static
• Similar in males/females
• Misses 50 of subjects that otherwise would be
  classified as having obesity

Romero-Corral A Int J Obes 200832959
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Sensitivity 50 specificity 90 of BMI for
Obesity They fail to identify half of the people
with excess BF
Okorodudu DO Int J Obes 2010 34, 791
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Correlation of BF Anthropometric measures
Flegal FM 2009 Am J Clin Nutr 89500-8
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Is BMI accurate?
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What is Sarcopenia

• Greek definition - poverty of flesh
• Sarcos flesh
• Penia loss

• Now defined as the loss of muscle that occurs
  with aging
• Coined in 1988

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Life course of Sarcopenia
Sayer AA J Nutr Health Aging. 2008 12(7)
427432
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Changes in body composition

• Fat-free mass (Muscle mass) tends to peak at the
  age of 20 years, and then drops with age
• Fat mass peaks at the age of 60-70 years and then
  drops after that
• As one becomes old old there is a
  re-distribution of body fat and FFM
• Baumgartner RN J Gerontol A Biol Sci Med Sci
  1995 50M307-16
• Gallagher D J Appl Physiol 1997 83229-39

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Why BMI?

• Easy to use in a clinical setting
• Measuring fat mass is not cost-effective nor
  practical

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Practical problems with BMIcutoffs in elderly

• In short body composition is over- or
  underestimated
• Crude index
• Values of overweight (gt25kg/m2)) obesity
  (gt30kg/m2) may differ between populations
• WHO 1997 Obesity Preventing Managing the
  Global Epidemic
• Depends on ethnicity
• Cutoffs have impact for public health policy

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Prevalence of Overweight BMIgt25kg/m21999-2004
Flegal KM JAMA 2010 303(3)235 Ogden CL JAMA.
20062951549
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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2010
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
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Prevalence of Obesity United States
1960-200820 years
Flegal KM JAMA 2010 303(3) 235 Ogden CL JAMA.
20062951549 Flegal KM Int J Obes 1998 2239
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Age-Adjusted Prevalence of ObesityAges 60-74,
1960-2000
NHANES III to 1999-2004 12 5-19 ? in males
7.3 3.9-10.6 in females NHANES II to III
10.3 6.3-14.3 increase in males 11.0
4.6-17.4 in females

• Flegal KM JAMA 20022881723

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Global Prevalence Overweight - BMI1980-2008
Finucane MM Lancet 2011 377557
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Global Prevalence Obesity - BMI1980-2008
Finucane MM Lancet 2011 377557
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Relative Risks of Mortality by BMI Category,
Survey, Age NHANES I to NHANES III
Flegal KM JAMA 2005 2931861
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Excess Deaths by Body Mass Index Category
Cardiovascular Disease
Overweight not assocd Obesity assocd
Flegal KM JAMA 2005 2931861
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BMI Survival in 65y-75y

• Mortality risk was lowest in those classified as
  overweight according to BMI
• Minimum mortality risk 26.6kg/m2 in men 26.3
  in women

Flicker L J Am Geriatr Soc 2010 58234
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P lt 0.05
Villareal et al. Obes Res 2004
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P lt 0.05
P lt 0.05
Ramsey et al. Am J Epi 2006
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Weight Incident Limitations - Males

• Adjusted for age, race, center, education,
  smoking, alcohol, physical activity

Risk of incident mobility limitations dependent
on duration of overweight/obesity Worse the
obesity the worse the limitations
Houston D Am J Epidemiol 2009 169(8) 927
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Obesity Functional Limitations

• English LSA
• Ages 65 for 5 years
• Excess body weight (particularly obese) suggests
  greater self-reported measured functional
  impairment (Short Physical Performance Battery)
• Lang IA 2008 561474

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Obesity Functional DeclineRural Setting
BMI OR 95 CI
Men
25.0-29.9 0.70 0.37-1.36
30.0-34.9 0.77 0.32-1.80
gt35.0 3.32 1.29-8.46
Women
25.0-29.9 0.91 0.54-1.53
30.0-34.9 0.82 0.43-1.51
gt35.0 2.61 1.39-4.95

• Geiseinger Health Plan (PA)
• gt65yo, 2634 participants
• Mean age 71yo
• BMIgt35kg/m2 assd with any functional decline
  ONLY
• Jensen GL J Am Geriatr Soc 2002 50918

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Weight Change SNF PlacementNHANES I
Epidemiologic Survey
Weight Change Quintile BMI lt25 BMI gt25
Large gain 7.59-0.78 1.20 (0.76-1.89) 2.13 (1.40-3.23)
Moderate gain 0.78-0.28 0.99 (0.62-1.59) 1.37 (0.90-2.04)
Maintain 0.28- (-0.13) 1.00 1.00
Moderate Loss -0.13 (-0.63) 1.60 (1.04-2.47) 1.47 (1.01-2.14)
Large Loss -0.64 (-5.5) 2.41 (1.58-3.66) 2.78 (1.98-3.92)
7,957 persons gt45 yo at NHANES I
(1971-1975) Followup in 1992
Zizza C J 2003 Clin Epidemiol 56906
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Sarcopenic Obesity
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Clinical Implications - Intuitive

• High fat mass low muscle mass leads to ?
  functional limitation metabolic d/o
• Many studies have examined these entities
  separately
• Synergistic effect of two have not been well
  examined

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Sarcopenia, Obesity Disability
3 Disabilities Balance Gait Falls
Males
SO 8.72 3.96 4.41 3.34
Obese 1.34 1.90 1.24 1.41
Sarcopenia 3.78 5.16 1.08 2.12
Females
SO 11.98 1.21 5.45 2.12
Obese 2.15 0.84 1.34 1.45
Sarcopenia 2.96 0.98 0.05 1.66
plt0.05
Baumgartner R Ann NY Acad Sci 2000
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Sarcopenic Obesity IADLs
HR 2.91 (1.36-6.21)
Baumgartner Obesity Res 2004121995
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Frail (Sarcopenic) Obese?
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Are there benefits of being obese in the elderly

• In short, Yes!
• Bone loss is a prominent feature of aging
• Elderly have higher incidence of hip fractures
• Obesity is a protective factor on bone strength
  with decreased osteoporosis hip fractures in
  both sexes
• Hormonal factors increased in obese patients
  (circulating estrogens, insulin, leptin) are
  beneficial on bone mineral density by stimulating
  bone growth and inhibit remodeling
• 1 SD decrease in fat mass was associated with a
  30 increase in risk of hip fracture

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So what we know at this point

• Low BMI and moderate obesity (BMIgt35kg/m2)
  clearly detrimental from medical, QOL, functional
  status, mortality
• Overweight and class I obesity (BMI 30-35kg/m2)
  may/may not be detrimental

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Why should we treat obesity in the elderly?

• Elderly have limited lifespan, even when not
  obese
• Patients prone to complications of obesity have
  already died leaving behind those who are more
  resistant to effects of obesity
• Excess fat may have less effect on mortality in
  elderly
• Reduced lipolysis seen

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How about overweight?

• Still controversial
• Current recommendations are that overweight
  patients (gt70 years), without chronic diseases
  should maintain their current weight
• That moderate overweight may be a sign of good
  health

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• 6 month f/u weight stable vs. wt loss
• Intensive weight loss intervention incorporating
  energy deficit diet exercise training improves
  function
• Greater improvements in function were observed in
  those with the most weight loss

• Miller GD Obes Res 2006 14(7) 1219

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Arthritis, Diet Activity Promotion Trial

• 316 community-dwelling adults
• Overweight Obese
• 60 y
• BMI 28kg/m2
• Osteoarthritis
• Primary outcome Physical Function

Messier SP 2004 Arthritis Rheum 50(5)1501
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Messier SP 2004 Arthritis Rheum 50(5)1501
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Villareal DT 2011 NEJM 3641218
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Study Outcomes

• Primary
• Change in baseline modified Physical performance
  Test
• Secondary Outcome
• Measures of frailty
• Body composition
• BMD
• Specific physical function
• Quality of life
• Follow-up at 6, 12 month

Villareal DT 2011 NEJM 3641218
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Intervention 52 week randomized study

• Control
• No advice not allowed to engage in weight loss
• Provided information only
• Weight management program (diet)
• Energy deficit of 500-760kcal/d
• Balanced diet
• 1g high-quality protein/kg body weight
• Met weekly with dietician
• Adjustment of caloric intake, goals behavioral
  therapy
• Review of food diaries
• Behavioral goals
• Set goals weigh in sessions
• Goal to lose 10 of baseline weight at 6 months
  maintain at 1 year

Villareal DT 2011 NEJM 3641218
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Intervention 52 week randomized study

• Exercise training (exercise)
• Gave information for diet
• 3x/week exercise 90 min
• Aerobic, resistance, flexibility, balance
• Led by physical therapist
• Both weight management exercise (diet/exercise)

Villareal DT 2011 NEJM 3641218
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Control Diet Exercise Diet-exercise Diet vs. Ctl Ex vs. Ctl Diet/Ex vs. Diet Diet/Ex vs. Ex
N27 N26 N26 N28
PPT Score
Baseline 26.8 28.6 27.1 28.0
6 mo 0.6 2.3 3.4 4.7 lt0.001 lt0.001 lt0.001 0.04
1 year 0.2 3.1 4.0 5.4
Lean Mass
Baseline 57.3 61.4 57.6 57.2
6 mo -0.7 -3.5 1.1 -1.7 lt0.001 lt0.001 0.04 lt0.001
1 year -0.8 -3.2 1.3 -1.8
Fat Mass
Baseline 43.8 42.8 41.6 41.9
6 mo -0.3 -6.0 -1.2 -5.6 lt0.001 0.004 0.57 lt0.001
1 year 1.2 -7.1 -1.8 -6.3
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Mean Change in Weight

• Diet Diet/Exercise

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Conclusions

• Diet, exercise both improved physical function,
  measures of frailty
• Combination is more effective than individual
  intervention
• Weight loss exercise may be important in frail,
  obese older adults
• Goal in older adults may be to improve physical
  function vs. treating obesity-associated medical
  complications

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Conclusions II

• Relative sarcopenia was reduced in all
  interventions
• Reduced fat relative lean body mass
• Diet regimen added to exercise preserves lean
  mass reduced fat mass

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Conclusions III

• Diet alone
• Reduction in lean mass BMD in hip
• ? Need to prescribe Ca/Vit D
• ? Endurance/resistance exercises
• Weight loss -gt leads to increased mortality

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Weight Loss Exercise on Physical Function
Single-blinded design

• Sedentary, overweight elders with mild-moderate
  functional limitations
• 55-79 years
• BMI gt28kg/m2
• lt20min/week of aerobic exercise
• Mild-moderate impairment on Short Physical
  Performance Battery
• Subjects agreed not to engage in any more
  activity than usual
• Stable weight with no life-limiting limitations

Anton SD Clin Interven Aging 2011
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Weight Loss Exercise on Physical
FunctionWeight loss/exercise vs. educational
control

• Intervention Group
• Targeted gt6 weight loss
• Reduction 500-1000kcal/day
• Exercise sessions aerobic resistance training
  of moderate intensity
• Weekly 60min group-based weight management
  session
• Nutrition education instruction in behavioral
  strategies
• Self-monitoring, goal setting, praising
• Problem solving therapy

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• Dietary component
• 750kcal/day rate of 0.7kg/week
• 55 CHO
• 30 Fats
• 15 Protein
• Supervised dietician
• Complete daily food records to sessions which
  were reviewed suggestions made
• Educational control group
• Monthly lecture on health issues
• Maintained usual eating/physical activity status
• Both control/intervention held in community
  settings

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Outcomes 24 weeks
Educational Control Weight Loss Exercise P-value
Weight (kg) -0.23 3.1 -6.5 4.2 0.004
SPPB Score 0.8 1.2 1.8 1.2 0.02
400m walk 0.03 0.2 0.13 0.2 0.009
Leg-strength (kg) 4.0 14.4 12.4 14.3 0.94
Diet/Exercise maintains muscle strength leads
to weight loss
Anton SD 2011
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TREATMENT GOALS OF MAINTAINING A HEALTHY WEIGHT

• So now that we know the evidence, what should we
  be recommending as clinical providers?

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Nutritional Assessment of the Older Patient

• Looking for red flags
• Recent change in health status
• medical or socioeconomic
• Recent hospitalization
• New medications
• Alcohol tobacco use
• Weight history
• Diet history

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National Heart, Lung, Blood Institute
Recommendations

• Age alone should not preclude treatment for
  weight loss in adult men and women

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National Heart, Lung, Blood Institute
Recommendations

• care must be taken to ensure that any weight
  reduction program minimizes the likelihood of
  adverse effects on bone health or other aspects
  of nutritional status

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National Heart, Lung, Blood Institute
Recommendations

• an evaluation of the potential benefits of
  weight reduction for day-to-day functioning
  reduction of the risk of future cardiovascular
  events, as well as the patients motivation for
  weight reduction

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How to approach losing or maintaining weight in
elders?

• Thorough medical evaluation is needed before
  beginning a weight reduction program
• Review of medications, dosages, patient-specific
  goals
• Previous strategies patients have used

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What goals should we set?

• Modest goals are the key to success
• 5-10 of starting body weight initially
• Maintaining this loss is goal
• Avoid unrealistic weight loss goals
• They will lead to failure
• Forgo need to aim for ideal body weight
• require substantial weight losses that are rarely
  maintained

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Timeline for Change
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Weight Loss in Elders
Improve physical function Quality of
Life Important to prevent muscle bone loss
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Behavior Modification

• Strategies include
• Self monitoring of eating and physical activity
• Stress Time management
• Problem solving
• Motivational interviewing
• Social support

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Goals?
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Achieving a Calorie Deficit
PORTION CONTROL
FOOD CHOICES
Courtesy of L Barre
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Plate Method
Courtesy of L Barre
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Protein Intake

• Current Recommended Daily
• Allowance is 0.8g/kg/day
• Revised should be 1.0-1.2g/kg/day

Weight (lbs) Weight (kg) Total Protein New Recs
130 pounds 60 kg 48g 72g
150 pounds 68 kg 54g 82g
200 pounds 91kg 73g 109g
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Fats
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What else can be done from a diet standpoint?

• Use a food log
• Self-monitoring has been shown to modify energy
  intake
• Reduce serving sizes
• Eliminate high-fat snacks
• Especially if patients can
• increase their physical activity

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What about dieting?Very-low energy / protein
sparing

• Not recommended unless monitored closely by
  skilled practitioner
• Risks of dramatic fluid, electrolyte, weight
  shifts
• These may not be tolerated in elderly
• Can lead to proportionally ? muscle mass loss

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Different Diets

• NEJM Mediterranean diet

• mean weight loss was 2.9kg for low-fat group,
  4.4kg for Mediterranean-diet, 4.7 kg for low-CHO
  (Plt0.001)

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Benefits of a dietician

• Crucial component of multidisciplinary effort
• Dietary assessment
• Past, current food intake
• Dietary instruction
• Behavior modification
• Review exercise records, weight change
• Important for there to be a longitudinal role
  build trust!

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Physical Exercise!!!
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Exercise Prescriptions

• Individually tailored
• 30 minutes daily of low-moderate intensity
  physical activity
• Divide this into several periods if needed
• Increases flexibility, strength, and endurance
• Start Low, Go Slow

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Strength Training

• Goal is 2 days/week
• 30minute sessions
• Rotate exercises
• Start with 1-2 pound weights
• 10-12 repetitions each for a few seconds
• Gradually start then add weights
• Otherwise injuries will arise
• BREATHE dont hold your breath

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Short-term goals

• Today
• I will decide to be more active
• Tomorrow
• I will find out about exercise classes in my area
• End of week
• Ask a friend to exercise with me
• In 2 weeks
• make sure you have shoes/clothes to start walking

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Flexibility
BioEx Systems, Inc
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Balance and Gait
BioEx Systems, Inc
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Long-term goal setting
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What is your Teams Role

• Share any unexplained symptoms promptly!
• Stop exercising until you do.
• Understand how exercise will improve health
  problems
• The goal is to be fun safe

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Ways to Gauge your Effort
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Drug Treatment

• Even in middle-aged patients, modest weight loss
  is achieved
• Usually lt 5-10 of excess weight
• BUT most trials have excluded elderly subjects
• Safety is an issue

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Bariatric Surgery in the Elderly

• Very little research
• Age cut-off is slowly increasing
• Center/surgeon dependent
• Experience of surgery size of center important
  for outcomes
• Goal is to improve quality of life

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Conclusions

• Overweight Obesity in Elders will continue to
  be an emerging public health concern
• Moderate Obesity has known detrimental effects
• Obesity (BMI gt30kg/m2) likely less so
• Overweight (BMI 25-30) may be OK in elders
• Balanced Diet important
• Physical activity to reduce rate of sarcopenia
  vitally important in weight-loss program

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Questions