Transcript PowerPoint - GRECC Audio Conferences

Management of Obesity in
Older Adults
Benefits and Risks of Body
Weight Interventions
after Age 65
Connie W. Bales, PhD, RD * +
Gwendolen Buhr, MD,MHS, CMD *
+GRECC,
*Division
Durham VAMC
of Geriatrics, DUMC
We know that frailty due to
underweight is linked with poor
health and functional
outcomes…
2
But energy imbalances, whether
positive or negative,
threaten health….
3
Management of Obesity in Older Adults
4
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1998, 2007
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1998
1990
33.2% increase in obesity
during the 1990’s
2007
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
5
6
Men
Men
Women
7
Expectations for 2010


8.3 million Americans
will be over the age of
50 yrs AND obese.
For those >60 yrs of
age, prevalence of
obesity 33.6-39.6%.
8
Causes of later life obesity:

Stable energy intake +
decreased energy requirement
positive energy balance, fat accrual

Also, shifts in the proportions of fat and lean
9
Fat Redistribution with Aging




Visceral fat increases
Decreases in subcutaneous fat in
abdomen, thigh, calves
Even without weight gain there is
accumulation of intra-abdominal fat;
increase in waist circumference
Fat redistribution into muscle
10
Sarcopenic Obesity: A special concern

Definition:
 Muscle mass 2 or more SD below gender
specific mean for young reference group
 Percent body fat greater than
27% in men
 38% in women


Approximate BMI of >27 kg/m2
11
Sarcopenic Obesity: A New Health
Concern in the Elderly1
Increased obesity rate
+
Age-related changes in body composition

There is excess weight along with reduced
muscle mass or strength
1Zamboni et al. Nutr Metab CVD;18:388-75. 2008
12
Obesity may greatly increase the impact of
sarcopenia on function
 Rolland et al.--women > 75 yrs




Healthy wt vs purely obese vs purely sarcopenic
vs sarcopenic obese
Purely sarcopenic-no effect
Purely obese- somewhat higher odds of difficulty
Sarcopenic-obese
 2.6 higher odds of difficulty climbing stairs
 2.3 higher odds of difficulty of descending
stairs
13
How bad is obesity for older adults?
Linked with major causes of
morbidity and mortality:





Diabetes mellitus
Hypertension and stroke
Dyslipidemia, CHD, CHF
Cancer
Disability
14
Obesity’s Effects on the Onset of Functional
Impairment Among Older Adults
Jenkins, KR. Gerontologist 44: 206-16. 2004.


Longitudinal data --Asset and Health
Dynamics Among the Oldest Old (AHEAD)
survey
Logistic regression models on the onset of
functional impairment over two time
points
15
Increased Functional impairments

Those overweight or obese are


more likely to experience onset of
functional impairment in various
domains.
have effects on the onset of impairment
in strength, lower body mobility, and
activities of daily living.
Jenkins. 2004.
16
Despite the known detrimental effects
of obesity on health outcomes and
function….
There is “great controversy”
concerning the net health impact
of obesity in the elderly.
Zamboni et al. Intl J Obesity 29:1011-29. 2005.
17
“Debate persists about the relation between
obesity in old age and total or diseasespecific mortality, the definition of obesity in
the elderly, its clinical relevance, and about
its need for treatment.”
Zamboni et al. Intl J Obesity 29:1011-29. 2005.
18
The BMI--Mortality Relationship


Evidence from epidemiological studies has
been sought to characterize the
relationship between body mass and
health that plays out as aging progresses.
At least 17 medium to large
epidemiological studies in the last ten
years alone
19
At later ages….


There is a weakening of the body
weight/mortality relationship
Only BMIs in the obese range are
associated with higher mortality
20
Bales C.W., Buhr G. (2009) Body mass
trajectory and energy balance as
determinants of health and mortality in
older adults. Obesity Facts: European
Journal of Obesity. 3; 171-178.
21
How bad is obesity for
older adults?

While being overweight in midlife is
hazardous to survival, a BMI roughly in
the 25-30 range is not associated with
increased mortality when it is achieved in
later life.
22
How bad is obesity for
older adults?

Most of the epidemiological findings
argue for a beneficial or neutral
rather than a detrimental effect of a
high BMI on length of life after the
age of 65 years.
23


In addition, several studies have found
recent weight loss to be linked with
reduced longevity.
Even a modest decline in BW is an
independent marker of mortality risk
Newman et al.

Overweight but otherwise healthy men
who lost weight had higher mortality rates
than those weight stable.
Nilsson et al.
24
The “Reverse Epidemiology” of BMI and
Survival in Late Life

Considerable evidence supports a survival
benefit of adiposity in wasting diseases like
end stage renal failure, heart failure, COPD
and other inflammatory wasting diseases.
25
The “Reverse Epidemiology” of BMI and
Survival in Late Life

May be explained by



a larger amount of energy stored as fat
larger stores of lean mass
influence of adiposity on fuel selection:
During starvation, the proportion of energy expenditure
derived from protein oxidation is lower.
Lean tissue is better preserved in persons with large fat
stores.
26
Arguments against this conclusion:

The interpretation of the
BMI/mortality relationship is
complicated by a host of confounding
variables:
 Specific vs. all cause
 Smoking, underlying disease
 Survival
27
Caveats about this conclusion:

Future mortality trends may differ due
to much higher rates of mid-life
obesity
 In those obese 30-49 there is 6-yr
less life expectancy and a reduction
in yrs free of disability
28
Since we cannot study effects on
human lifespan directly, we asked..


What happens when overweight older
adults intentionally lose weight?
Conducted a systematic review of
randomized controlled weight loss trials
29
Bales CW, Buhr G. Is obesity bad for
older persons? A systematic
review of the pros and cons of weigh
reduction in later life. J Am Med
Dir Assoc. 9:302-312. 2008.
30
Significance for this topic?


In general, guidelines for ideal body weight and
approaches for weight reduction in obese adults
over age 65 years is lacking.
Specifically, the MOVE! Program* for veterans
does not have any guidelines for eligible
veterans if they are age 70 or older.
*Managing Overweight and Obesity for Veterans
Everywhere
31
Overall Approach for the
Systematic Review


We examined data from randomized controlled
trials exclusively
For endpoints, we used medical diseases/
conditions associated with obesity or metabolic
abnormalities that are prevalent in the older
adult population, namely:





Cardiovascular disease and inflammation
Hypertension
Type 2 diabetes mellitus
Osteoarthritis and physical function
Osteoporosis
32
Overall Approach for the
Systematic Review
We wanted to identify the beneficial
-- improved metabolic parameters
-- enhanced function
as well as the negative outcomes of
intentional weight loss
--loss of bone mineral
-- loss of lean mass
33
Methods for the Systematic Review



PubMed database search
English only
4 search domains




Obesity
Weight loss
Weight loss interventions
Co-morbidities (as specified)
34
Results of Systematic Review

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Initial result = 268 articles
When narrowed for geriatric topic = 26
Applied these criteria:
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Subjects 60 >yrs of age
Baseline BMI > 27
Weight loss of > 3% or 2 kg achieved
Trial duration > 6 months
13 papers met criteria; review of them yielded 3
more; thus we reviewed a total of 16 papers
However, the 16 articles actually represented
only 5 major trials
35
Arthritis, Diet, and Activity
Promotion Trial (ADAPT)



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Sedentary
Knee OA on x-ray
Knee pain on most days causing difficulty
with IADLs or ADLs
Age ≥ 60
BMI ≥ 28
Miller GD. et al. Control Clin Trials 2003;24:462
36
ADAPT Design
n = 76
n = 80
n = 82
n = 78
Miller GD. et al. Control Clin Trials 2003;24:462
37
ADAPT Results
68 ± 6.3 years, BMI 34.5 ± 5.6
 % Weight Loss

Control – 1.3%;
 Exercise – 2.6%;
 Diet – 5.7%;
 Diet + Exercise – 4.4%

Messier SP. et al. Arthritis Rheum 2004;50:1501
38
ADAPT Primary Outcome Measure


Self-reported physical function (0-68 point scale)
Diet + Exercise improved 5.73 [2.63,8.83]

p <.05 compared to control
Messier SP. et al. Arthritis Rheum 2004;50:1501.
39
ADAPT Secondary Outcome Measures
Diet
Ex
Diet
+ Ex
NS
NS
↑
NS
↑
↑
↑
↑
↑
6-minute walk distance
NS
↑
↑
Stair climb time
NS
NS
↓
Knee pain
NS
NS
↓
SF-36 physical function composite
scale
Satisfaction with physical function
Satisfaction with appearance
Messier SP. et al. Arthritis Rheum 2004;50:1501; Rejeski WJ et al. Health Psychol
2002;21:419
40
Physical Activity, Inflammation, and
Body Composition Trial
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
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Symptomatic Knee OA
Self-reported difficulty due to pain with IADLs or
ADLs
Age ≥ 60
BMI ≥ 30
Randomized into control (n = 43) or Diet +
Exercise (n = 44)
6 months
Miller GD et al. Obesity 2006;14:1219.
41
Results


69.5 years, BMI 34.5
% Weight Loss




Control – 0%;
Diet + Exercise – 8.7%
6-minute walk distance improved
Stair climb time decreased
Miller GD et al. Obesity 2006;14:1219.
42
WOMAC score (0-96)
Self-Reported Physical Function at 6
months
Miller GD et al. Obesity 2006;14:1219.
43
Trial of Nonpharmacological Interventions in
the Elderly (TONE)



Systolic BP <145; diastolic <85 on antihypertensives
Age 60-80 years
30 months
975 Randomized
585 overweight
Weight Loss
Sodium Reduction
Yes
No
Yes
No
147
147
144
147
390 non-overweight
Sodium Reduction
Yes
196
No
194
44
TONE Results

66.5 ± 4.6 years; BMI 31
Whelton PK. JAMA 1998;279:839
45
TONE Results
Whelton PK. et al. JAMA 1998;279:839
46
Villareal DT et al.
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
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
Mild to Moderate Physical Frailty
Age ≥ 65
BMI ≥ 30
Randomized into control (n = 10) or Diet
+ Exercise (n = 17)
26 weeks
Villareal DT et al. Arch Int Med 2006;166:860; Villareal DT et al. Am J Clin Nutr 2006;84:1317.
47
Results

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Control 71 ± 4 yrs, Diet + Exercise 69 ± 5 yrs
BMI 39 ± 5
% Weight Loss

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
Physical Test Performance Score

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Control +0.5% ± 2.8%;
Diet + Exercise – 8.4% ± 5.6%
2.6 ± 2.5 vs. 0.1 ± 1.0 (p=.001)
Peak Oxygen Consumption
Functional status questionnaire score
Physical function domains of SF-36
Villareal DT et al. Arch Int Med 2006;166:860
48
Results cont.


Number of subjects with metabolic syndrome
decreased 59% (15 of 17 to 5 of 17 subjects)
in Diet + Exercise group
Improved all criteria except HDL cholesterol

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Waist circumference (-10 vs. +1 cm)
Glucose (-4 vs. +4 mg/dl)
Triglycerides (-45 vs. 0 mg/dl)
Systolic BP (-13 vs. -3 mm Hg)
Diastolic BP (-7 vs. -1 mm Hg)
Villareal DT et al. Am J Clin Nutr 2006;84:1317
49
Dunstan DW et al.
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
Uncontrolled DM-2 not on insulin,
sedentary, nonsmokers
Age 60 – 80 years
BMI > 27
Randomized into Diet (n = 17) or
Resistance Training + Diet (n = 19)
6 months
Dunstan DW et al. Diabetes Care 2002;25:1729
50
Results


67.6 ± 5.2 years; BMI 31.5 ± 3.7
% change in HbA1C


RT + Diet – reduced 1.2% ± 1.0%
Diet – reduced 0.4% ± 0.8%
51
Bone Density

TONE

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total body and femoral neck BMD declined
significantly in all groups
In a regression model controlling for baseline
BMD and biomarkers of bone metabolism,
weight loss was associated with decrease in
total body BMD (p = .003)
Dunstan

Total body BMD – no change in RT + Diet;
Decreased in Diet (p <.05)
Daly RM et al. Osteoporos INt 2005;16:1703; Chao D et al. J Am Geriatr Soc 2000;48:753
52
Lean Body Mass (LBM)

Physical Activity, Inflammation, and Body
Composition Trial


Villareal


Lower body fat and LBM in Diet + Exercise vs.
Control
Lower fat mass; no change in fat-free mass in
Diet + Exercise vs. Control
Dunstan

Lower fat mass in both groups; lower LBM in
Diet; higher LBM in RT + Diet
53
Summary of Weight Loss Trials by
Primary Focus, Beneficial
Outcomes, and Clinical Significance
Studies
Type of Outcome
Metabolic
Osteoarthritis ADAPT
or physical
Physical Activity,
function
Inflammation,
and Body
Composition Trial
Villareal et al
√
Clinical
Significance
Clinical
SelfReport
√
√
Probably
√
√
Probably
√
√
Probably
54
Summary of Weight Loss Trials by
Primary Focus, Beneficial
Outcomes, and Clinical Significance
Studies
Type of Outcome
Metabolic
Coronary Heart
Disease Risk
Factors, including
Hypertension
TONE
Type 2 Diabetes
Clinical
√
SelfReport
Clinical
Significance
Possibly
ADAPT
√
Villareal et al
√
Dunstan et al
√
Possibly
Villareal et al
√
Possibly
Unlikely
√
Probably
55
Summary of Negative Outcomes
Studies
Type of Outcome
Metabolic Clinical
Bone
Density
Lean
Body
Mass
SelfReport
Clinical
Significance
TONE
√
Unlikely
Dunstan et al
√
Unlikely
Physical Activity,
Inflammation, and
Body Composition Trial
√
Possibly
Villareal et al
√
Possibly
Dunstan et al
√
Possibly
56
Clinical Implications of Findings

While studies of mortality favor
maintaining weight in those who become
obese after age 66, there are clinically
significant benefits from weight loss for
 Osteoarthritis
 Physical
function
 Type 2 Diabetes mellitus (possibly)
 Coronary heart disease (possibly)
57
Implications

Clearly, decisions about whether or not to
institute a weight reduction intervention
should be made on a individualized basis,
considering
 weight history
 health priorities
 medical status
58
Current status of the issue:
A VA work group is developing a white
paper that includes recommendations for
primary health care providers for adults
70 and older with a BMI >30 kg/m2.
The question: Should all patients over the
age of 70 with a BMI > 30 kg/m2 be
offered a weight loss and exercise
program?
59
Important considerations

Co-morbidities considered should include:
Osteoarthritis and osteoporosis
 Dementia
 Diabetes and metabolic syndrome
 Hypertension
 Cardiovascular conditions

60
Tentative recommendations,
recognizing the scarcity of evidence:



A geriatric-based assessment should be
undertaken to define limitations for the
specific individual.
For many older individuals, the best
course may be to remain WEIGHT
STABLE.
IF the BMI is over 30 and weight reduction
is deemed appropriate, the following
recommendations apply…
61
Tentative recommendations




:
Most older adults embarking on a weight
reduction regimen would benefit from and
should receive nutrition counseling.
Dietary calorie reduction should be modest, no
more than 500 kcal per day
All intervention programs should include a
resistance training exercise component.
Calorie restriction alone should be avoided.
62
Am I
too fat?
Am I too frail?
J. Spratt
Age 76
BMI 23
Ms. Spratt
Age 70
BMI 30
More research
is needed!
63