Obesity is a chronic disease. Weight loss in older adults can be controversial and requires proper understanding of the disease, the obesity paradox, cardiorespiratory fitness, and how they all relate in the older adult with obesity. ¹

Obesity may have a negative impact in all four geriatric domains:

• Medical: increased risk for type 2 diabetes, cardiovascular disease, hypertension, stroke, breast cancer, colon cancer, gallbladder disease, osteoarthritis

• Functional: impaired mobility and disability

• Cognitive: risk for depression and dementia

• Social: risk of stigmatization and isolation. ¹

   

  Research and the Obesity Paradox:

  The Obesity Paradox refers to research regarding obesity in the elderly which found decreased mortality and complications in older adults with obesity when compared to leaner counterparts in patients with type 2 diabetes, and heart failure^2,3.  Such reports potentially indicate that greater weight is associated with better outcomes and can be confusing or potentially negate meaningful clinical interventions, fostering misunderstanding towards weight gain. Other researchers have found no evidence for this benefit, however.^4,5  When controlling for the role of physical function and incorporating the concepts of cardiorespiratory fitness and physical function, studies have shown that within BMI groups, the increased morbidity and mortality described in the paradox is present only in those with poor cardiorespiratory function^6-9.

   

Clinical Application:

• For obese older adults: encourage modest intentional weight loss through proper lifestyle improvements and slowly but progressively increasing physical activity.

• Obese older adults may have decreased muscle mass.Sarcopenia, usually pictured in the setting of undernutrition, cachexia, or severe terminal disease, affects between 20-45% of older obese adults.¹⁰

   

  Lifestyle management

Individualized management of the older person with obesity requires individualized goals.

No definitive studies show that obesity in older adults must be addressed similarly to younger adults. The evidence is quite scarce for pharmacologic agents or bariatric surgery, however, it is clear that obesity can lead to functional impairment and disability unless there are interventions to preserve physical function.  A randomized, multicenter trial including 1,635 obese individuals at risk for disability were randomized to a physical activity intervention versus health education only.  While the primary goal was not weight reduction, it was clear that the structured moderate-intensity physical activity program reduced major disability in these vulnerable adults .¹⁷

Practical recommendations:

• Identify and understand your patient’s individual goals

Weight loss may, or may not, be a priority for the individual patient.  Identifying and addressing the patient’s goals (e.g., take grandchildren to the park, have more energy) will increase motivation.

• Encourage reasonable physical activity and exercise

  Weight is not the ultimate outcome marker for success in the older adult with obesity.  The prevention of functional decline requires exercise interventions to preserve muscle mass and function.

• Plan a thoughtful approach to diet and nutrition

  Careful consideration of nutrition and proper exercise should be tailored to older adults supporting a multicomponent approach with adequate protein intake.^18-19

Conclusion:

              Obesity is a growing problem in the older adult population.  Begin by explaining the full scope of the issue, beyond “weight” itself, and address the multiple geriatric implications related to obesity.  Identify the patient’s goals and work together to improve dietary habits, a reasonable approach to caloric intake, and a well-structured exercise program, with the objective of modest-to-moderate intentional weight loss.