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, Durham VAMC * Division 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

1998 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% 33.2% increase in obesity during the 1990’s 5

6

Men Women 7

Expectations for million Americans will be over the age of 50 yrs AND obese. For those >60 yrs of age, prevalence of obesity %. 8

Causes of later life obesity: Stable energy intake + Stable energy intake + decreased energy requirement decreased energy requirement positive energy balance, fat accrual positive energy balance, fat accrual Also, shifts in the proportions of fat and lean Also, shifts in the proportions of fat and lean 9

Fat Redistribution with Aging Visceral fat increases Visceral fat increases Decreases in subcutaneous fat in abdomen, thigh, calves Decreases in subcutaneous fat in abdomen, thigh, calves Even without weight gain there is accumulation of intra-abdominal fat; increase in waist circumference Even without weight gain there is accumulation of intra-abdominal fat; increase in waist circumference Fat redistribution into muscle 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/m 2 11

Sarcopenic Obesity: A New Health Concern in the Elderly 1 Increased obesity rate + Age-related changes in body composition There is excess weight along with reduced muscle mass or strength There is excess weight along with reduced muscle mass or strength 1 Zamboni et al. Nutr Metab CVD;18:

Obesity may greatly increase the impact of sarcopenia on function Rolland et al.--women > 75 yrs Rolland et al.--women > 75 yrs Healthy wt vs purely obese vs purely sarcopenic vs sarcopenic obese Healthy wt vs purely obese vs purely sarcopenic vs sarcopenic obese Purely sarcopenic-no effect Purely sarcopenic-no effect Purely obese- somewhat higher odds of difficulty Purely obese- somewhat higher odds of difficulty Sarcopenic-obese Sarcopenic-obese 2.6 higher odds of difficulty climbing stairs 2.6 higher odds of difficulty climbing stairs 2.3 higher odds of difficulty of descending 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 Diabetes mellitus Hypertension and stroke Hypertension and stroke Dyslipidemia, CHD, CHF Dyslipidemia, CHD, CHF Cancer Cancer Disability Disability 14

Obesity’s Effects on the Onset of Functional Impairment Among Older Adults Jenkins, KR. Gerontologist 44: 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

Zamboni et al. Intl J Obesity 29: 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. 17

Zamboni et al. Intl J Obesity 29: “Debate persists about the relation between obesity in old age and total or disease- specific mortality, the definition of obesity in the elderly, its clinical relevance, and about its need for treatment.” 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. medium to large epidemiological studies in the last ten years alone 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;

How bad is obesity for older adults? While being overweight in midlife is hazardous to survival, a BMI roughly in the 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 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 May be explained by a larger amount of energy stored as fat a larger amount of energy stored as fat larger stores of lean mass larger stores of lean mass influence of adiposity on fuel selection: 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

The interpretation of the BMI/mortality relationship is complicated by a host of confounding variables: The interpretation of the BMI/mortality relationship is complicated by a host of confounding variables: Specific vs. all cause Specific vs. all cause Smoking, underlying disease Smoking, underlying disease Survival Survival Arguments against this conclusion: 27

Future mortality trends may differ due to much higher rates of mid-life obesity Future mortality trends may differ due to much higher rates of mid-life obesity In those obese there is 6-yr less life expectancy and a reduction in yrs free of disability In those obese there is 6-yr less life expectancy and a reduction in yrs free of disability Caveats about this conclusion: 28

Since we cannot study effects on human lifespan directly, we asked.. What happens when overweight older adults intentionally lose weight? What happens when overweight older adults intentionally lose weight? Conducted a systematic review of randomized controlled weight loss trials 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:

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. 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. 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 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: 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 Cardiovascular disease and inflammation Hypertension Hypertension Type 2 diabetes mellitus Type 2 diabetes mellitus Osteoarthritis and physical function Osteoarthritis and physical function Osteoporosis Osteoporosis 32

Overall Approach for the Systematic Review We wanted to identify the beneficial -- improved metabolic parameters -- enhanced function -- enhanced function as well as the negative outcomes of intentional weight loss intentional weight loss --loss of bone mineral -- loss of lean mass -- loss of lean mass 33

Methods for the Systematic Review PubMed database search PubMed database search English only English only 4 search domains 4 search domains Obesity Obesity Weight loss Weight loss Weight loss interventions Weight loss interventions Co-morbidities (as specified) Co-morbidities (as specified) 34

Results of Systematic Review Initial result = 268 articles Initial result = 268 articles When narrowed for geriatric topic = 26 When narrowed for geriatric topic = 26 Applied these criteria: Applied these criteria: Subjects 60 >yrs of age Subjects 60 >yrs of age Baseline BMI > 27 Baseline BMI > 27 Weight loss of > 3% or 2 kg achieved Weight loss of > 3% or 2 kg achieved Trial duration > 6 months Trial duration > 6 months 13 papers met criteria; review of them yielded 3 more; thus we reviewed a total of 16 papers 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 However, the 16 articles actually represented only 5 major trials 35

Miller GD. et al. Control Clin Trials 2003;24:462 Arthritis, Diet, and Activity Promotion Trial (ADAPT) Sedentary Sedentary Knee OA on x-ray Knee OA on x-ray Knee pain on most days causing difficulty with IADLs or ADLs Knee pain on most days causing difficulty with IADLs or ADLs Age ≥ 60 Age ≥ 60 BMI ≥ 28 BMI ≥ 28 36

Miller GD. et al. Control Clin Trials 2003;24:462 ADAPT Design n = 76 n = 82 n = 78 n = 80 37

Messier SP. et al. Arthritis Rheum 2004;50:1501 ADAPT Results 68 ± 6.3 years, BMI 34.5 ± ± 6.3 years, BMI 34.5 ± 5.6 % Weight Loss % Weight Loss Control – 1.3%; Control – 1.3%; Exercise – 2.6%; Exercise – 2.6%; Diet – 5.7%; Diet – 5.7%; Diet + Exercise – 4.4% Diet + Exercise – 4.4% 38

Messier SP. et al. Arthritis Rheum 2004;50:1501. ADAPT Primary Outcome Measure Self-reported physical function (0-68 point scale) Self-reported physical function (0-68 point scale) Diet + Exercise improved 5.73 [2.63,8.83] Diet + Exercise improved 5.73 [2.63,8.83] p <.05 compared to control p <.05 compared to control 39

ADAPT Secondary Outcome Measures DietEx Diet + Ex SF-36 physical function composite scale NSNS↑ Satisfaction with physical function NS↑↑ Satisfaction with appearance ↑↑↑ 6-minute walk distance NS↑↑ Stair climb time NSNS↓ Knee pain NSNS↓ Messier SP. et al. Arthritis Rheum 2004;50:1501; Rejeski WJ et al. Health Psychol 2002;21:419 40

Miller GD et al. Obesity 2006;14:1219. Physical Activity, Inflammation, and Body Composition Trial Symptomatic Knee OA Symptomatic Knee OA Self-reported difficulty due to pain with IADLs or ADLs Self-reported difficulty due to pain with IADLs or ADLs Age ≥ 60 Age ≥ 60 BMI ≥ 30 BMI ≥ 30 Randomized into control (n = 43) or Diet + Exercise (n = 44) Randomized into control (n = 43) or Diet + Exercise (n = 44) 6 months 6 months 41

Miller GD et al. Obesity 2006;14:1219. Results 69.5 years, BMI years, BMI 34.5 % Weight Loss % Weight Loss Control – 0%; Control – 0%; Diet + Exercise – 8.7% Diet + Exercise – 8.7% 6-minute walk distance improved 6-minute walk distance improved Stair climb time decreased Stair climb time decreased 42

Miller GD et al. Obesity 2006;14:1219. Self-Reported Physical Function at 6 months WOMAC score (0-96) 43

Trial of Nonpharmacological Interventions in the Elderly (TONE) Systolic BP <145; diastolic <85 on antihypertensives Systolic BP <145; diastolic <85 on antihypertensives Age years Age years 30 months 30 months Weight Loss Yes No Sodium Reduction YesNo 975 Randomized 585 overweight390 non-overweight Sodium Reduction YesNo

TONE Results 66.5 ± 4.6 years; BMI ± 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. Mild to Moderate Physical Frailty Mild to Moderate Physical Frailty Age ≥ 65 Age ≥ 65 BMI ≥ 30 BMI ≥ 30 Randomized into control (n = 10) or Diet + Exercise (n = 17) Randomized into control (n = 10) or Diet + Exercise (n = 17) 26 weeks 26 weeks Villareal DT et al. Arch Int Med 2006;166:860; Villareal DT et al. Am J Clin Nutr 2006;84:

Results Control 71 ± 4 yrs, Diet + Exercise 69 ± 5 yrs Control 71 ± 4 yrs, Diet + Exercise 69 ± 5 yrs BMI 39 ± 5 BMI 39 ± 5 % Weight Loss % Weight Loss Control +0.5% ± 2.8%; Control +0.5% ± 2.8%; Diet + Exercise – 8.4% ± 5.6% Diet + Exercise – 8.4% ± 5.6% Physical Test Performance Score Physical Test Performance Score 2.6 ± 2.5 vs. 0.1 ± 1.0 (p=.001) 2.6 ± 2.5 vs. 0.1 ± 1.0 (p=.001) Peak Oxygen Consumption Peak Oxygen Consumption Functional status questionnaire score Functional status questionnaire score Physical function domains of SF-36 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 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 Improved all criteria except HDL cholesterol Waist circumference (-10 vs. +1 cm) Waist circumference (-10 vs. +1 cm) Glucose (-4 vs. +4 mg/dl) Glucose (-4 vs. +4 mg/dl) Triglycerides (-45 vs. 0 mg/dl) Triglycerides (-45 vs. 0 mg/dl) Systolic BP (-13 vs. -3 mm Hg) Systolic BP (-13 vs. -3 mm Hg) Diastolic BP (-7 vs. -1 mm Hg) Diastolic BP (-7 vs. -1 mm Hg) Villareal DT et al. Am J Clin Nutr 2006;84:

Dunstan DW et al. Uncontrolled DM-2 not on insulin, sedentary, nonsmokers Uncontrolled DM-2 not on insulin, sedentary, nonsmokers Age 60 – 80 years Age 60 – 80 years BMI > 27 BMI > 27 Randomized into Diet (n = 17) or Resistance Training + Diet (n = 19) Randomized into Diet (n = 17) or Resistance Training + Diet (n = 19) 6 months 6 months Dunstan DW et al. Diabetes Care 2002;25:

Results 67.6 ± 5.2 years; BMI 31.5 ± ± 5.2 years; BMI 31.5 ± 3.7 % change in HbA1C % change in HbA1C RT + Diet – reduced 1.2% ± 1.0% RT + Diet – reduced 1.2% ± 1.0% Diet – reduced 0.4% ± 0.8% Diet – reduced 0.4% ± 0.8% 51

Bone Density TONE TONE total body and femoral neck BMD declined significantly in all groups 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) 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 Dunstan Total body BMD – no change in RT + Diet; Decreased in Diet (p <.05) 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 Physical Activity, Inflammation, and Body Composition Trial Lower body fat and LBM in Diet + Exercise vs. Control Lower body fat and LBM in Diet + Exercise vs. Control Villareal Villareal Lower fat mass; no change in fat-free mass in Diet + Exercise vs. Control Lower fat mass; no change in fat-free mass in Diet + Exercise vs. Control Dunstan Dunstan Lower fat mass in both groups; lower LBM in Diet; higher LBM in RT + Diet Lower fat mass in both groups; lower LBM in Diet; higher LBM in RT + Diet 53

Studies Type of Outcome Clinical Significance MetabolicClinical Self- Report Osteoarthritis or physical function ADAPT√√Probably Physical Activity, Inflammation, and Body Composition Trial √√Probably Villareal et al √√√Probably 54 Summary of Weight Loss Trials by Primary Focus, Beneficial Outcomes, and Clinical Significance

Studies Type of Outcome Clinical Significance MetabolicClinical Self- Report Coronary Heart Disease Risk Factors, including Hypertension TONE√Possibly ADAPT√Unlikely Villareal et al √√Probably Type 2 Diabetes Dunstan et al √Possibly Villareal et al √Possibly 55 Summary of Weight Loss Trials by Primary Focus, Beneficial Outcomes, and Clinical Significance

StudiesType of OutcomeClinical Significance MetabolicClinicalSelf- Report Bone Density TONE√Unlikely Dunstan et al√Unlikely Lean Body Mass Physical Activity, Inflammation, and Body Composition Trial √Possibly et al Villareal et al√Possibly et al Dunstan et al√Possibly Summary of Negative Outcomes 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 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 Osteoarthritis Physical function Physical function Type 2 Diabetes mellitus (possibly) Type 2 Diabetes mellitus (possibly) Coronary heart disease (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 Clearly, decisions about whether or not to institute a weight reduction intervention should be made on a individualized basis, considering weight history weight history health priorities health priorities medical status 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/m 2. The question: Should all patients over the age of 70 with a BMI > 30 kg/m 2 be offered a weight loss and exercise program? 59

Important considerations Co-morbidities considered should include: Co-morbidities considered should include: Osteoarthritis and osteoporosis Osteoarthritis and osteoporosis Dementia Dementia Diabetes and metabolic syndrome Diabetes and metabolic syndrome Hypertension Hypertension Cardiovascular conditions Cardiovascular conditions 60

Tentative recommendations, recognizing the scarcity of evidence: A geriatric-based assessment should be undertaken to define limitations for the specific individual. 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. 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… 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. 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 Dietary calorie reduction should be modest, no more than 500 kcal per day All intervention programs should include a resistance training exercise component. All intervention programs should include a resistance training exercise component. Calorie restriction alone should be avoided. Calorie restriction alone should be avoided. 62

Ms. Spratt Age 70 BMI 30 J. Spratt Age 76 BMI Am I too frail?Am I too fat? More research is needed!