Impact on quailty of life, and retaining physical functionality are key drivers to improve lives, if not reduce mortality, in patients who are dealing with diabetes and/or obesity in their later years.
“We are in the midst of a geriatric tsunami,” John A. Batsis, MD, told attendees at ObesityWeek in New Orleans, LA,1 “so the longer we live, the greater number of morbidities we face and with it an increased the risk of physical impairment, which will adversely impact quality of life for many.”2
This note of urgency was repeated by Samuel Klein, MD, to those attending his presentation at the 14th World Congress on Insulin Resistance, Diabetes and Cardiovascular Disease, in Los Angeles, CA.3 Older adults with diabetes may have heard that once they’ve reach a ripe old age, their obesity won't necessarily shorten their lifespan, said Samuel Klein, MD. But there's more to it than that.
While the elevated risk of death due to obesity may decline as people approach age 70 and beyond, but other complications remain serious enough to warrant attention to excess body weight, said Dr. Klein, the William H. Danforth Professor of Medicine and Nutritional Science, at Washington University School of Medicine in St Louis. The problem is significant enough to alert endocrinologists to become more responsive.
The clinical imperative should be to move away from obesity to focus on percent body fat, which is associated with elevated risk of disability.4 “A shift in mean body mass index (BMI) with age is impacted by a loss of skeletal mass and height, making [BMI] a less effective measure of adiposity,“ said Dr. Batsis, associate professor at Dartmouth-Hitchcock Medical Center, Dartmouth, NH.
"We have about 13 million people who are obese, and are 65 years old and over," Dr. Klein said. “That is about 35% of the older population.” Among seniors, two-thirds are already at ages 65 to 74, and another one-third top age 75 and older.3
These numbers are redefining frailty, he said. No longer does the stereotype of a small, hunched over woman in a nursing home fulfill the definition, according to Dr. Klein, and her neighbor, an obese older person with diabetes, is likely to be just as frail, with the same bone mass, muscle mass and cognitive deficits.
"Obesity is a major cause of frailty in older adults," said Dr. Klein. However, advising patients who have diabetes, are obese, and over 70 years to lose weight so they will live longer is not a reasonable goal, he said.
That's the good news. However, being obese at older ages is still very much a medical concern, Dr. Klein said, especially among patients who are facing complications of diabetes. "As we get older, we have an increased risk of having metabolic dysfunction, and this risk becomes even higher if you are obese," he said.
Obesity in older adults is also accompanied by decreased muscle mass and strength and joint abnormalities. "As we get older there is a deceased ability to use muscles for locomotion and activity," said Dr. Klein. Sarcopenia sets in, creating a lose-lose synergy in which a confluence of duel epidemics unfolds.5 Decreased mobility prompts a loss in muscle strength, which necessitates a view to global versus central obesity.
''Having a BMI of 30 to 35 [or higher] gives you an increased odds ratio of being in a nursing home because of this physical dysfunction," Dr. Klein said. As the population gets older, the BMI associated with the lowest mortality gets higher and higher. Seniors can expect to achieve the lowest mortality at a BMI range of 25-27, and the highest at a BMI of 33,6 rather than the current healthy weight range of 18.5 to 24.9 for all.
Weight loss improves the picture, said Dr. Klein. Obese older adults who start an exercise program, lose weight, or both, have improvement in their physical functioning. In one study, researchers found that obese older adults who participated in a diet and exercise program improved their physical performance test score by 20% over 12 months, compared to a slight decline in the control group.7
All that is needed for improved health parameters is a reduction in weight of just 5 to 10 percent to lessen abdominal fat and fat infiltration into ectopic adipose tissues deposits.8
Older and Wiser is Possible, With Optimal Health
Older adults are more compliant with interventions for weight loss and diet, Dr. Klein has found. "They are the easiest people to [adhere] to a weight loss programs." Among the factors, he said, are that they are often retired and don't have as many time pressures from work or family.
When talking to obese patients about weight, clinicians should strive to focus on health span, not life span, Dr. Klein told Endocrine Web.
Endocrinologists who talk to their obese older patients about weight loss, he said, can tell them to expect, ''an improved ability to function physically, to do daily activities, to have less joint discomfort and pain, and experience improved overall quality of life, and even better cognitive function."
What's still uncertain, he said, is the best approach to weight loss such that muscle mass is preserved, while promoting a sufficient loss of adiposity to improve functional parameters.
Dr. Klein called the population of older, obese adults ''a perfect storm'' that if left unattended, will become increasingly immobile.
''[Obesity] is a major predictor to retaining functional independence. The excess weight they carry around at 55 years old is no longer tolerable at age 75,'' said Dr. Klein. When physicians suggest a diet and exercise program for older adults, the aim, he said, is not to lengthen life, but improve it—with better physical function, improved quality of life, and enhanced metabolic function.
Focusing on the benefits beyond diabetes control for obese patients makes sense, said Dr. Dan Caruso, an endocrinologist in Reno, NV, who heard Dr. Klein speak. Not all older obese adults will heed advice to lose weight, he said, but some will; and they will benefit greatly.
He recalled one of his patients-- obese at age 78 with type 2 diabetes--who grew tired of relying on a cane and walker to get around. With his help, she went on a weight loss program and began swimming daily. "Then she signed up for water aerobics," he said.
Now at 80 years old, she was able to get rid of her walker and cane.
Dr. Klein reports owning stock in Aspire Bariatrics and consulting for Takeda, J&J, Merck and others.
1. Batsis JA. Pearls and pitfalls in managing the older adult with obesity. Presented at: ObesityWeek. November 1, 2016. New Orleans, LA.
2. Batsis JA, Gill LE, Masutani RK, et al. Weight Loss Interventions in Older Adults with Obesity: A Systematic Review of Randomized Controlled Trials Since 2005. J Am Geriatr Soc. 2016; Available at: https://www.ncbi.nlm.nih.gov/pubmed/27641543. Accessed December 5, 2016
3. Klein S. Obesity in Older Adults. Presented at: 14th World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. December 1, 2016. Los Angeles. CA.
4. Batsis JA, Mackenzie TA, Barre LK, Lopez-Jimenez F, Bartels SJ. Sarcopenia, sarcopenic obesity and mortality in older adults: results from the National Health and Nutrition Examination Survey III. Eur J Clin Nutr. 2014;68(9):1001- 1007.
5. Batsis JA, Germain CM, Vásquez E, Lopez-Jimenez F, Bartels SJ. Waist Circumference, Physical Activity, and Functional Impairments in Older U.S. Adults: Results from the NHANES 2005-2010. J Aging Phys Act. 2015;23(3):369-76.
6. Fiegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861-1867.
7. Villareal DT, Chode S, Parimi N. Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults. New Engl J Med. 2011;364:1218-1229.
8. Britton KA, Fox CS. Ectopic Fat Depots and Cardiovascular Disease. Circulation. 2011;124:e837-e841