Definition of Obesity Disease

Definition of Obesity Disease- The national epidemic of obesity has now extended to older persons. Substantial evidence links overweight and obesity to an increased risk  of serious comorbidities that include hypertension, dyslipidemia, heart disease, insulin resistance and diabetes, metabolic syndrome, cholelithiasis, respiratory impairment, gout, and osteoarthritis.  Obesity among older persons has also been linked with increased  like lihood of self-reported functional limitations, a decline in  measured physical performance, and an elevated risk of functional decline. An obese Medicare beneficiary costs $1,486 more in health care  expenses per year than does an individual of healthy weight. This entry  focuses on obesity in the elderly to include recent trends, etiologies, impact on health and function, and potential interventions.

Defining Overweight and Obesity

Body mass index (BMI) has become a widely used formula to assess body fat indirectly. BMI is calculated as body weight in kilograms (kg) /  height in meters squared (m2). In 1998,  the National Institutes of Health set criteria to define overweight and obesity as BMI ≥ 25 and BMI ≥ 30, respectively, but standards  have not been adopted specifically for older persons. Although BMI  suffers from limitations as a proxy of measure of adiposity, it is  nonetheless useful for screening applications and for guiding interventions.

Prevalence and Trends of Obesity

The prevalence of overweight and obesity in older Americans has  increased dramatically (Table 1). Obesity is  more prevalent among older women than among older men, and it is appreciably greater among young-older persons than among old-older  persons. The prevalence of obesity declines precipitously after 80 years of age.

The Causes of Obesity

Obesity is a multifactorial chronic disease. Selected key risk  factors include genetic predisposition, certain medications,  lifestyle, and behavior. Studies with twins reveal marked concordance in obesity. Pairs of twins exposed to periods of  positive and negative energy balance experienced greater  similarities for rate of weight gain, proportion of weight gain, and body site of excessive fat deposition than did non-twin pairs. A  number of gene polymorphisms have also been linked to increased risk of obesity.

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Weight gain is frequently experienced during middle age. The onset of menopause in women can be associated with additional weight gain.  Body fat tends to peak later in women than in men and may occur as  late as 50 to 60 years of age. A decrease in lean body mass (sarcopenia) and an associated decline in resting energy expenditure  also occur with aging. Most obese older persons were overweight or obese as middle-aged adults and have sufferedweight excess for many years.

Polypharmacy is common among older persons, and selected medications  may also contribute to weight gain. Antidepressants (e.g.,  fluoxetine, mirtazapine, phenelzine sulfate), antipsychotics (e.g., piperazine phenothiazine, risperidone, olanzapine), anticonvulsants (e.g., carbamazepine, valproic acid), and corticosteroids (e.g., cortisone, prednisone) are associated with increased caloric intake and increased body fat.

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Ultimately, weight gain results from positive energy balance and excessive energy intake from food in combination with decreased  energy expenditure from reduced physical activity. Food choices have a substantial influence on diet quality. Older people with higher  intakes of foods with low-nutrient density (e.g., breads, sweet breads, desserts, processed meats, eggs, fats, oils) are twice as  likely to be obese, twice as likely to have low serum Vitamin B12  levels, and 3 to 17 times more likely to have low nutrient intakes.  Those who consume foods with highnutrient density, such as cereal, vegetables, fruits, milk, poultry, fish, and beans, benefit from lower energy intake overall; higher energy-adjusted intakes of  fiber, iron, zinc, folate, and Vitamins B6, B12, and D; higher  plasma Vitamin B12; and smaller waist circumferences. Sedentary living is common for older persons and contributes to reduced energy  expenditure. Television watching and functional mobility limitations  are important contributing factors. Recent studies have suggested  that obesity is increasingly common among homebound elders. Unfortunately, many older adults accept inactivity and weight gain as a natural part of the aging process and exert minimal effort toward prevention.

The Impact of Obesity

Obesity-associated comorbidities include hypertension, dyslipidemia,  heart disease, insulin resistance and diabetes, metabolic syndrome, cholelithiasis, respiratory impairment, gout, and osteoarthritis of  the knee. Hypertension, affecting more than 50 million Americans, is  one of the most common chronic diseases in the United States.  Hypertension is associated with increased risk of cardiovascular  disease, stroke, and renal failure. The strongest predictors of blood pressure in humans are BMI and weight. Weight loss, even in  modest amounts, has been shown to reduce both blood pressure and the need for blood pressure medications. The risk of older people  developing type 2 diabetes also increases with obesity. Findings  from the second National Health and Nutrition Examination Survey  (NHANES II, 1976 to 1980) showed that the risk of developing  diabetes was 3.8 times greater for obese individuals 45 to 75 years of age. Diet and exercise can improve glycemic control in those with  diabetes; moreover, dietand exercise alone can sometimes curtail  the need for pharmacological treatment. Together, dyslipidemia,  hypertension, and diabetes comprise metabolic syndrome, which is  both prevalent among obese older persons and strongly associated  with risk of cardiovascular disease.

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Many older adults suffer from arthritis, most commonly  osteoarthritis. Obese adults are particularly vulnerable to the  development of destructive joint disease of the knees secondary to  mass-related shear forces and inflammation. Knee osteoarthritis can lead to poor balance, decreased mobility, and muscle atrophy, ultimately leading to physical disability. Not only is obesity associated with increased risk of developing  chronic diseases, it also is associated with increased prevalence of  functional impairments, especially mobility. High current or past  BMI is associated with increased risk of reporting functional limitations. These findings have been confirmed with objective physical performance testing. Obesity also places a person at risk  for functional decline, as supported by observations in longitudinal  outcome studies. Increasingly, many homebound older persons are found to be obese.

Intervention and Treatment

The 1998 National Institutes of Health guidelines suggest that  individual determinations should be made as to the appropriateness of weight reduction interventions for older persons. Nonvolitional weight loss in older persons often portends an ominous outcome because it is a proxy indicator of underlying inflammatory condition  or disease. Another concern is that weight loss in postmenopausal  women may be associated with a modest reduction in bone mineral  density. Nevertheless, the longitudinal Nurses Health Study found  that weight loss among overweight/obese women was associated with  improvements in self-reported physical function and lower levels of bodily pain.

A tailored intervention for older persons might include large-font  instructional materials, supplementation of calcium and Vitamin D,  and realistic moderate weight loss and physical activity goals. Weight loss medications and bariatric surgery have not been tested adequately in older adults to warrant recommendations for their use. Few weight reduction intervention studies have been conducted in  older persons. The Trial of Nonpharmacologic Interventions in the  Elderly (TONE) was a randomized controlled study that compared the  efficacies of reduced sodium intake, weight loss, both reduced  sodium intake and weight loss, and usual care in the treatment of  hypertension in older people. The results indicated that a decrease  in both sodium intake and body weight reduced the amount of  antihypertensive medication needed. Messier and colleagues studied  obese older persons with knee osteoarthritis. After the participants  completed a 6-month intervention program consisting of diet and/or  aerobic/strength exercises, it was observed that the combination of both weight loss and exercise, rather than weight loss alone,  contributed to improvements in physical performance, pain, and  disability. Gordon Jensen and colleagues enrolled community-dwelling  obese women 60 to 75 years of age in a 3-month weight-reduction program with diet modification and exercise. Self-selected obese  older women who achieved moderate weight loss and physical activity  goals were found to have improved laboratory, physical performance,  self-reported function, vitality, and quality of life outcomes. For  many frail older persons, emphasis should perhaps be placed on the  prevention of further weight gain with the promotion of strength and flexibility.

Conclusion
It is evident that the prevalence of obesity is increasing among  older persons. A serious burden of chronic disease and functional  decline may result. Age alone should not dictate restricted access  to treatment for obese older people. Reasonable intervention goals  should be considered based on patient's wishes and individual opportunity for health improvement.

• obesity
• weight loss
• self-reports
• weight gain
• weight

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