Nutritional concerns of overweight / obese older persons Gordon L Jensen, MD, PhD Dept Nutritional Sciences Penn State University
Prevalence of obesity among older adults: NHANES 1999-2004 Sex Age (years) Total (%) White Black Mexican- American Male 40-59 60-79 80+ 32.2 33.1 14.0 32.8 34.7 14.5 32.5 32.5 12.9 31.5 30.0 10.4 Female 40-59 60-79 80+ 37.4 36.9 19.2 35.9 35.3 19.1 53.1 55.4 31.1 47.9 41.5 13.1 Ogden CL, et al, Gastroenterol 2007; 132: 2087-2102
Obesity and Function An increase in self-reported functional limitations has been strongly linked with elevated current or past BMI. Physical performance testing has confirmed a negative association between elevated BMI and physical performance.
Predictors for homebound status Jensen GL, Obesity 2006;14: 509-17. Variable Odds Ratio 95% CI Age 75 2.21 1.55-3.19 BMI 35 1.75 1.04-2.96 Poor appetite Income < $6K 2.50 1.29-4.86 1.59 1.00-2.56 ADL /IADL 10.67 7.36-15.46
Body Composition Studies have found positive associations between body fat mass and functional limitations. Associations with muscle mass have not been consistently detected, but if one adjusts for body size then a relative decrement in muscle mass may be appreciated. Zoico E, et al, Int J Obes Relat Metab Disord 2004; 28:234-41. Villareal DT, et al. Obesity Res 2004; 12:913-20.
How does obesity impact function? Obesity is a proxy for sedentary living. Disease burden associated with medical comorbidities like diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, heart disease, and osteoarthritis of the knee are important contributing factors. Recent findings further implicate obesity associated inflammatory milieu, sarcopenia, and impairment of muscle function / strength.
Sarcopenic Obesity Factors may include loss of α-motor neuron input, changes in anabolic hormones, and malnutrition. Inflammation-promoted erosion of muscle mass as well as a vicious cycle of progressive physical inactivity with increased adiposity and accumulated disease burden likely culminate in sarcopenic obesity. Stenholm S, Curr Opin Clin Nutr Metab Care 11:693-700 (2008). Zamboni M, Nutr Metab Cardiovasc Dis 18:388-95 (2008). Jensen GL, Hsiao PY, Curr Opin Clin Nutr Metab Care 13: 46-51 (2010).
Sarcopenic obesity
Fat-selective magnetic resonance image of the lower leg Goodpaster, B. H et al. Am J Clin Nutr 2004;79:748-754 Copyright 2004 The American Society for Nutrition
Weight loss interventions for obese older persons remain controversial Non-volitional weight loss is associated with adverse outcomes. Overweight and mild obesity status may be associated with reduced mortality risk. Concerns for potential losses of muscle and bone mineral during weight reduction. However, a growing body of research supports consideration of weight reduction.
Fat mass protective in hospitalized elderly? Bouillanne O, AJCN 2009;90:505-10. 125 older patients, body composition by DEXA and BIA Fat mass was associated with reduced mortality and complications, while there was no relationship with lean mass or appendicular muscle mass.
Weight loss / exercise Rx frailty in obese older adults Villareal, Arch Intern Med 2006;166:860-6. 27 frail obese older persons randomized to 6 mos behavioral Rx with exercise versus control. Treatment group lost 8.4% body weight and 6.6 kg fat mass. Treatment group had improved Physical Performance Testing and functional assessments.
Lifestyle intervention to decrease CHD risk factors Villareal, Am J Clin Nutr 2006;84:1317-23. 27 obese older adults randomized to 6 mos diet and exercise therapy versus control. Treatment group lost 8.4% body weight. Treatment group exhibited improvements in waist circumference, glucose, triglyceride, blood pressure, CRP and IL-6. Treatment group had 59% decrease in subjects with metabolic syndrome.
Anti-inflammatory inflammatory role of weight loss Weight loss in obese subjects through diet/exercise or bariatric surgery markedly improves the systemic and adipose tissue inflammatory states. Can measure reduced levels of CRP, IL-6, and other inflammatory cytokines. Dalmas E, et al, Am J Clin Nutr 2011; 94:450-8.
Mean Percentage Changes in Objective and Subjective Measures of Frailty during the 1- Year Intervention. Villareal DT et al. N Engl J Med 2011;364:1218-1229 93 older obese subjects completed randomized, controlled trial Combination of weight loss and exercise provided greatest improvement in physical function.
Mean Percentage Changes in Body Weight during the 1-Year Intervention. Diet and diet + exercise groups 9-10% wt loss Villareal DT et al. N Engl J Med 2011;364:1218-1229
Nutrition risk assessment and obesity: a gender difference 179 persons sampled from the large cohort. Representative of the cohort, 81 males, 98 females, 66 to 87 years of age, 35% obese. 12-month study in community setting. Nutrition risk as defined by Level II Screen, overall diet quality, nutrient intakes, and laboratory biomarkers. Ledikwe JH, Am J Clin Nutr 77: 551-8 (2003).
Nutrient Intake Women had lower reported intakes of energy and all other nutrients. When adjusted for calorie intake, age, tobacco, and alcohol use, then only protein intake and vitamin D remained significantly lower in women. Inadequate intakes of folate, magnesium, vitamins E and B6, and zinc were common for either gender. Mean intakes of vitamin D and calcium were substantially less than AI.
Laboratory Biomarkers There were no gender differences in biomarkers. 3% had low PLP. Approx. 25% had low B12. About 10% had elevated homocysteine which correlated with low PLP, folate and B12.
Correlations between weight status and nutrient intake Only for females were BMI and waist circumference associated with nutrient intakes. Positively associated with fat and saturated fat intakes. Negatively associated with carbohydrate, fiber, folate, magnesium, iron, and zinc intakes. Negatively associated with HEI score.
Key Observations Many older persons were at risk based upon multiple domains of assessment. Obese older women were less likely than men to meet nutrient requirements and to have healthy eating patterns. In particular it was the women who lived alone who had higher BMI values and had poorer diet quality. Nutrient deficiencies and food insecurity are relatively common among obese older persons.
Research priorities Which obese older persons should be selected for weight reduction? What program of prudent diet, behavior modification, and/or exercise is appropriate for which audience? What degree of weight loss is appropriate for which audience? Are there better approaches to preservation of muscle and bone mineral during weight reduction?
Research Priorities For whom is an emphasis on strength and flexibility rather than weight loss the best option? Can benefits of weight reduction be maintained in aging subjects? Are there anti-inflammatory, resistance training, hormonal, nutritional or other interventions that may be helpful in prevention or treatment of sarcopenic obesity? Should priority for obese older persons be on diet quality, protein and micronutrients?
Is living inflammatory? It depends how you live your life. Jensen GL, JPEN 30: 453-63 (2006). Jensen GL. JPEN 33: 710-16 (2009). Sarcopenic obesity Stenholm S, Curr Opin Clin Nutr Metab Care 11:693-700 (2008). Zamboni M, Nutr Metab Cardiovasc Dis 18:388-95 (2008). Jensen GL, Hsiao PY, Curr Opin Clin Nutr Metab Care (2010).