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The health implications, medical management, and goals of treatment of obese elderly people are much different than with younger patients, according to experts at the Annual Scientific Meeting of NAASO, The Obesity Society, held October 20–24 in Boston.
Patterns of weight gain and distribution of fat change throughout life and have important implications for management, says Tamara Harris, MD, of the National Institute on Aging in Bethesda, Md.
About 44% of people lose weight in the later half of life, while 19% gain weight, Harris says. There also are significant racial differences in weight maintenance, with whites tending to continue gaining weight and blacks often losing weight in later years.
Weight gain in older age is as serious as it is in younger people, even if weight remains stable during the first half of life, Harris says. The unhealthiest pattern is continuously gaining weight throughout life, which results in a risk for type 2 diabetes.
In general, the percentage of body fat peaks in the sixth decade of life, says Dympna Gallagher, EdD, of the Obesity Research Center of Columbia University in New York City.
Studies with whole-body MRI show that overall adiposity increases with age and shifts within body spaces. While subcutaneous adipose decreases over the years, visceral and intramuscular adipose increases.
"There are many epidemiological studies suggesting that elderly people who lose weight face an increased risk of death," Harris says.
These studies fail to take into account that weight loss in the elderly is often a marker for an underlying disease process, and don't separate out elderly people who intentionally lose weight, according to Harris.
"Older people who intentionally lose weight have the same risks as those whose weight is stable," she says. "Some [researchers] had thought that a little overweight had a protective effect. That's not true. In people over 70, both thinness and overweight were associated with a higher rate of mortality."
There are a few benefits to overweight among the elderly. By stressing the skeleton, excess weight reduces the loss of bone mass, and overweight elderly people are less likely to suffer hip fractures, a major cause of morbidity and mortality. However, experts agree that the health risks of overweight and obesity are greater than any advantages.
Samuel Klein, MD, of Washington University in St. Louis, Mo., says obese elderly people are more likely to become disabled and to be admitted to a nursing home. Obesity is a major predictor for loss of independence and exacerbates age-related decline in physical functioning, Klein says.
MANAGING ELDERLY PATIENTS
The goal of treating obesity in the elderly is to reduce weight without losing lean mass or contributing to frailty. "The primary purpose [of treatment] is different; to increase physical functioning and quality of life, not to prevent disease," Klein says.
Bariatric surgery may be tried in some cases, although it generally is contraindicated for people >65 years of age. Elderly patients are "going to lose less weight than younger patients, and they're going to have more complications," Harris says. "You have to weigh the risks more carefully."
Similarly, medications such as phentermine, orlistat (Xenical, Roche), or sibutramine (Meridia, Abbott) sometimes are prescribed for elderly patients, but Harris says they should be used with caution because the elderly are likely to experience side effects, such as sleeplessness, more acutely.
Research suggests weight gain in older age is not caused by eating more or consuming energy-dense foods, but usually by a decline in physical activity. Prescribing a regimen of exercise may tip the balance of energy back toward normal.
Carol Apovian, MD, of Boston Medical Center, suggests a program of low-intensity physical activity, such as walking. "They don't have to join a health club," she says. "If they have a chair, they can do knee bends."
Several studies show benefits from progressive resistance training, which
helps conserve lean body mass, strengthen bone, and increase energy
expenditure. "There are lots of medical contraindications, but they are
fairly logical—cardiovascular or musculoskeletal conditions,"
Apovian says. 
Footnotes
A joint position statement reviews the clinical issues and weight-management guidelines related to obesity in older persons: Villareal DT, Apovian CM, Kushner R, et al.: Obesity in older adults: Technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society. Obes Res 13:1849–1863, 2005.
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