Obesity

Abstract

It is clearly recognized that obesity is reaching epidemic proportions in all segments of our society. Among older adults, the rate of obesity has risen dramatically over the past 20 years. It is now estimated that approximately 40% of individuals between the ages of 60 and 69 (42.5% of women and 38.1% of men) have a body mass index of 30 or more (ie, they are clinically obese). Thirty percent of those between the ages of 70 and 79 are obese (31.9% women and 28.9% men) [[1]National Health and Nutrition Examination Survey (NHANES) 1999–2000. US Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD2002Google Scholar]. At the same time, the geriatric population is this country is increasing. Currently, 13% of the population is over the age of 65, and this proportion is expected to reach 20% by 2030. The obesity epidemic will have a profound impact on the geriatric population. Obesity is clearly linked to a variety of chronic medical problems, including diabetes mellitus, hyperlipidemia, coronary artery disease, metabolic syndrome, hypertension, sleep apnea, venous stasis, and osteoarthritis of the lower extremities, particularly of the knee. Obesity in the elderly is also associated with functional decline, ill health, dependency, and poor quality of life. It is estimated that 40% of homebound elderly are obese. The Medicare costs of obese patients are $1486 more per year than those of normal weight individuals. Obesity may be a proxy measure for a more sedentary life style. With increased fat, there is often a concomitant decrease in muscle mass (“sarcopenic obesity”). Geriatricians must consider a changing phenomenon: the “frail” obese.More attention has recently been focused on the problem of obesity. The American Medical Association has published a primer for physicians [[2]Kushner R. Roadmaps for clinical practice: case studies in disease prevention and health promotion—assessment and management of adult obesity: a primer for physicians. American Medical Association, Chicago2003Google Scholar] on the assessment and management of adult obesity, and the Centers for Disease Control and Prevention (CDC) has published guidelines [[3]National Institutes of HealthClinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report.in: Panesl E. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Institutes of Health, Bethesda (MD)1998Google Scholar] on the identification, evaluation, and treatment of overweight and obesity, including recommendations for a healthful diet. The DASH diet, which includes less saturated fat and more fresh fruits and vegetables, whole grains, and low-fat dairy products, is now recommended as a heart-healthful diet and is listed on the Web site of the National Heart Lung and Blood Institute [[4]Appel I.J. Champagne C.M. Harsha D.W. et al.Effects of comprehensive lifestyle modification on blood pressure control: main results of the Premier Clinical Trial.JAMA. 2003; 289: 2083-2093Crossref PubMed Scopus (1164) Google Scholar]. However, these guidelines pertain to the general population; relatively little attention has been given to the problems obesity causes in the geriatric population. In this issue of the Clinics in Geriatric Medicine, we focus on the unique aspects of obesity in the elderly and the role of obesity as an independent risk factor for functional limitation and frailty.Dr. Gordon Jensen, in his article “Obesity and Functional Decline: Epidemiology and Geriatric Consequences,” describes the obesity “failure to thrive” syndrome as a cause of functional compromise and decline in the setting of excess weight. He discusses obesity as a risk for increased medical spending and chronic disease. He reviews the controversies involving weight recommendations for the elderly and the National Institutes of Health guidelines for weight loss in the elderly. In “Medical Assessment of the Obese Older Patient,” Dr. Calleo-Cross and colleagues review the assessment, classification, and treatment of older obese patients. The authors outline medications that can contribute to weight gain. Reasonable goals for weight loss are elucidated, as is the management of diseases that commonly complicate obesity. Dr. Maritza Groth, a pulmonologist, provides an update on one of these diseases, sleep apnea, which can present a diagnostic challenge in the elderly. Unfortunately, geriatric obese patients are more vulnerable to the serious cardiovascular complications of obstructive sleep apnea.Dr. Ronni Chernoff, a nutritionist, discusses the pros and cons of different weight loss diets and warns primary care providers to ensure that patients on these diets do not suffer major nutrient loss. Dietician Joanne Kiehn reviews the physician's role in nutritional counseling, particularly in motivating patients to lose weight and keep it off.Physical therapist Cheri Gostic offers practical advice on safe exercise prescription in this population in her article “The Crucial Role of Exercise and Physical Activity in Weight Management and Functional Improvement for Seniors.” Dr. Monica Mathys reviews pharmacologic strategies in weight management, although she remarks that few trials of weight loss agents have included elderly subjects.Dr. Susan Gallagher presents the nursing perspective as she discusses strategies to reduce caregiver injury and promote patient safety in her article, “Obesity and the Aging Adult: Ideas for Promoting Safety and Preventing Caregiver Injury.” Along similar lines, Dr. Jacob Dimant, in his article “Bariatric Programs in Nursing Homes,” notes that obesity is associated with a higher rate of nursing home admission. He delineates the medical and financial considerations of running such a program in a long-term care facility, the environmental modifications that must take place, the equipment that must be purchased, and the staff training that needs to occur for a long-term care bariatric program to be successful.Physicians practicing in the twenty-first century will be treating an increasing number of obese older patients. Geriatricians, in particular, must recognize that the syndrome of “frail elderly” may include the obese patient. This issue of the Clinics in Geriatric Medicine represents a collaborative effort among experts in several different fields who present state-of-the-art knowledge regarding the biologic basis, evaluation, and management of geriatric obesity. The treatment strategies listed, with the exception of exercise, have not been extensively studied in the older population. The paucity of clinical trials points to the need for more research in this emerging health problem.We are indebted to the authors for their in-depth coverage of this complex clinical issue. It is our hope that the information provided in this issue will assist geriatric health care providers in the interdisciplinary management and treatment of obese geriatric patients. It is clearly recognized that obesity is reaching epidemic proportions in all segments of our society. Among older adults, the rate of obesity has risen dramatically over the past 20 years. It is now estimated that approximately 40% of individuals between the ages of 60 and 69 (42.5% of women and 38.1% of men) have a body mass index of 30 or more (ie, they are clinically obese). Thirty percent of those between the ages of 70 and 79 are obese (31.9% women and 28.9% men) [[1]National Health and Nutrition Examination Survey (NHANES) 1999–2000. US Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD2002Google Scholar]. At the same time, the geriatric population is this country is increasing. Currently, 13% of the population is over the age of 65, and this proportion is expected to reach 20% by 2030. The obesity epidemic will have a profound impact on the geriatric population. Obesity is clearly linked to a variety of chronic medical problems, including diabetes mellitus, hyperlipidemia, coronary artery disease, metabolic syndrome, hypertension, sleep apnea, venous stasis, and osteoarthritis of the lower extremities, particularly of the knee. Obesity in the elderly is also associated with functional decline, ill health, dependency, and poor quality of life. It is estimated that 40% of homebound elderly are obese. The Medicare costs of obese patients are $1486 more per year than those of normal weight individuals. Obesity may be a proxy measure for a more sedentary life style. With increased fat, there is often a concomitant decrease in muscle mass (“sarcopenic obesity”). Geriatricians must consider a changing phenomenon: the “frail” obese. More attention has recently been focused on the problem of obesity. The American Medical Association has published a primer for physicians [[2]Kushner R. Roadmaps for clinical practice: case studies in disease prevention and health promotion—assessment and management of adult obesity: a primer for physicians. American Medical Association, Chicago2003Google Scholar] on the assessment and management of adult obesity, and the Centers for Disease Control and Prevention (CDC) has published guidelines [[3]National Institutes of HealthClinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report.in: Panesl E. NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. National Institutes of Health, Bethesda (MD)1998Google Scholar] on the identification, evaluation, and treatment of overweight and obesity, including recommendations for a healthful diet. The DASH diet, which includes less saturated fat and more fresh fruits and vegetables, whole grains, and low-fat dairy products, is now recommended as a heart-healthful diet and is listed on the Web site of the National Heart Lung and Blood Institute [[4]Appel I.J. Champagne C.M. Harsha D.W. et al.Effects of comprehensive lifestyle modification on blood pressure control: main results of the Premier Clinical Trial.JAMA. 2003; 289: 2083-2093Crossref PubMed Scopus (1164) Google Scholar]. However, these guidelines pertain to the general population; relatively little attention has been given to the problems obesity causes in the geriatric population. In this issue of the Clinics in Geriatric Medicine, we focus on the unique aspects of obesity in the elderly and the role of obesity as an independent risk factor for functional limitation and frailty. Dr. Gordon Jensen, in his article “Obesity and Functional Decline: Epidemiology and Geriatric Consequences,” describes the obesity “failure to thrive” syndrome as a cause of functional compromise and decline in the setting of excess weight. He discusses obesity as a risk for increased medical spending and chronic disease. He reviews the controversies involving weight recommendations for the elderly and the National Institutes of Health guidelines for weight loss in the elderly. In “Medical Assessment of the Obese Older Patient,” Dr. Calleo-Cross and colleagues review the assessment, classification, and treatment of older obese patients. The authors outline medications that can contribute to weight gain. Reasonable goals for weight loss are elucidated, as is the management of diseases that commonly complicate obesity. Dr. Maritza Groth, a pulmonologist, provides an update on one of these diseases, sleep apnea, which can present a diagnostic challenge in the elderly. Unfortunately, geriatric obese patients are more vulnerable to the serious cardiovascular complications of obstructive sleep apnea. Dr. Ronni Chernoff, a nutritionist, discusses the pros and cons of different weight loss diets and warns primary care providers to ensure that patients on these diets do not suffer major nutrient loss. Dietician Joanne Kiehn reviews the physician's role in nutritional counseling, particularly in motivating patients to lose weight and keep it off. Physical therapist Cheri Gostic offers practical advice on safe exercise prescription in this population in her article “The Crucial Role of Exercise and Physical Activity in Weight Management and Functional Improvement for Seniors.” Dr. Monica Mathys reviews pharmacologic strategies in weight management, although she remarks that few trials of weight loss agents have included elderly subjects. Dr. Susan Gallagher presents the nursing perspective as she discusses strategies to reduce caregiver injury and promote patient safety in her article, “Obesity and the Aging Adult: Ideas for Promoting Safety and Preventing Caregiver Injury.” Along similar lines, Dr. Jacob Dimant, in his article “Bariatric Programs in Nursing Homes,” notes that obesity is associated with a higher rate of nursing home admission. He delineates the medical and financial considerations of running such a program in a long-term care facility, the environmental modifications that must take place, the equipment that must be purchased, and the staff training that needs to occur for a long-term care bariatric program to be successful. Physicians practicing in the twenty-first century will be treating an increasing number of obese older patients. Geriatricians, in particular, must recognize that the syndrome of “frail elderly” may include the obese patient. This issue of the Clinics in Geriatric Medicine represents a collaborative effort among experts in several different fields who present state-of-the-art knowledge regarding the biologic basis, evaluation, and management of geriatric obesity. The treatment strategies listed, with the exception of exercise, have not been extensively studied in the older population. The paucity of clinical trials points to the need for more research in this emerging health problem. We are indebted to the authors for their in-depth coverage of this complex clinical issue. It is our hope that the information provided in this issue will assist geriatric health care providers in the interdisciplinary management and treatment of obese geriatric patients.