Obesity And Ageing Alert Or Alarm

Obesity and Ageing: Alert or Alarm? Gaining weight as we age is natural; becoming clinically obese is not. Keeping your weight (or overweight) stable after the age of 50 is a key to healthy ageing.

Introduction Is it possible that you are overweight? - I know I am. If you are, too, then we have that in common. But, in matters of overweight, there will be many differences between us. To name just a few: female or male, a range of ages, our genetic inheritance from mother and father, our food habits, the amount of exercise we take and - perhaps most important of all - by how much we are overweight when compared with the norms for our sex and age. Are we, in fact, just overweight, or have we gone beyond that point to a state of obesity or even gross obesity . To talk about the latter is not being rude or abusive. It is a technical term used by health professionals to define a medically dangerous level of obesity.

Definitions of 'overweight' and 'obesity' It is best to be clear about what is meant by these terms. The most widely accepted measure of obesity is Body Mass Index [BMI], calculated by dividing your weight by the square of your height. The metric form kg/m² is the internationally accepted standard. Expressed in everyday language, the more you weigh in relation to your height, the higher your BMI will be. We can easily calculate our own BMI: For example, for a person weighing 70 kg* and 1.60 meters* tall, the equation will read " 70 divided by [1.60 x 1.60] = 70 divided by 2.56 = BMI 27.3 (rounded) * Conversion from metric measures to pounds and feet/inches (approximate):Multiply 70 kg by 2.2 = 154 lbs; 1.60 meters by 3.3 = 5.28 feet = approx. 5' 3" In the example (above), a Body Mass Index of 27.3 would indicate that the person is overweight but not obese. Standard definitions are: BMI Overweight

25 - 29.9

Obese

30 - 39.9

Grossly (or morbidly) obese 40+ BMI should be regarded as broadly indicative rather than as a precise measurement of health status or medical risk.

The upward trend in clinical obesity In various countries of Europe and North America, BMI rose by between one-tenth and twofifths between 1980 and 1990. The long-term trend is worrying: in the USA, obesity (BMI 30+) of women in the age range 20-74 increased from 15% in 1960 to nearly 25% in 1991; the corresponding change for men was from 10% to nearly 20% (Seidell 1998 1 ). During the 1990s, the proportion of the population in the industrialised countries of the West that is clinically obese will have risen further. This relentless and seemingly unstoppable advance of obesity in the industrialised world has caused alarm bells to ring more and more stridently in government offices and among health care professionals and economists. The association between obesity and the risk of cardiovascular disease and Type-2 diabetes [non-insulin-dependent] is widely recognised. Since these diseases are also linked with advancing age, obesity in the elderly can be accompanied or followed by serious health problems.

Obesity and advancing age Are these problems the same among the elderly as among younger age groups? In general terms, they are similar but - as so often in medicine - obesity in old age needs to be viewed differently from obesity in younger age groups. Society is rightly alarmed at the rise in obesity among the young and the middle-aged which is threatening the health status of the working population as a whole. From the point of view of the individual , obesity is just as threatening to the health of the elderly as it is to younger persons. In terms of health policy on the other hand, alarm is rightly directed at the younger age groups. What the elderly need is alertness: to be aware of the risks, to act in order to diminish them, and to receive professional assistance when they need it or want it. The obesity threat to the health of the elderly is distinct in a number of ways from that faced by younger age groups. For one thing, the elderly have so many threats to their health and their lives that obesity stands out less clearly. For example, half of the elderly who are admitted to hospitals in the UK are reported to suffer from malnutrition. A member of the Malnutrition Advisory Group in the UK said recently: "People have got a bit obsessed with patients who are overweight, but we don't really make a big issue out of malnutrition" which can be caused by long-term illness that reduces appetite or the ability to eat, living alone, or poverty (The Times, 29th December 2000). It is also possible to be both malnourished and obese.

It is natural to gain weight as we age Evidently, we need to look at obesity in the elderly with a sense of proportion. We gain weight as we age, as a result of changes in the composition of our bodies towards more deposited fat and less fat-free tissue. However, the peak prevalence of overweight in the population occurs in the 50-59 age group when 42% of men and 52% of women are overweight (mean BMI 27.6 for men and 28.5 for women). For the 80+ age group, prevalence of overweight falls steeply to 18% of men and 26% of women (Schwartz 1998 2 ). These statistics are less strange than they seem at first sight. Surviving into your Eighties is helped by the fact that you were perhaps not overweight in your Fifties when large numbers of people fall ill or die from conditions associated with obesity. An American study of the elderly has concluded that stability of weight from the age of 50 onwards can be more beneficial for health than losing weight: "Those who had lost weight were older and reported worse health status than weight-stable persons." (Harris, Savage et al, 1997 3 ). Weight loss in the elderly is often caused by malnutrition, smoking, or excessively intensive dietary regimes that are unsuitable for the elderly and injurious to their health. A German study of more than 6,000 patients over a mean period of observation of nearly 15 years, also reached the conclusion that the 'excess mortality' of the obese (compared with the population as a whole) decreases with advancing age. However, that is not true of the 'grossly obese' whose death rates are substantially higher at any age than those of the general population (Bender, Jöckel et al 1999 4 ). Overall, the relatively few studies that have focused on the elderly tend to conclude that keeping your weight stable after the age of 50 is a very important aim for the later decades of life. Stability is, indeed, more beneficial for the moderately overweight than attempting to lose weight. Clinical obesity (BMI 30+), on the other hand, is harmful at any age.

The causes of elderly obesity At all ages, obesity is generally the result of taking in more calories than we use up. The surplus is deposited as fat. Although, with advancing age, the intake of calories in food tends to be either static or lower, less (or less intensive) physical activity among the elderly makes a surplus of calories more likely. At the same time, there is a loss of fat-free tissue (for example, muscle) as we age. Other factors that can influence obesity but are not specifically connected with ageing include a genetic pre-disposition, gender (women have a greater tendency than men, especially after the age of 50), and the level of education and income. It has even been observed that marriage tends to promote obesity - as a result of too much good food? or because both partners go out to work and subsist mainly on fattening fast foods?

Losing weight - with a 1-in-20 chance of lasting success? When it comes to action, weight loss campaigns have a poor record of success over the longer term. There is no shortage of preventive methods, practical advice, elaborate programmes and novel systems of obesity management. There is firm evidence that reducing weight results in real health benefit, Yet, as a general rule, the spirit may be willing but the flesh is weak: too weak to reduce eating, rationalise food habits, or make lasting efforts to increase and intensify physical activity. A community-based study by Australian and American researchers recruited 854 healthy overweight persons [mean BMI 25.7-28.0] aged 20-45 by direct mail and advertisements. The participants appeared to be motivated to lose weight and most had already made an effort to do so during the previous year. They were divided into three groups: 'no contacts'; with education by monthly newsletters; and education with incentives. The results: After 1 year, "slightly over half of the study population had gained weight". Just over 11% had lost more than 5% of their baseline BMI. Of these, 40% managed to maintain their weight loss to the end of the third year. These represented just 4.6% of the total study population. The study indicated that successful weight maintenance for 3 years was not associated with the following factors: • • • • • • • • • •

age education marital status the type of participant ethnicity BMI at the follow-up after the first of the three years whether participants had intentionally tried to lose or maintain weight changes in total calorie intake after the follow-up at the end of Year 1 fat as a percentage of total energy intake daily hours of watching television.

"Successful weight maintenance was associated with changes between 1 and 3 year followup in physical activity and the number of fast food meals consumed." (Crawford, Jeffery and French 2000 5 ). There it is! Physical inactivity and fast food were the culprits in this study which was, however, conducted with a relatively young study population. The results would not necessarily be the same for the elderly or 'oldest old'. Yet they fit in with what we know about declining physical activity and increasing malnutrition (of which fast food is an example) among the elderly. These observations do not represent an isolated or extreme case. The authors of the German study covering 14.8 years, referred to earlier, confessed that "The overall long-term effect on weight reduction by our obesity clinic intervention was almost negligible... a significant long-

term weight reduction was demonstrable in less than 5% of patients" (Bender, Jöckel et al, op.cit.1999) The frustration of lack of success is succinctly expressed in an editorial in 'obesity reviews' : "Recognising the limitations of treatment, many professionals are now turning to prevention as the key to fighting the escalating epidemic of overweight subjects and obesity, To date, however, preventing obesity in children and adults has not been particularly successful" (Rössner 2000 6 ). A review of 17 studies of the results of dietary treatment of obesity, published between 1931 and 1999 and which satisfied fairly stringent criteria for inclusion, produced somewhat more favourable conclusions. It indicated "long-term success of 15% among patients followed-up after dietary treatment for obesity, and this outcome seems fairly stable over time for up to 14 years of observation". The review concluded: "Diet combined with group therapy led to better long-term success rates (median 27%) than did diet alone (median 14%). Active follow-up was generally associated with better success rates than was passive follow-up (19% vs. 10%)". (Ayyad and Andersen 2000 7 ).

Where does this leave the elderly? There is little or no published evidence about success rates in preventing or treating obesity among the elderly. It would seem prudent to assume that the chances of success are not much higher than among younger persons, while the limitations of what is suitable or unsuitable for the elderly will be more restrictive. There are nevertheless clues. Physical activity - above all, the avoidance of inactivity - is perhaps the most important element in maintaining a favourable balance between calorie intake and 'burn'. For all elderly persons who are capable of doing exercises, walking or engaging in other appropriate forms of physical activity, regular and moderately intensive exercise is an essential step towards maintaining or losing weight. Dieting needs a more circumspect approach by and for the elderly. Rigorous, over-intensive diets are generally to be avoided by the elderly for fear of upsetting physical equilibrium and producing the effects of malnutrition which are probably more dangerous than being moderately overweight.Schwartz (quoted earlier) considers that "physicians need to be cautious in prescribing weight loss in otherwise healthy obese older patients." This advice is important for both dieting and the use of weight-reducing drugs. Finally, the evidence of weight loss campaigns among younger persons indicates the importance of conducting such efforts in a social context, involving education, personal contact and follow-up activities. There is no reason to believe that these are less relevant to the elderly. On the contrary, the problems of personal isolation and loss of partner are far more severe among the elderly than among younger age groups. It is unrealistic to expect lonely yet persistent effort among more than a small minority of utterly determined weight losers.

Alert or alarm? Overweight and obesity should alert rather than alarm the elderly. Being alert means aiming to maintain stable weight (even overweight) from the age of 50 into old age. Physical activity and reasonable dietary intake are the cornerstones of such an approach for elderly overweight and moderately obese persons, preferably in regular personal contact with others who have similar problems and aspirations, and with health professionals. Those who suffer from gross obesity (BMI 40+) clearly need medical attention for what is either a disease state or the forerunner of disease. It is those who are responsible for health policy in government, in the health care professions and in academia who need to cultivate a sense of alarm. With ever-increasing problems of overweight and obesity among the young and middle-aged, a serious health crisis will build up over the next twenty years - when the middle-aged will be old - unless obesity trends can be arrested and reversed. Today, the outlook for such a trend is bleak. Explanations, exhortations and expostulations are simply not enough. The input of substantial resources into research, experimentation, education and follow-up is needed if society is to make significant progress in stopping the creeping advance of obesity.