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Summary

A medical strategy of exercise and a loss of >5% from baseline weight can improve the co-morbidities and cardiovascular diseases associated with elderly obesity as addressed by Buch et al. [1]. Obesity has been defined as a body mass index (BMI) of >30 k/m2 in men and women and elderly as an age >65. The combination of weight loss and physical activity results in a better outcome than physical activity or diet alone. Obesity is associated with the metabolic syndrome, type 2 diabetes (T2D), atrial fibrillation, cognitive decline, thromboembolic events, and sleep apnea, just to mention a few. Aging obese individuals are also at risk for frailty, impaired mobility, and disability due to sarcopenia and the metabolic effects of obesity. These physical and metabolic alterations impact individual quality of life. There are also disrupted circadian rhythms and sleep disturbances linked to poor health outcomes. Late evening or nighttime eating can affect metabolic tissue systems because the timing and nutritional content of the main meal contributes to establishing circadian rhythms. Converting the main meal from evening to morning [morning large and evening small] is a potential strategy for weight loss and the improvement of obesity and T2D. Intermittent fasting, by delaying food intake beyond the overnight fast for up to 14 hours, has been described as effective for weight loss [2]. Intermittent fasting reduces cognitive decline in small animals and could be useful in preventing senile dementia [2]. Intermittent fasting can decrease inflammation and potentially increase autophagy in the brain [3,4]. Bariatric surgery can accelerate weight loss in the elderly without evidence of increased surgical complications compared to younger individuals. Dietary alterations from these interventions affect multiple indices of health and result in a deceleration of aging with increased longevity. The combination of exercise and a patient specific dietary modification can result in achieving individual weight loss goals. The recommendation to improve health includes dietary intervention and physical activity of as little as 150 minutes per week that include aerobic exercise, muscle strength, flexibility and balance. The health care provider needs to counsel the elderly that continued motivation and consistency is required to demonstrate improvement in weight loss, exercise tolerance and general health.

Commentary

The commented paper of Buch et al. [1] is a must read for managing obesity at any age. Authors address elderly individuals who are obese who could and should be aggressively treated to reduce the morbidity and mortality associated with obesity [1]. Although the manuscript targets the elderly a preventive health strategy for obesity at any age should utilize these recommendations. Improvements in function and health can be noted with exercise and diet, while a bariatric surgical intervention could be considered with limited to no increase in risk despite the elderly person’s age. The increase in obesity in the elderly is often associated with sarcopenia, a loss of muscle mass that contributes to further functional physical impairment and the need for greater assistance in normal living [5]. To negate these aspects of metabolic and physical decline an individual intervention is required with a planned approach that includes dietary protein, vitamin D, micronutrients (vitamins and minerals), exercise, and a low calorie diet to prevent bone loss and muscle wasting [1,6,7]. This menu can be designed to address the specific patient needs and conditions. The concepts presented for the elderly can be generalized to obesity at any age. Foremost is that initiating intervention at an earlier age than 65 should further reduce morbidity and potential mortality with increasing age. Obesity is not limited to elderly individuals, in fact it exists at all ages and is a chronic condition that should be immediately addressed with a comprehensive and individualized care plan. Other therapeutic interventions for weight loss are presented in the manuscript such as the use of GLP1 inhibitors (i.e liraglutide and semaglutide). These drugs increase saity (the feeling of fullness) and can result in significant weight loss. Gastric banding or a gastric bypass can be performed at any age and especially in the elderly without apparent increase in morbidity and mortality. The decision to use a surgical approach should be done after careful consideration of the individual and their efforts to improve with behavioral and medical interventions as first line treatment. The best outcome for the elderly obese person is an individualized approach that includes dietary modification with daily body movement (exercise) to accomplish the goal of weight loss and improve physical and mental function.

David F. Archer, MD
Professor of Obstetrics and Gynecology
Eastern Virginia Medical School
Norfolk, Virginia, USA

References

  1. Buch A, Marcus Y, Shefer G, Zimmet P, Stern N. Approach to Obesity in the Older Population. J Clin Endocrinol Metab. 2021;106(9):2788-2805.
    https://pubmed.ncbi.nlm.nih.gov/34406394/
  2. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381(26):2541-2551.
    https://pubmed.ncbi.nlm.nih.gov/31881139/
  3. Eshraghi M, Adlimoghaddam A, Mahmoodzadeh A, et al. Alzheimer’s Disease Pathogenesis: Role of Autophagy and Mitophagy Focusing in Microglia. Int J Mol Sci. 2021;22(7):3330.
    https://pubmed.ncbi.nlm.nih.gov/33805142/
  4. Festa BP, Barbosa AD, Rob M, Rubinsztein DC. The pleiotropic roles of autophagy in Alzheimer’s disease: From pathophysiology to therapy. Curr Opin Pharmacol. 2021;60:149-157.
    https://pubmed.ncbi.nlm.nih.gov/34419832/
  5. Colleluori G, Villareal DT. Aging, obesity, sarcopenia and the effect of diet and exercise intervention. Exp Gerontol. 2021;155:111561.
    https://pubmed.ncbi.nlm.nih.gov/34562568/
  6. Bičíková M, Máčová L, Jandová D, Třískala Z, Hill M. Movement as a Positive Modulator of Aging. Int J Mol Sci. 2021;22(12):6278.
    https://pubmed.ncbi.nlm.nih.gov/34208002/
  7. McCarthy D, Berg A. Weight Loss Strategies and the Risk of Skeletal Muscle Mass Loss. Nutrients. 2021;13(7):2473.
    https://pubmed.ncbi.nlm.nih.gov/34371981/

 


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