is obesity worth treating in the elderly?

Is Obesity Worth Treating in the Elderly?Rosa María Ortega1 and Pedro Andrés2

1 Department of Nutrition, Faculty of Pharmacy, Universidad Complutense, Madrid, Spain2 Technical Instrumentation Laboratory, Faculty of Pharmacy, Universidad Complutense,

Madrid, Spain

Summary Obesity is associated with a range of health problems and affects an increasingnumber of people. However, the body mass index (BMI) that is associated withminimum mortality increases with age. Therefore, when a bodyweight loss pro-gramme is initiated, the possible benefits should be carefully measured againstthe potential risks.

Elderly people with severe obesity, or those who have associated health riskssuch as hypertension or diabetes mellitus, are in greatest need of bodyweightcontrol. The use of drugs may be advisable in some individuals, but the treatmentduration should be short and administered under strict supervision.

Many studies have shown that habitual, moderate physical activity and dietaryimprovement (i.e. moderating fat intake, avoiding micronutrient deficiencies andincreasing fibre consumption) can be useful in achieving bodyweight control inthe elderly. These measures are especially effective in improving nutritional statusand may therefore be recommended in elderly individuals.

LEADING ARTICLE Drugs & Aging 1998 Feb; 12 (2): 97-1011170-229X/98/0002-0097/$02.50/0

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1. The Frequency of Obesity andAssociated Health Risks

Given the increasing numbers of elderly people,the study of the problems that affect their qualityof life is an urgent public health concern.[1,2] Obes-ity [defined as a body mass index (BMI) of >30kg/m2] is a common form of malnutrition amongolder people;[3,4] however, its incidence diminisheswith increasing age and it occurs less frequently inpersons aged >75 years.[5,6]

Obesity is associated with an increased risk ofmyocardial infarction, stroke, hypertension, hyper-lipidaemia, non–insulin-dependent diabetes mel-litus (NIDDM), osteoarthritis of the lower extrem-ities, biliary pathologies and several types ofcancer.[1-3,7-12] It is therefore associated with in-creased mortality.[7]

2. The Relationship Between Obesityand Longevity

To date, no long term clinical trials have beenperformed to determine whether interventions thatare designed to induce bodyweight loss actually de-crease morbidity and mortality in the elderly. Therelationship between obesity and increased mor-tality is attenuated with age, and the BMI associatedwith minimum mortality increases with aging.[13]

In a study of obese individuals (BMI ≥35 kg/m2),Borrelli et al.[14] showed that the mortality rateamong the study population was 6.9 and 4.3 timesthe normal rate in women and men, respectively,aged between 25 and 54 years. However, in 55- to72-year-old individuals, the corresponding ratioswere 3.5 and 1.6, respectively.

Haruyama[15] showed that bodyweight in the

elderly is positively associated with survival. How-ever, overweight individuals more frequently hadnonfatal cerebral infarctions and other degenera-tive disorders. Prolonged survival would thereforeappear to be associated with greater disability. Somestudies have shown that obese elderly people havea significantly higher bone mineral density com-pared with individuals with a lower BMI.[16]

These data underline the need to determine theoptimum bodyweight for each patient. In someindividuals, especially those with hypertension,diabetes mellitus or osteoarthritis, bodyweight lossmight be advisable, while in others it may actuallybe deleterious to their health.

3. The Necessity of Treatment

The main therapeutic resources for the controlof obesity in the elderly include dietary treatmentand lifestyle modification. In some individuals,pharmacological treatment may be advisable.[7,11]

4. Drug Therapy

4.1 Thermogenic Drugs

Thermogenic drugs are compounds that are des-igned to increase energy expenditure. Among thethermogenic group of drugs, the most commonlyused are the sympathetic nervous system stimulants(e.g. caffeine). These stimulants are capable ofincreasing the output of noradrenaline (norepi-nephrine) or inhibiting its catabolism or reuptakeby sympathetic neurons. A potential advantage ofthese drugs is that they increase insulin sensitivity,which could be very beneficial given the frequentassociation of both carbohydrate intolerance anddiabetes mellitus with obesity.[17]

However, their use may also be associated withsecondary effects such as hypertension, tachycar-dia and nervousness. Therefore, these drugs are onlyindicated in patients who show a fall in their energyexpenditure before treatment is initiated, as meas-ured by calorimetric techniques.[11]

4.2 Gastrointestinally Acting Drugs

Dietary fibre is very useful because it increasesthe need for chewing, which means that meals takelonger to ingest. Fibre also contributes to an increasein the size of the food bolus, thus leading to agreater feeling of satiety. An additional advantageis the increase in faecal mass, which helps to com-bat constipation; the latter is a frequent problem inthe elderly[18] and is even more common in thosewho are obese.[19]

Amongst the drugs that inhibit intestinal absorp-tion, metformin appears to be especially useful inobese, insulin-resistant patients with NIDDM.[20,21]

However, there are many reasons why this drugcannot be used in elderly patients.[20] Its most com-mon adverse effects are gastrointestinal reactions(nausea, diarrhoea, anorexia), a metallic taste andcyanocobalamin (vitamin B12) malabsorption.[21]

In general, drugs that inhibit the digestion/ab-sorption of carbohydrates and lipids would appearto have little promise because they affect the absorp-tion of both macro- and micronutrients. This has anegative effect on the individual.[11] Given thatnutritional deficiencies are common in the elderly,any treatment that might increase the risk of suchevents must be seen as negative.[2,4] The use ofdrugs that inhibit the intestinal absorption of macro-and micronutrients may be an option, with appro-priate supplementation with micronutrients.

4.3 Anorectic Drugs

The most commonly used anorectic drugs exerttheir influence on serotonergic pathways.[11] Bothfenfluramine and its derivative dexfenfluraminehave an anorectic effect and also increase meta-bolic energy expenditure in obese patients.[11]

Dexfenfluramine induces bodyweight loss inpatients with NIDDM and reduces visceral fat inobese men.[22] It also improves glycaemic controlthrough an apparent improvement in insulin sensi-tivity.[22] Dexfenfluramine might also be useful inhypertensive, obese patients in whom dietary inter-vention alone has proven insufficient to reducebodyweight. In addition to assisting bodyweight

98 Ortega & Andrés

© Adis International Limited. All rights reserved. Drugs & Aging 1998 Feb; 12 (2)

loss, it also helps in the treatment of hypertension.This might be considered a positive feature withregard to cardiovascular risk.[23]

The selective serotonin (5-hydroxytryptamine;5-HT) reuptake inhibitor fluoxetine improves gly-caemic control without causing a significant in-crease in adverse events in elderly patients withNIDDM.[24] A combination of fluoxetine (duringthe day) and dexfenfluramine (at night) may bemore effective than fluoxetine alone in promotingbodyweight reduction.[25]

A combination of fenfluramine and phenter-mine may be as effective as either drug alone, buttheir use in combination allows a lower dosage ofeach drug to be used and may be associated withfewer adverse effects. However, recent studieshave shown that the use of this combination maybe associated with valvular heart disease.[26]

The decision to use medications to treat obesityshould depend on good clinical judgement, basedon considerations such as BMI, body composition,body fat dissociation, age, gender, comorbid con-ditions such as diabetes mellitus and hypertension,[8]

and the use of other drugs.[20]

5. Desirable Dietary Modifications

Several studies have demonstrated that dietarycomposition, rather than energy consumption, mightbe important in the development of obesity.[27-30]

Although obese individuals tend to underestimatetheir food intake,[29-31] studies of institutionalisedpatients have confirmed that obese individuals donot consume more calories than their non-obesecounterparts.[29]

It has been confirmed that overweight peoplehave less healthy dietary habits than people of nor-mal bodyweight.[27,29] Miller et al.[27] reported thatdietary quality deteriorates with increasing BMI.Vitamin and fibre intakes decrease while there isan increase in the proportion of dietary energy thatis derived from fat. Ortega et al.[29] found that over-weight/obese individuals ate less fruit and moremeat than those with a lower bodyweight. Further-more, more of their energy was obtained from pro-teins and less from carbohydrates. They also had a

higher cholesterol intake per megajoule than didindividuals of normal bodyweight.

Blundell and Halford[32] also found a greater fatconsumption in obese individuals. Elderly obesepeople were also found to take less adequate break-fasts than those of normal bodyweight and to omitthis meal more frequently.[28] Inadequate diets ofpoor nutritional value can contribute to the impair-ment of health in the overweight elderly.[29]

Given that the diets of obese elderly people areless adequate than those of elderly people with nor-mal bodyweight, the first step in treatment shouldbe to improve and reorganise their nutritional hab-its. Excessive consumption of fat should be avoided,as should diets causing deficiencies in micronutri-ents. The energy profile of the diet should also bebrought closer to that which is recommended (i.e.fats should provide <35% of energy and proteins10 to 15%, with the rest coming from carbohy-drates). The enhancement of dietary nutrient den-sity, including an increased intake of fruit andvegetables, is recommended in the treatment ofobesity. In addition, this reduces the likelihood ofother diseases that are associated with excessivebodyweight.[1]

In elderly obese people, energy balance shouldbe controlled and, in bodyweight loss programmesfor such patients, specific guidelines should be rec-ommended. Although the amount of energy derivedfrom fats should be restricted, a protein intake ofabout 70 g/day is desirable.[3,4] The intake of vita-mins and minerals should also be monitored becausedeficiencies of these nutrients can cause health prob-lems that are worse than the obesity itself.[4,33]

In elderly people, it has been shown that obesityis often associated with forms of osteoarthritis. Withrespect to this pathology, several authors haveshown a frequent association with nutritional defic-iencies.[12,34] Wilhelmi[12] reported that tocopher-ols (vitamin E), riboflavin (vitamin B2) and ascor-bic acid (vitamin C) exert an inhibitory effect onosteoarthritis. Moreover, this author also found[12]

that vitamin supplementation can have a beneficialeffect on the symptomatology of human degenera-tive joint disease, particularly supplementation

Treating Obesity in the Elderly 99


with tocopherols and the combination of thiamine(vitamin B1), pyridoxine (vitamin B6) and cyano-cobalamin. Diets that cause calcium, zinc and selen-ium deficiencies can induce skeletal damage andshould therefore be avoided.[12]

6. Exercise

Exercise is an important element in bodyweightloss programmes and contributes towards a generalsense of well-being.[3,9] It is therefore highly rec-ommended for the elderly, especially those con-cerned about their weight, to undertake some formof exercise. However, the limitation of movementin some elderly patients may necessitate the use ofinnovative forms of exercise.[3]

Endurance and resistance exercises have differ-ent effects on energy expenditure and substrate usein the elderly. Vigorous endurance exercise causesa compensatory decline in energy expenditure dur-ing the non-exercising hours of the day, suggestingthat this type of exercise may actually be counter-productive in the promotion of fat loss.[35] Poehl-man et al.,[35] who investigated resistance traininginterventions in older individuals, suggested thatthis type of exercise increases the basal metabolicrate and sympathetic nervous system activity.Exercise interventions that preserve fat-free massand/or enhance aerobic capacity may increase ormaintain fat oxidation and possibly reduce the ten-dency towards increasing adiposity in older indi-viduals.[35]

7. Conclusions

The optimum bodyweight for elderly peopleshould be assessed on an individual basis, and thebenefits of bodyweight loss carefully measuredagainst the risks. Both the restriction of energyintake and drug treatment would presumably bereserved for a minority of patients, probably thosemost severely affected or those in whom obesitymore seriously impairs their health.[7]

Behavioural modification, including regularexercise and the development of healthy eating hab-its, remains the best option for long term body-weight loss.[7] Neither of these measures pose a risk

to health but, rather, are likely to provide benefits.Although long term compliance with lifestyle mod-ifications is difficult to achieve, their implementa-tion could help to control bodyweight. Above all,they would improve the health and quality of lifeof the patient and may be advisable generally forthis age group.

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Correspondence and reprints: Dr Rosa María Ortega,Departamento de Nutrición, Facultad de Farmacia, Uni-versidad Complutense, E-28040 Madrid, Spain.

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is obesity worth treating in the elderly?

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