LM Donini, Wm. Cameron Chumlea*, B Vellas** , V del Balzo, C Cannella

Istituto di Scienza dell'Alimentazione - University of Rome "La Sapienza" (Italy)
*Wright State University Boonshoft School of Medicine (Dayton, USA)
**Toulouse Alzheimer's Disease Clinical Center, Department of Geriatrics, University of Toulouse (France)

Other experts who contributed to this Conference Report:
- SN Blair: Cooper Institute, Dallas (Texas, USA)
- O Bosello: University of Verona - Clinica Geriatrica (Italy)
- A Clementi: S. Camillo-Forlanini Hospital - Rome (Italy)
- M Cuzzolaro: University of Rome "La Sapienza" (Italy)
- L De Bernardini: Istituto Clinico Riabilitativo "Villa delle Querce" di Nemi (RM - Italy)
- N de Rekeneire: Centers for Disease Control and Prevention, Atlanta (USA)
- G Enzi: University of Padova - Dept of Medical and Surgical Sciences (Italy)
- M Giampietro: Specialist in Sports Medicine and Nutrition (Italy)
- EW Gregg: Centers for Disease Control and Prevention, Atlanta (USA)
- RL Kennedy: James Cook University (Queensland - Australia)
- L Ovesen: National Heart Foundation, Copenhagen (Denmark)
- A Pietrobelli: University of Modena and Reggio Emilia (Italy)
- O Resta: University of Bari - Dept of Respiratory Diseases (Italy)
- A Scuteri: INRCA/IRCCS, Rome (Italy)
- G Spera: University of Rome "La Sapienza" - Dept of Medical Pathophysiology (Italy)
- E Troiano: Italian Association Dietitians (Italy)
- B Valerii: Istituto Clinico Riabilitativo "Villa delle Querce" di Nemi (RM - Italy)
- S Volpato: University of Ferrara - Dept of Internal Medicine, Gerontology and Geriatrics (Italy)
- J Woo: School of Public Health - Dept of Community of Family Medicine - Shatin (HK)
- M Zamboni: University of Verona - Clinica Geriatrica (Italy)

Obesity in the elderly: the evidence
Obesity is a world-wide health problem at all ages of the lifespan. Obesity is a prevalent health problem also among the elderly in developed and emerging countries. The health risk relationships between obesity and chronic disease in young and middle aged adults are also altered in the elderly and include gait and functionality problems. In the elderly, obesity contributes to the early onset of chronic morbidity and functional impairment and is related to premature mortality.
In children and adults, obesity is easily defined as an excess of body weight and adipose tissue, but there is no consensus on the definitions for obesity among the elderly for any race or ethnic group nor are there genetic determinants of these definitions. The World Health Organization has laid down values of BMI for the classification of overweight and obesity, as well as "at risk" values for waist circumference and waist-to-hip ratio. The question of whether these values are appropriate targets for the elderly population has received little attention.
Methods of assessing obesity among the elderly need to continue to be improved so as to increase our understanding of the changes occurring at this stage of life and their relationships with concurrent metabolic changes and subsequent health and chronic disease.
Changes in body composition during the aging process increase variation in the amounts and distributions of muscle and fat among race and ethnic groups that are not present at younger ages. Obesity is accompanied by an increase in fat-free mass, but in the elderly, the wasting of fat-free mass can produce obesity characterized by a stable or low body weight but a high percentage of body fat.

The prevalence of sarcopenic-obesity increases with age in each sex. Cross-sectional as well as longitudinal studies indicate that subjects classified as sarcopenic-obese show significantly higher prevalence of physical impairment and disability, as well as higher prevalence of metabolic syndrome.
Fat redistribution, absolute or relative sarcopenia, limited physical activity and fitness, chronic inflammation and endocrine changes are frequent in old age and are clinical markers and contributors to obesity. These and other clinical factors and their interactions may be important in determining the onset, duration and consequences of obesity thus accelerating the senescence process and the cost of health care.

Obesity and morbidity in the elderly
Significant association has been observed between increased fat mass, overall disability and mobility disability but there is little information on the long-term effects of obesity, overweight and weight stability during adulthood into old age on health, disease and function.

The shifting of amounts of tissues on and in the body in old age can create or exacerbate pre-existing conditions that can accelerate adverse health and functional problems. Trunkal fatness increases with old age and this can increase existing abdominal fatness prevalent during middle age which is already related to increased heart size and cardiovascular disease and the metabolic syndrome.
Equally, subjects who became obese in adulthood, in the old age have an increased load of cardiovascular, metabolic and arthropathic pathologies. Those pathologies have different degrees of seriousness related to coexisting lifestyles and genetic features.
The advanced age adds other pathologies due to the typical degenerative aspects of the age and to reduced functional capacity of the internal organs. The concurrence of all these conditions implies a total disability which is higher than the sum of the disabilities connected to single pathologies.
A non negligible aspect is the fact that the presentation of this illness is complex, but its phenomenology in the different obese subjects is constant. Patients always have a reduced mobility, or even a substantial immobilisation, with sarcopenia caused by the non use of the musculature of the trunk and of the lower limbs, and/or by malnutrition.
The physiological modifications of physical and motor skills that inevitably accompany advancing age are even more emphasised by the sedentary life-style, which is cause and/or effect of fat increase and which is typical of most elderly people, whose motor skills and physical fitness are thus progressively reduced. The lack of sufficient and continuous movement, namely, emphasises the progressive loss of muscle tone-trophism (sarcopenia) and of the mineral content of bone tissue (osteoporosis), which are characteristic of old age, with a consequent increase in the risk of fractures and of immobilization.
The mobility of the main articulations of the lower limbs is extremely reduced or absent and gonarthrosis and coxarthrosis often occur too. These conditions lead to the loss of autonomy in ADL, with a step progression and a sequence of acute synovitis episodes also caused by slight efforts. The chronic suffering of synovias may cause arthrofibrosis even after only 15 days the articulations have not been used or since the patient is lying in the bed, due to intervening causes. The ankylosis of the articulations that are necessary for mobility follows this condition.

Obese elderly patients often have a reduced respiratory efficiency that can reach insufficiency and a dyspnoea due to light efforts related to a cardiovascular insufficiency of various degrees. In old subjects the natural decay of respiratory function, that involves the whole respiratory parameters, furtherly compromises the daytime respiratory function, exacerbating the obesity effects. We observe an increase in the incidence of Sleep Apnea Syndrome, that in these patients is connected to a greater risk of developing hallucinatory and cognitive disorders caused by hypoxia during sleep.

The prevalence of risk factors for cardiovascular disease is elevated in obese elderly subjects due to elevated high values of blood pressure, hypertriglyceridemia, low HDL cholesterol and high fasting plasma glucose. The prevalence of the metabolic syndrome is also very high and in this subgroup the prevalence of cardiovascular diseases (any artery disease) in elderly subjects was significantly higher. This may be related to a high level of visceral fat accumulation The metabolic syndrome is associated with increased risk for cardiovascular disease independently of traditional cardiovascular risk factors and the individual domains of the syndrome.

The diabetes epidemic concerns the whole age range, however the greatest absolute increase and total numbers of subjects with diabetes occurs among the oldest.
Type 2 diabetes, the most common type in the elderly, is the result of the interplay of genetic factors and environmental exposures. The most important environmental factors appear to be those that lead to obesity and physical inactivity. Yet genetic factors are also very important in determining which individuals are susceptible to developing the disease. Finally, several age-related metabolic impairments interact with genetic background to explain the progressive increase of diabetic incidence and prevalence with aging. The available evidence suggests that type 2 diabetes is an inflammatory disease and that inflammation is a primary cause of obesity-linked insulin resistance and hyperglycemia. Adipose body mass may be an important mediator in these relations. Obesity is associated with a state of chronic, systemic low-grade inflammation. CRP, IL-6 and TNF-? levels are increased in obese, insulin-resistant individuals.
Besides, poorer glycemic control in diabetic individuals is associated with higher levels of inflammation compared to those with better glycemic control and aging itself is associated with increased inflammatory activity including proinflammatory and anti-inflammatory
In older diabetic patients the negative effects of hyperglycemia and related metabolic abnormalities interact with the age-related pathophysiological changes and multysystemic reduction of functional reserve expanding the spectrum of traditional diabetes complications. Besides micro- and macrovascular complications, diabetes has been associated with excess risk of a number of clinical conditions typical of the geriatric population including, physical disability, falls, fractures, cognitive impairment, and depression. These conditions are common and will profoundly affect the quality of life of older patients with diabetes.

A growing number of studies suggests that obesity in middle age increases the risk of future dementia independently of comorbid conditions and there is also a positive association between obesity and depression. Negative emotional states seem to predict poor treatment outcomes, particularly for obese women. Overweight and obese groups seem to be heterogeneous with respect to sexual satisfaction and obese elderly subjects present a greater decrease of sexual desire compared with 5 years prior than normal weight men.

When considering health-related quality-of-life outcomes among veterans, the optimal body mass index may be above the "normal" range. Relative contribution of functional and medical comorbidities, as well as health-promoting behaviors to quality of life (QOL), may be different in community-dwelling and institutionalized elders. Physical and cognitive function deficits, overweight/obesity, and lack of regular physical activity are among primary predictors of decreased QOL in home-dwelling elders. In institutionalized subjects, these functional/behavioral data seem to be of lesser importance, the role of concomitant diseases becoming dominant.

Multidisciplinary treatment of obesity in the elderly
The changes in body habitus and their interactions may represent potential therapeutic goals. However our knowledge of their clinical relationships and significance with obesity needs to be more firmly established with a greater evidence in the elderly. Likewise, the balance between the potential benefits of treatment interventions, reducing premature morbidity and mortality, and the impact on quality of life in old age may be different from young and adult age and need to be seriously considered.

Weight maintenance essentially involves a healthy lifestyle in terms of diet, physical activity, smoking and alcohol intake. Lifestyle or behavioural changes may not be easily achievable in the elderly population due to financial, social, or health constraints. Obesity as a risk factor for various diseases should be considered in the context of age, which is itself a very strong risk factor, and life expectancy. Measures to reduce weight should take the magnitude of these risks into account, the quality of life, and also whether measures that are achievable in the elderly (dietary modification, exercise) have any beneficial affect on the anthropometric indices used in the classification of obesity. Other health outcome measures may be more relevant, such as improved physical functioning and qualify of life measures.

Of available treatments for the elderly obese, exercise is by far the most successful. Aerobic exercise, endurance programmes, and progressive resistance training can all be useful in helping to decrease or maintain body weight and improve function. Obese individuals who are fit have much lower risk of mortality than lean individuals who are unfit, and low cardiorespiratory fitness in overweight or obese men is as hazardous as having diabetes, smoking, or having high levels of cholesterol or blood pressure. For "physically fit - healthy " individuals, in particular, it will be important to maintain and possibly improve their level of physical efficiency; for those who are "physically unfit - unhealthy, independent" (those affected by age-related pathologies but still self-sufficient for daily activities), instead, the goal will be to prevent the development of chronic diseases and to promote the improvement of functional capacities; for individuals included in the group of the "physically unfit - unhealthy, dependent", the purpose of the physical activity programme will be mainly aimed at improving life quality and functional capacities, and it will be directed towards recovering greater autonomy.

Nutritional interventions need to take into account dietary habits, economic factors, and patient preferences. Care should be taken to avoid interventions that improve body weight but unfavourably alter body composition. Planning the nutritional intervention needs, however, the careful evaluation of all the conditions associated with obesity such as the physiologic changes of ageing (body composition changes, sensory losses, oral health status, gastrointestinal funcion, neurologic function), the use of medications, the presence of comorbidites. Each older adult has unique needs, so dietary recommendations should be individualized. Nutrient density becomes even more important with age: the diet must provide enough fluids, calcium, fiber, iron, proteins, folic acid, and vitamins A, D, B12 and C without extra calories. Basic diet planning principles -that include moderation, balance, and variety- apply to the older adult and comply with the Dietary Guidelines. Individualized programs with the goal of achieving modest weight reduction are likely to result in immediate (e.g. arthritic pains, glucose intolerance) and possibly long-term (e.g. cardiovascuolar risk) healthcare benefits. Management should then emphasize education and changes in lifestyle, which remain the key issues in obesity treatment. Studies on the effect of voluntary weight loss in the elderly are scarce, but they suggest that even small amounts of weight loss (between 5?10% of initial body weight) may be beneficial.

Food service is obviously intimately involved in developing food service concepts that address the current problems of food provision to the elderly. Operators must approach the challenge in a holistic way, for example by looking at how the different steps in the food service chain and the education can be improved. Food service must look beyond the kitchen door and toward the hospital wards, nursing homes etc. in order to improve the cooperation between ward and kitchen personnel. Food service must choose the technology and logistics that best meet the individual's needs and are at the same time economically sustainable. It is crucial that different groups taking care of the elderly, e.g. food service and ward staff, physicians, dieticians, nurses and orderlies must combine efforts in order to make food service become successful nutrition.

Drug therapy for obesity has its place in the elderly, but we need to consider other drugs the patient may be taking and co-morbidities such as hypertension. There is also a place for bariatric surgery in those at very high levelso of obesity, although there is limited published data relating specifically to the elderly for the use of this surgery.
From a psychic point of view, pathologies are accompanied by an inadequacy of the mood (syndromes below the threshold) that reduces the capability to face a) the complexity of the pathologies, b) the mobilization of the existing resources and of the coping abilities needed to face the medical rehabilitative treatment and the physical effort and the pain connected with the recovery of lost functions. The aim of improving psychophysical health is the construct of the quality of life in the elderly. The decline noted subjectively in the quality of one's own life (lower mobility, higher disability, loss of a social role, economical discomfort, social and affective isolation, etc.) is one of the main reasons that lead the elderly to look for a treatment for obesity, since it severely affects himself/herself and his/her functioning. The psychologist gives support to the behavioural habits and brings out those typical aspects of the elderly people - that they now perceive as dysfunctional -coming from their long life experience. It is necessary to give a different view of the past life giving emotional support to the intense request for care, to the feeling of inadequacy, to the constant catastrophising thoughts that lead to anxiety, depression and to the consequent inability to manage emotions.

Thus, we observe a natural phenomenon (ageing) and a complex world-wide illness (obesity) that should not be merely treated as the sum of the treatments for the elderly and for the obese. More information is still needed on the levels and changes in body composition leading up to and during old age in order to understand and classify obesity clearly. The ideal intervention might combine a tailored exercise programme with suitable nutritional advice and psychological treatment. The use of anti-obesity drugs for defined periods and bariatric surgery may be considered, particularly if they decrease need for other drugs including oral hypoglycaemics and antihypertensives and improve QOL. The impact of obesity in the elderly will impact quality of life, treatment modalities and affect the cost of health care for all nations.

Correspondence

Prof. Lorenzo M. Donini

Università degli Studi di Roma "La Sapienza"
Istituto di Scienza dell'Alimentazione
Ple Aldo Moro, 5 - 00185 - Roma
Phone: +39.06.4991.0996 Fax: +39.06.4991.0699
e-mail: lorenzomaria.donini@uniroma1.it