Our moms and grandmas are leading longer lives than expected seeing their grandkids and great grandkids attend school and college! They belong to a generation who is blessed to witness such a sight in their life and all this is because of advancements in science, especially in the field of health care. Life expectancy of the elderly generation is reaching new highs and so are their obesity rates. That’s because, ageing is accompanied by changes in body composition of individuals. Above the age of 70, both fat free mass and fat mass decrease with fat mass being redistributed in the visceral component and fat deposits are significantly visible in the skeletal muscle and liver. Body fat is mainly determined by the difference between energy intake and energy expenditure. Though there is no great increase in intake portion sizes in the elderly population their physical activity levels also witness a downslide and such decreased energy expenditure plays a prominent role in increasing fat mass with ageing. Also, there is a 2-3% decrease in resting metabolic rate every decade after the age of 20 and all these together account for decrease in energy expenditure with ageing.
But the actual question is whether obese elderly individuals must try to lose weight! For some of you who wonder what’s the point in asking questions when one is obese and there are clear evidences that obesity is a serious risk factor for heart diseases, diabetes, hypertension and hyperlipidaemia, I guess you have not heard of the obesity paradox! According to it, certain studies and meta-analyses show that a higher BMI can be protective of the elderly population decreasing (instead of increasing) their risk of death. There are various population-based studies that show that weight loss is linked to an increase in mortality rates; weight loss increases muscle loss (sarcopenia), there is a loss of the protective effect of fat (such as against hip fractures) and fat loss also exists which releases fat-soluble toxins into circulation. The next question is whether BMI is a good measure of body fat? In fact, it is not! People sometimes tend to lose height due to bending of the spinal cord as they age and, in such cases, some of them seem to have a higher BMI when their weight has not changed at all. Also, muscle loss, fat distribution and fat increase are not evident in BMI values. In such cases, waist circumference (WC) acts as a perfect measure for calculating obesity in older adults as this gives a clear picture of total fat and intra-abdominal fat. WC is extremely cost-effective, useful and can give a clear picture of the visceral fat adiposity levels in an individual. WC is one of the five criteria that defines metabolic syndrome which is in the first place linked to functional decline, frailty and disability. While ageing itself brings about disability, functional decline and loss of mobility studies show an association between BMI and mobility impairment. But there are very few which focus on WC as a factor for functional decline, falls and decrease in quality of life. Osteoarthritis (OA) is yet another reason for diminishing functional abilities in the elderly population and it also has the ability to increase changes in body composition that occur with aging. A study specifically focused on a cohort of older adults at risk for OA probing whether increased WC impacted quality of life, physical activity and daily life activities in these people.
Osteoarthritis Initiative (OAI)
Osteoarthritis initiative (OAI) is an observational study of osteoarthritis in adults aged between 45 and 79 years belonging to any ethnic group. Those suffering from rheumatoid arthritis, severe joint space narrowing, bilateral total knee replacements, unable to undergo an MRI, unable to provide blood samples or having any comorbidities were excluded from participating in the study. Baseline information in the form of questionnaires, interviews and physical assessment were collected. Every participant went through follow-up assessments annually and the present study used six-year outcome data for analysis.
All the study participants were put into one of the three subgroups-clinically significant knee osteoarthritis at risk of disease progression, subjects at high risk of developing clinically significant knee OA (incident) and control group. Individuals in the progression subgroup complained frequently of knee symptoms or radiographic tibiofemoral knee OA in at least one native knee. Though the incident subgroup did not have baseline symptomatic knee OA they had certain other risk factors such as the presence of heberden’s nodes in both hands, increased weight, previous knee injury or operation, family history and pain in the knee on most days of the preceding month. The control group neither had pain nor risk factors or radiographic findings.
The study consisted of 2,182 subjects whose height, weight and waist circumference were measured. Waist circumference was measured at the level of the umbilicus between the lower rib and the iliac crest. BMI was calculated as weight divided by height squared. Gait was calculated using the 20m walk test using which each of the participant’s walking speed was noted down. The study also measured occupational, household and leisure activities using the physical activity scale for the elderly (PASE) which is a 26-item questionnaire with greater scores indicating higher intensity of activity.
Results showed that there was a higher proportion of women in the lower WC quartile and the number of medications increased with increasing WC quartile. Also, the proportion of individuals with knee OA increased by quartile. The study compared individuals who participated in the research to those who were excluded and found that the excluded individuals were older, less likely to belong to the female sex and were likelier to have higher comorbidities score and medications. They also had lower SF-12 (quality of life score) score at baseline but there were no differences found in PASE scores. The outcomes were measured at baseline and six years after start of study-it was found that SF-12 rates dropped as waist circumference increased at baseline and follow-up. A decline in PASE score was also observed over time and also between groups at baseline and 6 years after follow-up. Late-life disability index (LLDI) scores decreased at follow-up and activities of daily living (ADL) impairments increased significantly from 18% in the lowest WC quartile to 36.6% in the upper WC quartile.
SF-12 values were observed to be age-dependent and those in the high WC quartile had lower scores than the lowest quartile. High WC quartile subjects had decline in PASE score compared to other categories but this was evident only in the 70+ age group. LLDI score also had maximum impact in the same age group compared to the low WC quartile. Also, gait speed was lowest in the highest WC quartile compared to other categories. Patients with OA had lower outcome measures compared to the low WC quartile. The study is a clear indication that high waist circumference is linked to decreased quality of life and physical activity. Hence, rather than focusing on BMI the primary focus must be to improve functional stability, manage weight and increase physical fitness in such a way that there is an overall improvement in physical performance and quality of life of the elderly individual.
The Impact of Waist Circumference on Functional and Physical Activity in Older Adults: Longitudinal Observational Data from the Osteoarthritis Initiative: https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-13-81
Obesity in the Elderly: More Complicated than You Think: https://www.mdedge.com/ccjm/article/96020/geriatrics/obesity-elderly-more-complicated-you-think/page/0/1
Obesity in the Elderly: https://www.ncbi.nlm.nih.gov/books/NBK532533/
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