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 two-
fifths 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 follow-
up 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.