ABSTRACT
Obesity should be managed in older adults. However, challenges in this age group include multimorbidity, polypharmacy, limited mobility and sensation, and, in particular, sarcopenia, a natural consequence of aging exacerbated by weight loss. Lifestyle recommendations should emphasize adequate protein intake and exercise, particularly strength training, adapted to mobility. Antiobesity medications and metabolic-bariatric surgery are useful in select patients.
Weight loss should be recommended for older adults with excess adiposity who can lose weight safely, particularly those with complications such as cardiometabolic disease and loss of functional status.
The goals of treating obesity in older adults should be to prevent complications, improve existing complications, and improve functional status and quality of life.
Loss of fat-free mass, particularly muscle and bone, that may result from intentional weight loss in older adults can be mitigated with adequate protein intake and physical activity and monitored by body composition analysis.
Multimodal weight-loss strategies incorporating lifestyle modifications, antiobesity medications, and metabolic-bariatric surgery are safe and effective when individualized to the older adult.
Similar to the general adult population, 41.5% of US adults 60 years and older have obesity—a chronic medical condition characterized by excess adiposity, defined as a body mass index (BMI) of 30.0 kg/m2 or higher.1 The older adult population is growing: about 5% of the world’s population was age 65 or older in 1950, rising to about 10% in 2021, and projected to increase to about 17% in 2050.2
Sedentary lifestyle, unhealthy eating patterns, reduced sleep quality and quantity, and mental health disorders are major contributors to the development of obesity in all age groups and have nuanced contributions to obesity in older adults.
Weight-related comorbidities are more common in older than in younger adults and are associated with significant morbidity and mortality.3 Wang et al4 found that greater waist circumference and higher BMI were associated with lower health-related quality of life in older adults.
While earlier data suggested patients with obesity lived longer than those without, a trend termed the obesity paradox, Chen et al5 found that older adults with obesity actually have a higher mortality rate, and that the earlier data were skewed by older adults who were experiencing unintentional weight loss.
SCREENING BY BMI
Professional society guidelines6,7 recommend screening all adults for obesity annually by calculating their BMI and applying the World Health Organization8 classification:
Overweight—25 to 29.9 kg/m2
Class 1 obesity—30 to 34.9 kg/m2
Class 2 obesity—35 to 39.9 kg/m2
Class 3 obesity—40 kg/m2 or greater.
In Asian people, the WHO cutoffs are lower: overweight is 23 to 27.4 kg/m2, class 1 obesity is 27.5 to 32.4 kg/m2, and class 2 obesity is 32.5 kg/m2 or higher, without a definition for class 3. Countries in Asia each have nuanced BMI cutoffs.
However, these guidelines do not discuss how to assess obesity in older adults, in whom body composition can differ from that of younger adults.
STAGING BY COMPLICATIONS
The American Association of Clinical Endocrinologists and American College of Endocrinology7 refine their definition by considering complications of obesity in patients with BMI of 25 kg/m2 or higher:
Stage 0 obesity—no complications
Stage 1 obesity—at least 1 mild to moderate complication like prediabetes
Stage 2 obesity—at least 1 severe complication like stroke.
Canadian guidelines9 recommend the Edmonton Obesity Staging System,10 which categorizes obesity into stages 0 to 4 based on the presence of complications:
Stage 0—no complications
Stage 1—subclinical complications like elevated blood pressure or prediabetes
Stage 2—mild to moderate chronic complications like type 2 diabetes
Stage 3—severe chronic complications like heart failure
Stage 4—end-stage complications like organ failure.
American guidelines6,7 recommend using waist circumference as a cost-effective tool to stratify cardiometabolic risk, with cutoffs of 102 cm (40 inches) or more in men and 88 cm (35 inches) or more in women, and 84 cm (33 inches) in Asian men and 79 cm (31 inches) in Asian women. Compared with BMI, waist circumference correlates more strongly with visceral adiposity, which is more metabolically active and linked to cardiometabolic disease compared with subcutaneous adiposity.6
WITH AGE: MORE ADIPOSITY, LESS MUSCLE AND BONE
Age-related changes in body composition have implications for the diagnosis, assessment, and treatment of obesity in older adults.
Fat-free mass, particularly skeletal muscle and bone, declines by 3% to 8% each decade of life beginning at age 30—with a precipitous decline in women around menopause—owing to hormonal and metabolic mechanisms (reviewed by Volpi et al11). This is an important consideration for older adults attempting to lose weight, because when people intentionally lose weight, for example, by taking glucagon-like peptide (GLP) 1 receptor agonists, 25% to 40% of their total weight loss is fat-free mass. The topic has been reviewed by Conte et al,12 who, however, argue that the effects of GLP-1 receptor agonists on body composition have been heterogeneous in different studies of different agents and “the recent concern that marked weight loss induced by GLP-1–based antiobesity medications can cause physical frailty or sarcopenia is not supported by data.”
Muscle function also declines with age due to insulin resistance and changes in sex hormone signaling, particularly for women.13
The same age-related pathophysiologic mechanisms unfavorably alter the ratios of subcutaneous, visceral, and brown adipose tissue: visceral adipose tissue increases and brown adipose tissue decreases with age, which depresses resting energy expenditure. Nonresting energy expenditure also declines with age.13
Screening for sarcopenic obesity
Because of these age-related changes, older adults are at increased risk of sarcopenic obesity, characterized by both low and dysfunctional muscle mass and excess adiposity.13 The Gerontological Society of America14 recommends screening older adults with overweight or obesity for sarcopenia using the SARC-F questionnaire, which consists of 5 questions relating to strength, assistance with walking, rising from a chair, climbing stairs, and falls.15 A positive screen with SARC-F is considered a surrogate for muscle dysfunction.
All definitions of sarcopenic obesity, including the European diagnostic criteria, also require that there be elevated fat mass, in addition to muscle dysfunction.16 Fat mass can be measured by a number of techniques, such as dual energy x-ray absorptiometry.7 Alternatively, bioimpedance analysis is a low-cost office-based measurement tool but is less accurate at very high BMIs and when dehydration or fluid overload is present.14 Modern consumer bioimpedance analysis scales lack data on their accuracy.
PRINCIPLES OF TREATING OBESITY IN OLDER ADULTS
The goal of treating obesity in older adults should be to prevent and improve complications and to improve functional status and quality of life. Treatment of obesity does not need to achieve weight loss in order to promote these improvements. Weight-loss goals should be individualized in the context of an older adult’s specific health goals and life expectancy, balanced against the risk of losing fat-free mass, which may affect function.
Treatment for obesity should be comprehensive and individualized. It can include lifestyle counseling such as education on nutrition, physical activity, sleep, and stress management; pharmacologic interventions (both eliminating medications that cause weight gain and prescribing ones that cause weight loss); and metabolic-bariatric surgery. Particular challenges in older adults include frailty, sensory impairment, multimorbidity, and polypharmacy.
LIFESTYLE COUNSELING
Lifestyle interventions for older adults include nutrition, physical activity, stress management, restorative sleep, and social connection. A comprehensive lifestyle plan should include realistic goals, adapted for the older adult. For example, if cognitive impairment is present, simplifying instructions and involving caregivers can be helpful.
Nutrition
For older adults attempting to lose weight, the PROTAGE (Protein With Age) Study Group recommends a daily dietary protein intake of 1.0 to 1.2 g/kg of actual body weight per day, and 0.8 g/kg per day if the estimated glomerular filtration rate is less than 30 mL/min, to mitigate loss of fat-free mass.17 This amounts to about 25 to 30 g of protein per meal, or more, which many older adults would struggle to consume. For them, protein supplements in powder or liquid form can be useful. Leucine-rich protein (eg, eggs, lentils, cottage cheese, peanuts, hemp protein) stimulates muscle synthesis. It is important to emphasize adequate hydration in older adults attempting intentional weight loss.
Reducing calories by 500 to 700 kcal per day is both safe and effective in older adults with overweight or obesity, and, as part of a comprehensive lifestyle plan, it can improve morbidity, quality of life, and functional status. Clinicians must assess whether the patient has access to healthy food or experiences food insecurity, because improving nutrition quality will achieve the aforementioned treatment benefits independent of caloric reduction.6,7,18 Frozen or low-sodium canned vegetables are a cost-effective solution.
Of note, however, Medicare does not cover medical nutrition therapy for obesity management without a qualifying comorbid medical condition.
Physical activity
Physical activity is essential for preserving muscle mass, preventing sarcopenia, and enhancing quality of life. While exercise by itself does not lead to much weight loss, combining aerobic and resistance training can maintain muscle and bone mass and prevent weight regain.7 Thus, physical activity is crucial in maintaining fat-free mass during intentional weight loss.
Resistance exercises, particularly those that target core strength, improve balance and flexibility, while both aerobic and resistance training improve weight-related comorbidities such as hypertension and diabetes.19
Exercise prescriptions for older adults should be individualized to accommodate impairments in sensation, balance, mobility, transportation, and neighborhood safety. Necessary adaptations may include seated, water, virtual, and supervised exercises. The American College of Cardiology recommends 150 to 300 minutes per week of moderate-intensity aerobic activity, and resistance training on 2 or 3 days per week, for all ages.7 However, it is unclear if this will preserve fat-free mass in older adults attempting intentional weight loss, highlighting the need for an individualized approach.
Psychosocial health
Loneliness negatively affects health in older adults and can impede comprehensive lifestyle change. Remarkably, addressing isolation can lessen the mortality risk of obesity.20 Lifestyle modification programs such as the one used in the Diabetes Prevention Program may be beneficial.21
Behavioral health conditions such as depression are common among older adults and can increase food cravings and emotional eating, attenuate satiety, and increase body fat through metabolic dysregulation, while impairing progress on lifestyle changes. However, there are not much data on how psychosocial health affects eating behaviors in older adults. Obesity management plans should incorporate behavioral health management and include professional referrals when necessary. Of note, intentional weight loss can improve mood.
Restorative sleep
Sleep disorders, including obstructive sleep apnea, are more prevalent among older adults and should be screened for.22 Untreated, they can lead to excess adiposity through increased preference for calorie-dense foods, increased appetite, reduced physical activity and adherence to obesity treatment recommendations, and increased cardiometabolic disease and insulin resistance.
Though the impact of age-related changes in circadian rhythm on obesity is unclear, counseling to separate eating from bedtime and to achieve 7 to 9 hours of sleep per night are important components of comprehensive obesity plans.23
PRUNING WEIGHT-PROMOTING MEDICATIONS IF POSSIBLE
Many drugs promote weight gain. Clinicians should take a critical look at the patient’s medication list, especially for older adults taking multiple medications, and weigh the risks and benefits of continuing each one. Replacing a weight-promoting drug with an alternative medication may help patients lose weight (Table 1).24
Medications that promote weight gain and potential alternatives
ANTIOBESITY MEDICATIONS
Safety and efficacy data for antiobesity medications are limited in older adults because clinical trials of these drugs exclude or recruit fewer participants older than 65. Also, comorbidities and medication interactions limit antiobesity medication use in older adults. In addition, a federal law passed in 2003 excludes Medicare Part D coverage of medications for the indication of overweight or obesity. However, some of these drugs are covered if they are prescribed for other indications.
Incretin therapies
Although data are limited, incretin therapy (eg, semaglutide, liraglutide, and tirzepatide) appears safe and effective in older adults. The magnitude of risk of losing fat-free mass with incretin therapy is unclear, but reasonable evidence-based mitigation strategies exist.
Semaglutide. In the STEP (Semaglutide Treatment Effect in People With Obesity) trials,25 233 (9%) of the semaglutide recipients were 65 to 75 years old, and 23 (1%) were 75 or older. The drug was as safe and effective in these 2 groups as in the younger participants. A mean weight loss of 16% was reported for participants who received semaglutide along with intensive lifestyle intervention.
The SUSTAIN (Trial to Evaluate Cardiovascular and Other Long-Term Outcomes With Semaglutide in Subjects With Type 2 Diabetes) trials 1 through 5 included 853 adults age 65 and older and 3,045 younger participants, who were randomized to receive semaglutide 0.5 or 1.0 mg weekly or placebo. The number of participants 75 years and older was not reported. A pooled analysis showed equal safety and efficacy in the older adult group compared with younger participants.26
The SELECT (Semaglutide Effects on Cardiovascular Outcomes in People With Overweight or Obesity) trial27 evaluated once-weekly subcutaneous semaglutide up to 2.4 mg for adults with preexisting cardiovascular disease and overweight or obesity but without diabetes for secondary prevention of atherosclerotic cardiovascular disease. It included 5,362 participants age 65 through 74 years and 1,366 participants 75 years and older. Although subgroup analyses are not yet available, in the overall cohort, mean age 61, fewer patients died in the semaglutide group than in the placebo group.
Medicare Part D covers semaglutide when prescribed for treatment of noncirrhotic metabolic dysfunction–associated steatohepatitis with F2 to F3 fibrosis or for secondary atherosclerotic cardiovascular disease prevention, namely, for a patient with a history of myocardial infarction, ischemic or hemorrhagic stroke, or peripheral arterial disease with either claudication symptoms or history of amputation and BMI 27 kg/m2 or higher.
Liraglutide. Trials evaluating once-daily subcutaneous liraglutide up to 3.0 mg for adults with overweight or obesity also included older adults. In the SCALE (Satiety and Clinical Adiposity—Liraglutide Evidence in Nondiabetic and Diabetic Individuals) trials, the 232 participants age 65 and older had safety and efficacy outcomes comparable to those of younger participants, though it is possible the older participants experienced more side effects.28
Furthermore, intentional weight loss achieved with liraglutide does not appear to adversely affect body composition; in a study of 746 participants age 19 to 79 with type 2 diabetes, there was no change in bone density, though doses of only up to 1.8 mg were studied.29 There was no subgroup analysis for older adults in that trial, but a smaller trial of 9 older adults (mean age 68) found similar results with doses up to 3.0 mg.30
Tirzepatide. Two SURMOUNT (Study of Tirzepatide [LY3298176] in Participants With Obesity or Overweight) trials (SURMOUNT-1 and SURMOUNT-2) evaluating once-weekly subcutaneous tirzepatide for overweight or obesity with or without type 2 diabetes included 226 adults age 65 and older, and 13 were 75 or older.31 There were no differences in safety or efficacy for older adults compared with younger participants. In these 2 studies, the mean weight loss from baseline was up to 20% for patients who received tirzepatide.
Medicare Part D covers tirzepatide when prescribed for moderate to severe obstructive sleep apnea when BMI is 30 kg/m2 or higher.
Nonincretin therapies
High-quality data on the safety and efficacy of nonincretin antiobesity medications for older adults are lacking.
Naltrexone-bupropion has little data on its use in older adults, as only 62 (2%) of the participants in clinical trials of this combination were age 65 and older, and none were 75 or older.32 This was not enough to conduct subgroup analysis.
Phentermine-topiramate is available in an extended-release formulation. Trials of this agent included 254 adults age 65 to 69, though none 70 or older.33 Again, this was not enough for subgroup analysis. Older patients (≥ 65) in the treatment group had an increased rate of psychiatric and sleep disturbances (28.6%) compared with placebo (6.3%).
Because a side effect of topiramate is cognitive dulling, prescribers need to be prudent when using it in older adults with cognitive impairment. In addition, levodopa may worsen these side effects of topiramate.
Contraindications to phentermine include history of clinical atherosclerotic cardiovascular disease (ie, angina, myocardial infarction, stroke, or symptomatic peripheral arterial disease), heart failure, arrhythmia, and uncontrolled hypertension with blood pressure above 160/90 mm Hg. The clinical trials of phentermine-topiramate did not specifically exclude participants with subclinical atherosclerosis and thus likely included a large number of participants with subclinical disease, which is common among adults with metabolic risk factors. However, there is a paucity of data for solo phentermine in older adults.34
Experts recommend antiobesity medications other than sympathomimetics for older adults but suggest that phentermine-based regimens can be considered for them as second-line agents.35 It is reasonable then to consider sympathomimetics for those who cannot tolerate or afford incretin therapy. In particular, the clinician must thoroughly weigh the risks and benefits of sympathomimetics for older adults with cardiovascular risk factors such as hypertension or type 2 diabetes, for which a screening electrocardiogram may be reasonable.35
Orlistat, a lipase inhibitor, blocks intestinal fat absorption. There are insufficient data to determine its safety and efficacy in older adults. Side effects including steatorrhea, flatulence, fecal incontinence, and malabsorption of fat-soluble vitamins36 may be of more consequence for older adults at risk for sarcopenia and falls. Orlistat also affects absorption of other medications,36 of particular concern for older adults already on several medications. Orlistat is available as a 60-mg, 3-times-daily over-the-counter dose as well as a 120-mg, 3-times-daily prescription dose.
Metformin. The American Diabetes Association37 recommends metformin for adults with overweight or obesity who are at risk for diabetes. The results from the Diabetes Prevention Program studies21 showed that metformin prevented diabetes and reduced weight by about 5% in adults age 60 and older. Metformin is safe, cost-effective, and usually well tolerated. Moreover, a post hoc analysis from the Diabetes Prevention Program Outcomes Study21 indicates that participants who achieved 5% weight loss with metformin and continued the drug maintained their weight loss.
In sum, despite the lack of safety data, it is reasonable to prescribe antiobesity medications to older adults who have no contraindications to them, because most older adults who use lifestyle modifications alone will not achieve clinically significant weight loss, and the benefits of antiobesity medications may outweigh their risks.
METABOLIC-BARIATRIC SURGERY
The 2022 American Society for Metabolic and Bariatric Surgery guidelines recommend that older adults be considered for this surgery after careful assessment of comorbidities and frailty.38 Metabolic-bariatric surgery is an effective intervention for weight loss and comorbidity resolution in all adults, and more than 10% of patients who undergo these surgeries are age 60 and older,39 including individuals over 70, for whom it is as effective as in younger adults.40 It is critical to ensure adequate support for postsurgical recovery for older adults, especially those with cognitive impairment.
Older adults experience slightly higher rates of complications than younger patients do, likely due to frailty and comorbidities rather than age alone.38 Frailty is independently associated with higher rates of postoperative complications following metabolic-bariatric surgery.41 In fact, in the absence of frailty, a Canadian registry-based cohort of 22,981 patients younger than 65 and 532 older than 65, followed for 3 years, found equivalent safety and efficacy for both groups.42 There are limited data for endoscopic interventions in adults 65 years and older.43
CONCLUSION
Obesity is associated with significant morbidity and mortality in all populations, including older adults. Intentional weight loss should be recommended for older adults at risk for or with complications of excess adiposity such as cardiometabolic disease and loss of functional status. Treatment targets are prevention or amelioration of these complications rather than absolute weight loss. The most salient risk of intentional weight loss in older adults is reduction of fat-free mass, most notably muscle and bone mass. This reduction is a small proportion of total weight loss and occurs with any method at any age, but it is particularly impactful for older adults, who already experience age-related decline in fat-free mass. It can be mitigated with adequate protein intake, physical activity, and monitoring of body composition. When individualized to the older adult, multimodal weight-loss strategies incorporating lifestyle modifications, antiobesity medications, and metabolic-bariatric surgery are safe and effective.
DISCLOSURES
Dr. Valencia has disclosed serving as a research principal investigator for Eli Lilly. The other authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
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