27 Prevalence and management of obesity among adults

Suman Dua

epgp books

 

 

 

Contents:

 

Introduction

1.  Overnutrition and Obesity in older People

1.1 Prevalence

1.2 Appetite and Food Intake among elderly

2.  Body Weight and Body Composition among elderly

2.1 Body Weight

2.2 Body Composition

2.2.1 Distribution of Fat

2.2.2 Loss of Skeletal Muscle (Sarcopaenia)

3.  Management of obesity

3.1 Primary Health care Services:

3.2 Capacity building

3.3 Rehabilitation

4.  Secondary Level Health care services

5.  Tertiary Level Health care services

6.  Professional training

Summary

 

Learning O bjectives:

    1.  To understand the concept of obesity

2.  To study obesity among the elderly

3.  To study the prevalence of obesity among adults

4.  To study the management of obesity among adults

 

Introduction

 

1. Overnutrition and Obesity in Older People

 

Obesity is defined as the excess of fat in the body, which increases the risk of medical illness and premature mortality. The prevalence of obesity is increasing in all age groups, including older persons.

 

1.1. Prevalence

 

Obesity is found to show variation in its prevalence among different populations. This phenomenon is most notable in the elderly population, perhaps due to the greater difficulties in correctly obtaining anthropometric measurements in individuals as they grow older. The frequency of overweight in the population 70–79 years varies enormously among countries, from 0% in some Asian and African populations to 35% in Greece (Launer et al., 1996). Other studies that include the elderly from different countries also show a large variability in the prevalence of overweight and obesity in this population group (Villareal et al., 2005).

 

Obesity, particularly abdominal obesity, represents one of the cardiovascular risk factors. Data existing in literature, suggest that the prevalence is more than twice as high at age 55 as at age 20 and t h e most affected are women. However, appropriate treatment and management for obesity in older persons is controversial because of the reduction in relative health risks associated with decreasing body mass index and the concern that weight loss could have potential harmful effects in the older population (Villareal et al., 2004). It is also difficult to accurately measure body fat mass in most clinical settings, it requires the use of sophisticated technologies that are not readily available.

 

Therefore, body mass index ( BMI), calculated as body weight in kilograms (kg) divided by the square of height in metres (m), has been widely used and accepted as a simple method to classify medical risk by weight status (WHO, 1998; NHLBI Expert Panel, 2002; US Department of Health and Human Services, 2000). This index provides a measure of the relatio between height and weight and correlates well with percentage body fat in young and middle-aged adults (Willett et al., 1999).

 

Although it has been suggested that the use of alternative methods to estimate height, such as knee height (Prothro et al., 1993) or arm span (Kwok et al., 1991), may provide more reliable estimates of BMI, these approaches have not been adequately validated. Another limitation of using BMI to estimate disease risk is the effect of ageing on fat distribution. Visceral fat, subcutaneous abdominal fat, intramuscular fat, and intrahepatic fat, which are risk factors for insulin resistance and metabolic diseases, increase with ageing (Beaufrere et al., 2000). Therefore, the size of these depots is likely to be greater in older than in young adults at any given BMI value. The prevalence of obesity (defined as a BMI ≥ 30) in all age categories has increased during the past 25 years in the United States (Kuczmarski et al., 1994; Flegal et al., 1998; Hedley et al., 2004).

 

The number of obese older persons has markedly increased due to an increase in both the total number of older persons and in the percentage of the older population who are obese. In 1991, 14.7% of persons in the United States who were 60–69 years of age and 11.4% of those who were >70 years old were obese (Mokdad et al., 1999). In 2000, the prevalence of obesity in these age groups increased to 22.9% and 15.5%, respectively, which represents increases of 56% and 36%, respectively.According to recent large surveys (Flegel et al., 1998; Mokdad et al., 2001), approximately 71% of Americans 60 years or older and 60% of those 65 years or older were overweight (body mass index, BMI ≥25 kg/m2), while approximately 32% of those 60 years or older and 20% of those 65 years or older were obese (BMI ≥30 kg/m2).

 

Similarly, 29% of 55- to 64-year- olds in England were obese, while 43% of Australians over 65 were overweight and 25% of Australians aged 65–74 years and 14.4% over 75 years were obese (Kopelman, 2000). Not only are many older people overweight or obese, but the rates are increasing rapidly, in parallel with the dramatic increase over recent years in rates in younger adults.

 

For example, the prevalence of obesity (BMI ≥30 kg/m2) among people in the USA over 60 years increased from 20 to 32% between 1988–1994 and 1999–2000 and among those over 70 years from 11.4 to 15.5% between 1991 and 2000. There have been similar increases in other countries (Kopelman, 2000). With ageing, changes in appetite, food intake, energy expenditure and body composition occur.

 

1.2 Appetite and Food Intake among elderly

 

On average, adults become less hungry and eat less as they get older, even if healthy (Guha, 1994). This physiological, age-related reduction in appetite and energy intake has been termed as ‘the anorexia of ageing’ (Shah and Parbhakar, 1997), and appears to have many causes (Purty et al., 2006). Average daily energy intake decreases by up to 30% between 20 and 80 years (Garry et al., 1992). Most of the age related decrease in energy is probably a response to the decline in overall energy expenditure that also occurs as people get older. Changes in body weight and body composition reflect the balance of these two declines. As indicated below, body weight tends to increase through early adult life into middle age, suggesting a more rapid decline in energy expenditure than in food intake during this time. In contrast, body weight tends to decrease in older people, suggesting a faster decline in food intake than in energy expenditure in later life.

 

2. Body Weight and Body Composition among elderly

 

2.1 Body Weight

 

Population studies show that on average people in westernised countries gain weight until they are about 50–60 years old and after that tend to lose weight (Flegel et al., 1998; Mokdad et al., 2001). Although some of the decline in mean body weight after age 50–60 years detected in cross-sectional studies is due to the premature death of obese people, the decline in body weight among older people has also been demonstrated in longitudinal studies. For example, in a 2-year prospective study, community-dwelling American men over 65 years lost on average 0.5% of their body weight per year and 13.1% of the group had weight loss of 4% per annum or more. As a result of this weight loss in older people, and the premature death of obese people at younger ages, the prevalence of overweight and obesity, as defined by standard BMI criteria (BMI ≥25 and ≥30, respectively) peaks around age 50–60 years. It then remains fairly stable until about age 70– 75 years, before decreasing (Stevens et al., 1998).

 

A substantial minority of older people have quite marked weight changes over time. In one study 17% of home-dwelling people in the USA over 65 years lost obesity level in old age ,with 99 5% or more of their initial body weight over 3 years, while 13% gained 5% or more. Other studies provided similar numbers. There is evidence for interactive effects on health of body weight category and change in body weight, particularly of adverse effects in already underweight people who lost weight, and in already overweight people who gained weight. (Newman et al., 2001)

 

2.2 Body Composition

 

2.2.1 Distribution of Fat:

 

With normal ageing there is a progressive increase in fat and decrease in fat-free mass, the latter mainly due to loss of skeletal muscle. Consequently, at any given weight, older people on average, have substantially more body fat than young adults. In one study, the mean body fat of 75-year-old men weighing 80 kg was 29%, compared to 15% in 20-year-old men of the same weight (Baumgartner et al., 1995; Beaufrere and Morio, 2000). The increase in body fat with ageing is multifactorial in origin, with decreased physical activity as a major cause, and contributions from reduced growth hormone secretion, declining sex hormone action and reduced resting metabolic rate and thermic effect of food. Not only do older adults have more body fat than young adults, but it is distributed differently.

 

There is presence of a greater proportion of body fat in older than young people is intrahepatic, intramuscular, and intra-abdominal (versus subcutaneous) (Beaufrere and Morio, 2000) changes that in both young and older adults are associated with increased insulin resistance. For example, in one study intramuscular fat stores were 50% greater, intrahepatic stores four times greater and insulin resistance two times greater in older (65–74 years) than young adults (20–32 years) (Cree et at., 2004). In younger adults, such changes to body fat stores and increases in insulin resistance are associated with adverse metabolic outcomes, including increased rates of diabetes mellitus and cardiovascular disease. It might, therefore, be predicted that the age-related changes in body fat stores would lead to particularly bad metabolic outcomes in older people. This is not proven, however. Given that the body weight compatible with longest survival increases with increasing age, and much if not all of the increase in body weight is due to increased fat stores, it may be that advancing age blunts in some way the harmful effects of increasing body fat. This possibility warrants further study.

 

2.2.2 Loss of Skeletal Muscle (Sarcopaenia:

 

Ageing is associated with a decrease in muscle mass and strength, with loss of up to 3 kg of lean body mass per decade after age 50 years. After age 60 years, loss of body weight is proportionately of lean body tissue, predominantly skeletal muscle. The causes of age-related skeletal muscle loss are multiple and not fully understood, but probably similar to those leading to fat gain, including reduced exercise and anabolic hormone action. The excessive loss of skeletal muscle leads to sarcopaenia.

 

3. Management of obesity

 

India’s health program and policies have been focusing on issues like population stabilization, maternal and child health, and disease control. However, current statistics for the elderly in India gives a prelude to a new set of medical, social, and economic problems that could arise if a timely initiative in this direction is not taken by the program managers and policy makers. There is a need to highlight the medical and socio-economic problems that are being faced by the elderly people in India, and strategies for bringing about an improvement in their quality of life also need to be explored Currently India has excellent health service delivery mechanisms, which are efficient in extending the lives of her people by treating chronic conditions and cancer. However, the question is whether such “improvements” in technology are addressed only to cure ailing population or can India address preventive programs aimed at decreasing the burden of obesity and chronic conditions. Hence, the next big threat to Life Expectancy improvements appears to be stemming from obesity and chronic diseases in middle and old age, which are directly linked to an increased risk for death and morbidity. Attempts to predict life expectancy of Indian population, in terms of whether it is improving or getting worse becomes even more intricate in the absence of scientific data available for such evaluations. (Arora and Bedi, 1989; Reddy, 1996).

 

There is a general agreement that BMI is not the best indicator for defining body fatness. This is because BMI gets altered in old age due to age-dependent changes in numerator and denominator in calculation (Shah and Parabhakar, 1997; Purty et al., 2006). Evidence from studies indicates that obesity and overweight in adulthood are associated with decrease in life expectancy and increase in high incidence of mortality.

 

The Central and State governments have already made efforts to tackle the problem of economic insecurity by launching policies such as the National Policy on Older Persons, National Old Age Pension Program, Annapurna Program, etc. However, the benefits of these programs have been questioned several times in terms of the meager budget, improper identification of beneficiaries, lengthy procedures, and irregular payment (Vijay Kumar, 1995). With a brief overview of the health and socio-economic challenges that are being faced by the elderly population in India, the following strategies may be explored by the program managers of the public health care system to bring about improvement in the quality-of-life of the geriatric population.

 

3.1 Primary Health care Services

 

At present, most of the geriatric outpatient department (OPD) services are available at tertiary care hospitals. Also, most of the government facilities such as day care centers, old age residential homes, and counseling and recreational facilities are urban based. A study conducted to assess the unmet needs of the geriatric population in rural Meerut observed that as many as 46.3% of the study participants were unaware of the availability of any geriatric services near their residence and 96% had never used any geriatric welfare service. About 59% of them stated that the nearest government facility was 3 kilometers from their homes.(Goel, 1999)

 

Since 75% of the elderly reside in rural areas, it is mandatory that geriatric health care services be made a part of the primary health care services. This calls for specialized training of Medical Officers in geriatric medicine. Also, factors such as a lack of transport facilities and dependency on somebody to accompany an elderly person to the health care facility impede them from accessing the available health services. Thus, peripheral health workers and community health volunteers should also be trained to identify and refer elderly patients for timely and proper treatment. An ICMR task force project, which was known as “Health Care of the Rural Aged”, conducted in the Primary Health Center area near Madurai found this strategy to be beneficial. (Rao, 1984)

 

In difficult to access areas, screening camps for cataract and non-communicable diseases and mobile clinics could play a significant role in reaching out to the elderly population. Advocacy with non-governmental organizations (NGOs), charitable organizations, and faith- based organizations could play an important role in this aspect. Premier NGOs like Help Age India have already been organizing screening camps and providing Mobile Medical Units in rural and difficult to access areas.

 

Ensuring good quality geriatric health care services at the primary level would greatly help in improving the utilization rates of the available health services. Health care services should be based on the “felt needs” of the elderly population. This would involve a comprehensive baseline morbidity survey and functional assessment in health areas that are perceived to be important to them. This should be transformed into a community database that would help to prioritize interventions and allocate finances accordingly. The felt needs may vary depending upon gender; socio-economic status as well as differences would exist in the rural and urban areas. Until now, secondary prevention strategies in the form of screening and early management and tertiary care in the form of rehabilitation have been given more importance as compared with primary prevention by the geriatric health care services. Projections made by the World Health Organization (WHO) suggest that by 2015 deaths from chronic diseases such as cancer, hypertension, cardiovascular diseases, and diabetes will increase by 17 percent, from 35 million to 41 million. (WHO, 2005) This calls for a multi-pronged intervention program that should be viable and easily monitored. (Natrajan, 1987) An ideal preventive health package should include various components such as knowledge and awareness about disease conditions and steps for their prevention and management, good nutrition and balanced diet, and physical exercise. For the promotion of a positive mindset and to create a feeling of well being, meditation, prayer, and strategies for motivation should also be included. (Ramamurti and Jamuna, 1993).

 

3.2 Capacity building

 

Capacity building can be done for different groups of health personnel by training of Medical Officers and peripheral health workers. Besides this, an entirely distinct team of health providers known as “Community Geriatric Health Workers” may be trained to provide home care to the disabled elderly population. This strategy has been demonstrated to be successful in a community based project in Cochin, known as “Urban Community Dementia Services” wherein these health workers provide home-based care as well as care in day care centers.(Shaji and Roy, 1999) According to the findings of the 60th NSSO Round, the proportion of aged persons who cannot move and are confined to their bed or home ranges from 77 per 1000 in urban areas to 84 per 1000 in rural areas. Strengthening the elderly in the process of self-help can be done by means of physical, psychosocial, and vocational rehabilitation.

 

Also, capacity building of the community leaders is essential for the success of community- based geriatric and rehabilitative health services. Community leaders can play an important role in identifying the felt needs of the elderly and in resource generation.

 

3.3 Rehabilitation

 

This includes

(i)    provision of visual aids/mobility aids at geriatric health facilities,

(ii)   the availability of physiotherapy services, and

(iii)  imparting health education about staying mobile and providing practical tips.

   Rehabilitation also comprises of provisions for counseling services wherein older persons can benefit from psychological assistance in the face of stressful life events, interpersonal conflicts, and changes imposed by ageing. Under rehabilitation, health care facilities should aim for holistic development by organizing training workshops in accordance with the skills of the elderly. This calls for advocacy with NGOs and charitable organizations. Opportunities for employment should be provided simultaneously.

 

4. Secondary Level Health care services

 

Among the secondary level health facilities, which mainly include the district hospitals, sub-  district, and medium-size private hospitals, it is seen that India has about 12,000 hospitals with 7 lakh beds and most of these are under the public sector (Chaubey, 1999). The need of the hour is to set up geriatric wards that would fulfill the specific needs of the geriatric population by provision of distinct OPD services. Providing screening services as well as curative and rehabilitative services and convalescent homes to provide long-term care, which may be a part of designated hospitals, is also a priority.

 

5. Tertiary Level

 

At the tertiary care level, which comprises of super specialty and medical college hospitals, there needs to be provision of geriatric wards and separate OPDs. A “multi-disciplinary team” specifically trained to meet the needs of the geriatric population need to be created. This team would be comprised of a physician, psychiatrist, orthopaedician, diabetologist, gynecologist, cardiologist, urologist, eye surgeon, psychologist, physiotherapist, dietician, dentist, and nurses trained in geriatric medicine. Elderly patients from poor and low income facilities should be supplied with free or reasonably priced treatment through public-private partnership.

 

Day care hospitals could play an important role in providing close supervision and follow-up of patients with chronic diseases. Moreover, the cost of a day care centre is comparatively less than that of a nursing home. India has very few hospices that can provide terminal patient care. Hospices should be set up at the district level. NGOs, charitable organizations, and faith-based organizations could play an important role in this area. (Chaubey, 1999)

 

6. Professional training

 

There is a need to promote professional training in Geriatrics and Gerontology. Few universities, for example, the Indira Gandhi National Open University, offer a Post-graduate diploma in Geriatric Medicine. There is a need to give emphasis to geriatric medicine in undergraduate medical as well as paramedical courses. Geriatric dentistry should also be developed as a separate, independent specialty at the post-graduate level (Shah, 2005). Research in Geriatrics and Gerontology needs to be further encouraged. An ICMR Workshop on “Research and Health Care Priorities in Geriatric Medicine and Ageing” recommended that research be conducted in areas such as the evaluation of the nutritional and functional status of the elderly, common chronic and neuro-degenerative disorders like Alzheimer’s disease, cardiovascular disorders, depression, etc., basic sciences, dealing with the process of ageing, pharmacokinetics and pharmacodynamics of drugs, health system research and research in alternative medicine. (Shah, 2005) Certain lacunae in the field of research on gerontology have been identified, such as the lack of attention given towards the aged in rural India, failure to view elderly people as active participants in the economy, the perception of older persons as being mere recipients of social welfare services, and a lack of focus on policy recommendations. (Chakraborty, 2001)

 

Summary

 

Obesity is found to show variation in its prevalence among different populations. This phenomenon is most notable in the elderly population. Current trends in demographics coupled with rapid urbanization and lifestyle changes have led to an emergence of a host of problems faced by the elderly in India. Obesity, particularly abdominal obesity, represents one of the cardiovascular risk factors. Data existing in literature, suggest that the prevalence is more than twice as high at age 55 as at age 20 and t h e most affected are women. However, appropriate treatment and management for obesity in older persons is controversial because of the reduction in relative health risks associated with decreasing body mass index and the concern that weight loss could have potential harmful effects. It is also difficult to accurately measure body fat mass in most clinical settings, it requires the use of sophisticated technologies that are not readily available. Evidence from studies indicates that obesity and overweight in adulthood are associated with decrease in life expectancy and increase in high incidence of mortality. Central and State governments have already made efforts to tackle the problem of economic insecurity by launching policies such as the National Policy on Older Persons, National Old Age Pension Program, Annapurna Program, etc. Strategies can be explored by the program managers of the public health care system to bring about improvement in the quality-of-life of the geriatric population. Primary Health care services, capacity building, rehabilitation, secondary health care services, special wards for the old and professional training in geriatric health care are important aspects.

 

Although this paper has mainly focused on the medical problems of the elderly and strategies for improving health care services, it must be remembered that improving the quality-of-life of the elderly calls for a holistic approach and concerted efforts by the health and health-related sectors.

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References

  • Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960 –1994. Int J Obes Relat Metab Disord 1998;22:39 – 47.
  • Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286:119
  • Kopelman PG. Obesity as a medical problem. Nature 2000;404:635– 43. Age care statistics. [cited on 2007 Oct 6]. Available from: http://www.helpageindia.com.
  • Arora VK, Bedi RS. Geriatric Tuberculosis in Himachal Pradesh: A Clinical Radiological Profile. J Assoc Physicians India. 1989;37:205–7. [PubMed]
  • Reddy PH. The health of the aged in India. Health Transit Rev. 1996;6:233–44. [PubMed]
  • Guha R. Morbidity Related Epidemiological Determinants in Indian Aged – An Overview. In: Ramachandran CR, Shah B, editors. Public Health Implications of Ageing in India. New Delhi: Indian Council of Medical Research; 1994.
  • Villareal DT, BanksM, Siener C, Sinacore DR, Klein S. Physical frailty and body composition in obese elderly men and women. Obes Res 2004;12:913–20
  • Shah B, Prabhakar AK. Chronic morbidity profile among elderly. Indian J Med Res. 1997;106:265–72. [PubMed]
  • Purty AJ, Bazroy J, Kar M, Vasudevan K, Veliath A, Panda P. Morbidity Pattern among the elderly population in the rural area of Tamil Nadu, India. Turk J Med Sci. 2006;36:45–50.
  • Garry PJ, Hunt WC, Koehler KM, VanderJagt DJ, Vellas BJ. Longitudinal study of dietary intakes and plasma lipids in healthy elderly men and women. Am J Clin Nutr 1992;55:682– 8.
  • Vijaya Kumar S, editor. Challenges before the elderly: An Indian scenario. New Delhi: M.D. Publications; 1995. [Ref list]
  • Rao Venkoba A. Health care of rural aged. New Delhi: Indian Council of Medical Research; 1984. [Ref list]
  • Preventing chronic disease: A vital investment. Geneva: WHO; 2005. World Health Organization (WHO) [Ref list]
  • Natarajan VS. Geriatrics: A new discipline. Indian J Community Guidance. 1987;4:63–70. [Ref list]
  • Ramamurti PV, Jamuna D. Development and Research on ageing in India. In: Palmore EB, editor. Development and Research on ageing –An International Handbook. West Port: Greenwood Press; 1993. [Ref list]
  • American Psychological Association. Training guidelines for practice in clinical geropsychology. Report of the APA interdivisional task force on qualifications for practice in Clinical and Applied Geropsychology. Draft#8. 1996. [Ref list]
  • Chaubey PC, Vij A. Planning consideration of comprehensive geriatric care in India. J Acad Hosp Admin. 1999;11:22–4. [Ref list]
  • Shah N. Need for gerodontology education in India. Gerodontology. 2005;22:104–5. [PubMed] [Ref list]
  • Shah B. New Delhi: Indian Council of Medical Research; 1999. Report of the workshop on research and health care priorities in geriatric medicine and ageing. [Ref list]
  • Chakraborty F. Contributors of the elderly in an agrarian setting in rural West Bengal: Perspectives on Policy. Paper presented at the Conference “Livelihoods and Poverty Reduction: Lessons from Eastern India; 25-27 September, 2001; Bhubaneswar, India. Organized by Centre for Development Studies, Swansea, United Kingdom, and Institute for Socio economic Development, Bhubaneswar, India and NCCDS, Bhubaneswar, India. [Ref list]
  • Newman AB, Yanez D, Harris T, Duxbury A, Enright PL, Fried LP. Weight change in old age and its association with mortality. J Am Geriatr Soc 2001;49:1309 –18.
  • Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiology of sarcopenia among the elderly in New Mexico1. Am J Epidemiol 1998; 147:755– 6348. Stevens J, Cai J, Pamuk ER, Williamson DF, Thun MJ, Wood JL. The effect of age on the association between body-mass index and mortality. N Engl J Med 1998;338:1–720.
  • Willett WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med 1999;341:427–34. Sorkin JD, Muller DC, Andres R. Longitudinal change in height of men and women: implications for interpretation of the body mass index: the Baltimore Longitudinal Study of Aging. Am J Epidemiol 1999;150: 969 –77.
  • Prothro JW, Rosenbloom CA. Physical measurements in an elderly black population: knee height as the dominant indicator of stature. J Gerontol 1993;48:M15– 88.
  • Kwok T, Whitelaw MN. The use of armspan in nutritional assessment of the elderly. J Am Geriatr Soc 1991;39:492– 6.
  • Beaufrere B, Morio B. Fat and protein redistribution with aging: metabolic considerations. Eur J Clin Nutr 2000;54(suppl):S48 –53.
  • Cree MG, Newcomer BR, Katsanos CS, et al. Intramuscular and liver triglycerides are increased in the elderly. J Clin Endocrinol Metab 2004;89:3864 –71

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