Clinical Context

All healthcare professionals have some responsibility in promoting healthy lifestyles, including appropriate diet and exercise, for our patients, but translating health promotion into health results can be challenging, particularly among older adults. Older adults have more chronic illnesses that might interfere with the ability to follow diet and exercise recommendations. In addition, biases among older adults and their healthcare professionals can result in worse outcomes in the management of conditions such as obesity. There is doubt that diet and exercise can improve health outcomes among older adults with longstanding obesity.

Villareal and colleagues assessed the effects of interventions for diet, exercise, or both vs a control group among adults at age 65 or older with obesity. Their results were published in the March 31, 2011 issue of the New England Journal of Medicine.^[1]

The investigators randomly assigned 107 adults and set the intervention period as one year. The main study outcome was the Physical Performance Test, and all 3 intervention groups performed better than the control group at the end of the study in this outcome; however, the combination of diet and exercise was more potent than either diet or exercise alone for physical performance.

Body weight declined in the diet-exercise and diet-only groups but not in the exercise-only or control groups. There was also an advantage of diet-exercise vs diet-only for lean body mass and bone mineral density, and strength and balance also improved from baseline in the diet-exercise cohort.

These results are enlightening, but can routine interventions to promote weight loss work well among older adults? The current study by Leyden and colleagues examined this issue in a hospital-based obesity service in the United Kingdom.

Study Synopsis and Perspective

Older adults should be recommended for hospital-based lifestyle interventions to reduce weight, say UK investigators after finding there was no difference in weight loss between older and younger individuals in their program for persons with morbid obesity.

Thomas M. Barber, PhD, and colleagues looked back at nearly 250 randomly selected adults who attended their obesity service over an 11-year period.

Older individuals, defined as age 60 years and over, had higher rates of type 2 diabetes (T2D) but experienced a similar percentage weight loss and reduction in body mass index (BMI) as younger patients over the course of around 40 months.

"Age should be no barrier to lifestyle management of obesity," said Barber, of University of Warwick, Coventry, United Kingdom, in a news release from his institution.^[2]

"Rather than putting up barriers to older people accessing weight loss programs, we should be proactively facilitating that process," he advised. "To do otherwise would risk further and unnecessary neglect of older people through societal ageist misconceptions."

He urged service providers and policymakers to "appreciate the importance of weight loss in older people with obesity for the maintenance of health and well-being and the facilitation of healthy aging.

"Furthermore, age per se should not contribute towards clinical decisions regarding the implementation of lifestyle management of older people," he concluded.

The research was published online October 22 in Clinical Endocrinology.^[3]

Real-World Data Will Inform Clinical Practice

Jason Halford, PhD, a professor of biological psychology and health behavior, told Medscape Medical News, "The fear is that older patients are perceived not to respond" to lifestyle interventions to control obesity, "and that's clearly a fallacy, according to this study."

The findings are strengthened by the fact that these are real-world data, "and so it will inform clinical practice," he added.

One of the "more interesting" findings was that [type 2] diabetes was "more prevalent" in the older group, "but they're still losing weight," he noted.

"Traditionally it's been thought that people with [T2D] find it more difficult to lose weight because you're trying to manage two conditions," said Halford, of the University of Leeds, United Kingdom, who is also president-elect of the European Association for the Study of Obesity.

Don't Discount Older Patients

The researchers noted that many of the comorbidities associated with obesity "develop over time" and that "no one is immune to obesity," regardless of their age, sex, ethnicity, and socioeconomic status.

Barber said there are "a number of reasons" why healthcare professionals "may discount weight loss in older people," including "an 'ageist' perspective that weight-loss is not relevant to older people and misconceptions of reduced ability of older people to lose weight through dietary modification and increased exercise."

In addition, "older people may feel that hospital-based obesity services are not for them," he noted.

To determine the effect of age on the ability to lose weight through lifestyle interventions, Barber and colleagues randomly selected 242 patients with morbid obesity who attended their hospital-based service between 2005 and 2016.

Of these, 167 were aged 18 to 60 years and 75 were aged 60 years and older. Most participants were women (75.4% of the younger patients and 60% of the older patients).

The proportion of patients with confirmed diabetes was markedly higher in the older group compared with the younger group, at 62.7% vs 35.3%, although older patients had a significantly lower mean baseline BMI, at 46.9 ± 6.1 kg/m² vs 49.7 ± 8.7 kg/m² (P < .05).

The mean duration of the lifestyle intervention was more than 3 years (41.5 ± 33.1 months) in the younger patients and 33.6 ± 30.1 months in the older patients.

There was no significant difference in percentage weight loss between younger and older patients, at 6.9% ± 16.7% and 7.3% ± 11.6%, respectively, and no difference in percentage reduction in BMI, at 8.1% ± 14.9% vs 7.8% ± 11.7%.

Further analysis demonstrated no significant correlation between age at referral to the hospital-based service and percentage weight loss (correlation coefficient, –0.13).

Halford said it would have been "useful" to know the proportion of patients achieving 5% and 10% weight loss because if a third of patients lost more than 10% of their weight, "even in an elderly population, that would suggest there'd be real benefits in terms of things like [T2D]," he noted.

He would like to have seen more data around how long participants had been struggling with obesity, as it is "just an assumption that the second group is further down the path because they're older, but we can't be 100% sure."

The team noted the study is limited by being retrospective and including a random selection of patients attending the service rather than the entire cohort.

Halford agreed but said the analysis is a "starting point" and could be used as a platform to conduct "much more systematic research on this area."

No funding or relevant financial relationships were declared.

Clinical Implications

• In a trial by Villareal and colleagues of older adults with obesity randomly assigned to diet plus exercise, exercise-only, diet-only, and control groups, the combination of diet and exercise was more potent than either diet or exercise alone for physical performance. Body weight declined in the diet-exercise and diet-only groups but not in the exercise-only or control groups. There was also an advantage of diet-exercise vs diet-only for lean body mass and bone mineral density.
• In the current study by Leyden and colleagues, a lifestyle intervention program was similarly effective in promoting weight loss and reducing BMI among younger and older adults.
• The healthcare team should reinforce the importance of diet and exercise to older adults with overweight and obesity and proactively encourage participation in programs that encourage healthy lifestyle modification for weight loss.

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