譯者：高雄醫學大學附設中和紀念醫院婦產部主治醫師 盧紫曦

摘要

運動和基本體重減少>5%的醫療策略可以改善老年肥胖相關的合併症和心血管疾病[1]。肥胖的定義是為男性和女性的體重指數（Body mass index, BMI）大於30 kg / m2。同時結合飲食控制和運動，比單獨運動活動或飲食控制有更好的成效。肥胖與代謝症候群、第二型糖尿病，心房顫動，認知能力下降，靜脈栓塞和睡眠呼吸暫停等有相關聯。傍晚或夜間進食會影響代謝，因為主餐的時間和營養成分有助於建立晝夜節律。 將主餐從晚上轉換到早上(早餐大份量和晚上小份量進食)是一個可改善肥胖和第二型糖尿病的潛在減重策略。間歇性禁食：將攝入的食物延遲排空到到隔夜並禁食長達14小時，對減重有一定的效果[2]。間歇性禁食從動物實驗中證實可減少認知功能的下降，並可用於預防老年性癡呆症[2]。同時結合運動和飲食調整可以達到客製化的減肥目標。改善健康的建議包括：飲食調整和每週少至150分鐘的運動(包括有氧運動，肌肉訓練，伸展運動和平衡及協調運動)。 醫療保健提供者需衛教老年人需要持之以恆的運動，以達到減重，運動耐受力和健康情況的改善。

評論

Buch等人的評論論文[1]是處理任何年齡肥胖症的必讀論文。作者針對肥胖的老年人，提出建議應該積極治療，以減少肥胖相關的發病率和死亡率[1]。 雖然這篇論文是針對老年人，但任何年齡的肥胖預防和健康策略都應該利用這些建議。通過運動和飲食可以改善健康，而雖然老年人年齡較大，但還是可以考慮進行減肥手術，並不會增加手術風險。 老年人肥胖通常與肌少症有關，肌肉流失而導致進一步的身體功能損失，並且需要更大的生活協助[5]。為了減少代謝和身體功能方面的喪失，需要採取個人化的預防措施：包括攝取高蛋白質飲食、維生素D、微量營養素（維生素和礦物質）、運動和低熱量飲食，以防止骨質流失和肌肉萎縮[1，6，7]。該功能表設計可以滿足患者的特定需求和條件。 這為老年人提供的概念也可以推廣到任何年齡的肥胖管理。重要的是，在65歲以前就開始進行健康管理，可進一步降低發病率和隨著年齡增長的潛在死亡率。 肥胖不只限於老年人，事實上它存在於所有年齡層。肥胖是一種慢性疾病，應該立即積極處理以及使用個人化的治療計畫。論文中也介紹了其他的的減重方式，例如使用 GLP1 抑製劑（例如liraglutide 和semaglutide）。 這些藥物會增加飽足感，並減輕體重。 縮胃手術或胃繞道手術可以在任何年齡進行，特別是在老年人中，並不會明顯增加發病率和死亡率。 使用手術減重的決定應在個人生活行為模式調整或使用藥物治療無效後再考慮進行。老年肥胖者的最佳成效是個人化治療：包括飲食調整和日常身體活動（運動），以達到減肥目標並改善身心功能。

Summary

A medical strategy of exercise and a loss of >5% from baseline weight can improve the co-morbidities and cardiovascular diseases associated with elderly obesity as addressed by Buch et al. [1]. Obesity has been defined as a body mass index (BMI) of >30 k/m2 in men and women and elderly as an age >65. The combination of weight loss and physical activity results in a better outcome than physical activity or diet alone.  Obesity is associated with the metabolic syndrome, type 2 diabetes (T2D), atrial fibrillation, cognitive decline, thromboembolic events, and sleep apnea, just to mention a few. Aging obese individuals are also at risk for frailty, impaired mobility, and disability due to sarcopenia and the metabolic effects of obesity. These physical and metabolic alterations impact individual quality of life. There are also disrupted circadian rhythms and sleep disturbances linked to poor health outcomes.  Late evening or nighttime eating can affect metabolic tissue systems because the timing and nutritional content of the main meal contributes to establishing circadian rhythms.  Converting the main meal from evening to morning [morning large and evening small] is a potential strategy for weight loss and the improvement of obesity and T2D.  Intermittent fasting, by delaying food intake beyond the overnight fast for up to 14 hours, has been described as effective for weight loss [2]. Intermittent fasting reduces cognitive decline in small animals and could be useful in preventing senile dementia [2]. Intermittent fasting can decrease inflammation and potentially increase autophagy in the brain [3,4]. Bariatric surgery can accelerate weight loss in the elderly without evidence of increased surgical complications compared to younger individuals.  Dietary alterations from these interventions affect multiple indices of health and result in a deceleration of aging with increased longevity.  The combination of exercise and a patient specific dietary modification can result in achieving individual weight loss goals.  The recommendation to improve health includes dietary intervention and physical activity of as little as 150 minutes per week that include aerobic exercise, muscle strength, flexibility and balance.  The health care provider needs to counsel the elderly that continued motivation and consistency is required to demonstrate improvement in weight loss, exercise tolerance and general health.

Commentary

The commented paper of Buch et al. [1] is a must read for managing obesity at any age. Authors address elderly individuals who are obese who could and should be aggressively treated to reduce the morbidity and mortality associated with obesity [1]. Although the manuscript targets the elderly a preventive health strategy for obesity at any age should utilize these recommendations. Improvements in function and health can be noted with exercise and diet, while a bariatric surgical intervention could be considered with limited to no increase in risk despite the elderly person’s age. The increase in obesity in the elderly is often associated with sarcopenia, a loss of muscle mass that contributes to further functional physical impairment and the need for greater assistance in normal living [5]. To negate these aspects of metabolic and physical decline an individual intervention is required with a planned approach that includes dietary protein, vitamin D, micronutrients (vitamins and minerals), exercise, and a low-calorie diet to prevent bone loss and muscle wasting [1,6,7]. This menu can be designed to address the specific patient needs and conditions.  The concepts presented for the elderly can be generalized to obesity at any age. Foremost is that initiating intervention at an earlier age than 65 should further reduce morbidity and potential mortality with increasing age.  Obesity is not limited to elderly individuals, in fact it exists at all ages and is a chronic condition that should be immediately addressed with a comprehensive and individualized care plan. Other therapeutic interventions for weight loss are presented in the manuscript such as the use of GLP1 inhibitors (i.e liraglutide and semaglutide). These drugs increase saity (the feeling of fullness) and can result in significant weight loss.  Gastric banding or a gastric bypass can be performed at any age and especially in the elderly without apparent increase in morbidity and mortality.  The decision to use a surgical approach should be done after careful consideration of the individual and their efforts to improve with behavioral and medical interventions as first line treatment.  The best outcome for the elderly obese person is an individualized approach that includes dietary modification with daily body movement (exercise) to accomplish the goal of weight loss and improve physical and mental function.

References

1.Buch A, Marcus Y, Shefer G, Zimmet P, Stern N. Approach to Obesity in the Older Population. J Clin Endocrinol Metab. 2021;106(9):2788-2805.

https://pubmed.ncbi.nlm.nih.gov/34406394/

2.de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381(26):2541-2551.

https://pubmed.ncbi.nlm.nih.gov/31881139/

3.Eshraghi M, Adlimoghaddam A, Mahmoodzadeh A, et al. Alzheimer's Disease Pathogenesis: Role of Autophagy and Mitophagy Focusing in Microglia. Int J Mol Sci. 2021;22(7):3330.

https://pubmed.ncbi.nlm.nih.gov/33805142/

4.Festa BP, Barbosa AD, Rob M, Rubinsztein DC. The pleiotropic roles of autophagy in Alzheimer's disease: From pathophysiology to therapy. Curr Opin Pharmacol. 2021;60:149-157.

https://pubmed.ncbi.nlm.nih.gov/34419832/

5.Colleluori G, Villareal DT. Aging, obesity, sarcopenia and the effect of diet and exercise intervention. Exp Gerontol. 2021;155:111561.

https://pubmed.ncbi.nlm.nih.gov/34562568/

6.Bičíková M, Máčová L, Jandová D, Třískala Z, Hill M. Movement as a Positive Modulator of Aging. Int J Mol Sci. 2021;22(12):6278.

https://pubmed.ncbi.nlm.nih.gov/34208002/

7.McCarthy D, Berg A. Weight Loss Strategies and the Risk of Skeletal Muscle Mass Loss. Nutrients. 2021;13(7):2473.

https://pubmed.ncbi.nlm.nih.gov/34371981/