Sarcopenic Obesity and Cardiovascular Disease in Older Adults

Editor's Note: Please see the associated Expert Analysis here.

Obesity rates defined using body mass index (BMI) exceed 40% in adults aged 65 years and older.1 However, BMI is a poor measure for the ascertainment of adiposity because its sensitivity drops markedly with increasing age.2 Most significantly, BMI fails to account for body composition changes with aging, specifically the age-related decline in muscle mass, strength and function termed sarcopenia.3 Sarcopenic obesity, defined as low muscle mass or muscle weakness, in the presence of obesity, has been shown to be associated with functional impairment and is strongly associated with cardiovascular disease (CVD).4,5 This association is due, in part, to intramyocellular deposition and central fat distribution that promote inflammation and can lead to frailty,6 itself a risk factor for CVD.

Epidemiologically, both sarcopenia and obesity have been independently associated with changes in cardiovascular risk factors and cognitive function.7,8 Few studies have evaluated the synergistic combination of sarcopenia and obesity with changes in cognitive function. Recognition of cognitive impairment is critically important in shared-decision making, informed consent, advanced care planning and its interplay with functional status. Therefore, the routine assessment of cognitive assessment in persons with sarcopenic obesity has now become incorporated into the Annual Wellness Visit for older adults.

Clinicians evaluating older adults should be mindful of the limitations of BMI and be aware that other anthropometric measures such as waist circumference can enhance predictive ability for adverse outcomes.2 Ascertainment of muscle strength in clinical practice is feasible; a hand dynamometer is affordable (~$200) and it takes less than 3 minutes to test grip strength. This allows identification of those with sarcopenic obesity who are at higher risk for adverse outcomes, including CVD, institutionalization and stroke. Engaging and referring individuals to multidisciplinary programs focusing on nutritional habits and specifically resistance training has been shown to improve functional capacity, even in frail older adults with considerable multimorbidity.9 While enhancing aerobic capacity is important, the combination of aerobic and resistance training is synergistic and both modalities should be encouraged. This differs from conventional cardiac rehabilitation, which predominantly focuses on aerobic function and suggests the need to either modify or augment existing approaches in this population. Future research should evaluate the relationship of sarcopenic obesity to important geriatric-specific outcomes such as cognition, institutionalization and quality of life.

References

  1. Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 2015-2016. JAMA 2018;319:1723-1725.
  2. Batsis JA, Mackenzie TA, Bartels SJ, Sahakyan KR, Somers VK, Lopez-Jimenez F. Diagnostic accuracy of body mass index to identify obesity in older adults: NHANES 1999-2004. Int J Obes (Lond) 2016;40:761-7.
  3. Sayer AA, Syddall H, Martin H, Patel H, Baylis D, Cooper C. The developmental origins of sarcopenia. J Nutr Health Aging 2008;12:427-32.
  4. Baumgartner RN, Wayne SJ, Waters DL, Janssen I, Gallagher D, Morley JE. Sarcopenic obesity predicts instrumental activities of daily living disability in the elderly. Obes Res 2004;12:1995-2004.
  5. Stephen WC, Janssen I. Sarcopenic-obesity and cardiovascular disease risk in the elderly. J Nutr Health Aging 2009;13:460-6.
  6. Batsis JA, Villareal DT. Sarcopenic Obesity in Older Adults: Definition, etiology, epidemiology, treatment and future directions. Nature Reviews Endocrinology (in press) 2018.
  7. Abellan van Kan G, Cesari M, Gillette-Guyonnet S et al. Sarcopenia and cognitive impairment in elderly women: results from the EPIDOS cohort. Age Ageing 2013;42:196-202.
  8. LeBlanc ES, Rizzo JH, Pedula KL et al. Weight Trajectory over 20 Years and Likelihood of Mild Cognitive Impairment or Dementia Among Older Women. J Am Geriatr Soc 2017;65:511-519.
  9. Villareal DT, Aguirre L, Gurney AB et al. Aerobic or Resistance Exercise, or Both, in Dieting Obese Older Adults. N Engl J Med 2017;376:1943-1955.

Clinical Topics: Geriatric Cardiology

Keywords: Geriatrics, Waist Circumference, Sarcopenia, Body Mass Index, Adiposity, Risk Factors, Frail Elderly, Cardiac Rehabilitation, Quality of Life, Obesity, Body Composition, Inflammation, Stroke, Delirium, Dementia, Amnestic, Cognitive Disorders


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