V. Di Francesco

Health consequences of obesity in the elderly: a review of four unresolved questions

Obesity prevalence is growing progressively even among older age groups. Controversy exists about the potential harms of obesity in the elderly. Debate persists about the relation between obesity in old age and total or disease-specific mortality, the definition of obesity in the elderly, its clinical relevance, and about the need for its treatment. Knowledge of age-related body composition and fat distribution changes will help us to better understand the relationships between obesity, morbidity and mortality in the elderly. Review of the literature supports that central fat and relative loss of fat-free mass may become relatively more important than BMI in determining the health risk associated with obesity in older ages. Weight gain or fat redistribution in older age may still confer adverse health risks (for earlier mortality, comorbidities conferring independent adverse health risks, or for functional decline). Evaluation of comorbidity and weight history should be performed in the elderly in order to generate a comprehensive assessment of the potential adverse health effects of overweight or obesity. The risks of obesity in the elderly have been underestimated by a number of confounders such as survival effect, competing mortalities, relatively shortened life expectancy in older persons, smoking, weight change and unintentional weight loss. Identification of elderly subjects with sarcopenic obesity is probably clinically relevant, but the definition of sarcopenic obesity, the benefits of its clinical identification, as well as its relation to clinical consequences require further study. Studies on the effect of voluntary weight loss in the elderly are scarce, but they suggest that even small amounts of weight loss (between 5–10% of initial body weight) may be beneficial. In older as well as in younger adults, voluntary weight loss may help to prevent the adverse health consequences of obesity.

Physical disability and muscular strength in relation to obesity and different body composition indexes in a sample of healthy elderly women

OBJECTIVES: The aim of the present study was to test the association between muscular strength, functional limitations, body composition measurements and indexes of sarcopenia in a sample of community-dwelling, elderly women at the high end of the functional spectrum.DESIGN: Cross-sectional.SUBJECTS: In all, 167 women aged 67–78 y were selected from the general population in central Verona. A group of 120 premenopausal healthy women aged 20–50 y represented the young reference group.MEASUREMENTS: Body weight, height, body mass index (BMI) and the presence of acute and chronic conditions were evaluated in each subject. Body composition was measured by dual-energy X-ray absorptiometry (DXA). Physical functioning was assessed using a modified version of the Activities of Daily Living Scale. Dominant leg isometric strength was measured with a Spark Handheld Dynamometer.RESULTS: Elderly women with BMI higher than 30 kg/m2 and in the highest quintile of body fat percent showed a significantly higher prevalence of functional limitation. In our population study, about 40% of sarcopenic elderly women and 50% of elderly women with high body fat and normal muscle mass were functionally limited. The prevalence of functional limitation significantly increased in subjects with class II sarcopenia, defined according to the skeletal muscle mass index (SMI=skeletal muscle mass/body mass × 100). In logistic regression models, after adjusting for age and different chronic health conditions, subjects with BMI higher than 30 kg/m2, in the highest quintile of body fat, or with high body fat and normal muscle mass or class II sarcopenia according to SMI, had a 3–4 times increased risk of functional limitations. Finally, isometric leg strength was significantly lower in subjects in the lowest quintile of relative muscle mass and in sarcopenic and sarcopenic obese women.CONCLUSIONS: High body fat and high BMI values were associated with a greater probability of functional limitation in a population of elderly women at the high end of the functional spectrum. Among the different indexes of sarcopenia used in this study, only SMI predicted functional impairment and disability. Isometric leg strength was significantly lower in subjects with sarcopenia and sarcopenic obesity.

Alcohol and Smoking as Risk Factors in Chronic Pancreatitis and Pancreatic Cancer

The aim of this study was to compare alcohol andsmoking as risk factors in the development of chronicpancreatitis and pancreatic cancer. We considered onlymale subjects: (1) 630 patients with chronic pancreatitis who developed 12 pancreatic and 47extrapancreatic cancers; (2) 69 patients withhistologically well documented pancreatic cancer and noclinical history of chronic pancreatitis; and (3) 700 random controls taken from the Verona pollinglist and submitted to a complete medical check-up.Chronic pancreatitis subjects drink more than controlsubjects and more than subjects with pancreatic cancer without chronic pancreatitis (P < 0.001).The percentage of smokers in the group with chronicpancreatitis is significantly higher than that in thecontrol group [odds ratio (OR) 17.3; 95% CI 12.6-23.8; P < 0.001] and in the group with pancreaticcarcinomas but with no history of chronic pancreatitis(OR 5.3; 95% CI 3.0-9.4; P < 0.001). In conclusion,our study shows that: (1) the risk of chronic pancreatitis correlates both with alcoholintake and with cigarette smoking with a trendindicating that the risk increases with increasedalcohol intake and cigarette consumption; (2) alcoholand smoking are statistically independent risk factors forchronic pancreatitis; and (3) the risk of pancreaticcancer correlates positively with cigarette smoking butnot with drinking.

Waist circumference and abdominal sagittal diameter as surrogates of body fat distribution in the elderly: their relation with cardiovascular risk factors

OBJECTIVE: To evaluate the relationship between supine sagittal abdominal diameter (SAD) and other indicators of body fat distribution with cardiovascular (CVD) risk factors in the elderly.SUBJECTS: One-hundred and forty-six women aged from 67 to 78 y with a body mass index (BMI) ranging from 18.7 to 50.6 kg/m2 and 83 men aged between 67 and 78 y with BMI ranging from 19.8 to 37.1 kg/m2.MEASUREMENT: Body fat distribution was assessed using anthropometric indicators: waist circumference, SAD, waist-to-hip ratio (WHR), waist-to-height ratio and SAD-to-thigh ratio.RESULTS: In women, there was a negative correlation between HDL-cholesterol and body weight, BMI, waist, SAD, WHR, waist-to-height ratio and SAD-to-thigh ratio. A significant association was found between triglycerides, basal glucose, 2 h glucose during oral glucose tolerance test (OGTT), systolic blood pressure (SBP), diastolic blood pressure (DBP) and anthropometric variables. In men a negative correlation was found between HDL-cholesterol and all the anthropometric variables. A significant association was found between triglycerides, DBP and body weight, BMI, waist, SAD and waist-to-height ratio. In women, after adjusting for age and BMI, a significant correlation was observed between waist and HDL-cholesterol, triglycerides and basal glucose. This was also seen with SAD and SAD-to-thigh ratio and triglycerides, basal and 2 h glucose. In men, after adjusting for age and BMI a significant correlation was found between SAD and HDL-cholesterol and triglycerides. When adjustments were made for age and waist, the correlations between BMI and metabolic variables as well between BMI and SBP and DBP were no longer significant.CONCLUSIONS: Our study shows that indicators of body fat distribution are associated with CVD risk factors in the elderly independently of BMI. Our data also show that waist and SAD are the anthropometric indicators of fat distribution which are most closely related to CVD risk factors in old age.

Cigarette smoking : an independent risk factor in alcoholic pancreatitis

It is not known whether cigarette smoking plays a role as a risk factor in alcoholic pancreatitis. The aim of this study was to compare drinking and smoking habits in three groups of male subjects with an alcohol intake in excess of 40 g/day: (i) 67 patients with acute alcoholic pancreatitis, without other known potential causative agents; (ii) 396 patients with chronic alcoholic pancreatitis; and (iii) 265 control subjects randomly selected from the Verona polling lists and submitted to a complete medical checkup. The variables considered were age at onset of disease, years of drinking and smoking, daily alcohol intake in grams, number of cigarettes smoked daily, and body mass index (BMI). Cases differed from controls in daily grams of alcohol, number of cigarettes smoked and BMI (Mann-Whitney U test, p < 0.00001 for each comparison). Multivariate logistic regression analysis, comparing acute and chronic cases, respectively, versus controls, revealed an increased relative risk of pancreatitis in the two comparisons, associated in both cases with a higher alcohol intake (p < 0.00001) and cigarette smoking (p < 0.00001). No significant interaction between alcohol and smoking was noted, indicating that the two risks are independent. In conclusion, in males a higher number of cigarettes smoked daily seems to be a distinct risk factor in acute and chronic alcoholic pancreatitis.

Effect of alcohol and smoking on pancreatic lithogenesis in the course of chronic pancreatitis.

The aim of the study was to establish whether correlations were discernible between calcification, smoking, and other variables—including alcohol intake—in chronic pancreatitis. A total of 637 patients with chronic pancreatitis diagnosed over the period of 1973—1989 were reviewed. Only patients who had had one or more instrumental tests (ultrasonography, endoscopic retrograde cholangiopancreatography, computed tomography, plain film of the abdomen) every 3 years were included in the study. Onset of calcification was taken as the end point of the follow-up. No statistically significant correlation was found between alcohol intake and calcification. As regards smoking habits, patients were divided into two groups: nonsmokers and medium-to-heavy smokers (210 cigarettedday). Of 637 patients, only 570 fulfilled our criteria. Three hundred seventy-six patients (66%) developed calcifications, whereas 64 (10%) already presented calcifications at the time of diagnosis. Smoking correlated with formation of calcifications (p < 0.004). The mean time to onset of calcification in smokers was 8 years as against 12 years in nonsmokers. The relative risk of calcification in smokers versus nonsmokers was 1.21 (95% confidence limits: 1.10-1.32). By the end of follow-up (17 years), 277 smokers (69%) with chronic pancreatitis had developed calcifications compared with only 93 nonsmokers (55%). The results show that, in this sample of chronic pancreatitis sufferers, smokers present a significantly increased risk of developing calcifications.

Long-term follow-up of patients with chronic pancreatitis in Italy.

BACKGROUND We investigated the epidemiologic, clinical, and radiologic aspects of a mixed medicosurgical series of chronic pancreatitis patients observed at the University of Verona Centre for the Study of Pancreatic Diseases over the period 1971-1995. METHODS Even though the pathogenesis of chronic pancreatitis has yet to be clarified and the classification is still debatable, the patients were subdivided in accordance with the Marseilles-Rome classification into those with alcoholic, obstructive, familial, and idiopathic forms of the disease. A total of 715 patients were analysed with a median follow-up period of 10 years (range, 1-25 years). RESULTS AND CONCLUSIONS At the end of follow-up the dropout rate amounted to 7.1% (51 patients), and 176 patients (24.6%) had died. Data are reported about the type of chronic pancreatitis, sex, and age distribution at the onset of the disease, drinking and smoking habits before onset and during follow-up, and incidence of calcifications, pain, diabetes, steatorrhoea, and pseudocysts. Surgical aspects, survival curves, and causes of death are also analysed, and the most frequent concomitant diseases in chronic pancreatitis sufferers are discussed.

Comparison of Ultrasound-Secretin Test and Sphincter of Oddi Manometry in Patients with Recurrent Acute Pancreatitis

Manometry is considered the gold standard forevaluating sphincter of Oddi dysfunction. It hasrecently been demonstrated that the ultrasound (US)secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddidysfunction yields a substantial percentage ofpathological findings in patients with acute recurrentpancreatitis. The aim of this study was to compare theresults of the US secretin test with sphincter of Oddimanometry findings in a consecutive series of patientswith recurrent acute pancreatitis. Forty-seven patientsadmitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwentultrasonographic measurement of the main pancreatic ductat baseline and for 60 min after maximal stimulationwith secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects,the test results were considered to indicate pathologywhen the duct was still dilated after 20 min. Withinthree to seven days the same patients underwent perendoscopic manometry. Thirty-six patients(17 men, 19 women; mean age 41 ± 15 years) had asuccessful US secretin test and sphincter of Oddimanometry. Eleven patients (30.6%) presented normalmanometric findings. Two of these had an abnormal USsecretin test. Twenty-five patients had abnormalmanometry findings, revealing stenosis in 19 (52.7%) (17with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test).Compared to manometry findings, the US secretin testsensitivity and specificity for sphincter of Oddidysfunction were 88% and 82%, respectively. Inconclusion, most patients with recurrent acute pancreatitishave sphincter of Oddi dysfunction documented by both atthe US secretin test and sphincter of Oddi manometry;results of the US secretin test are reliable compared to sphincter of Oddi manometry, andtherefore the US secretin test may offer a validalternative to the more expensive and invasivemanometric procedure for assessing sphincter of Oddidysfunction in patients with recurrent acutepancreatitis.

The Anorexia of Aging

Malnutrition in the elderly is one of the greatest threats to health, well-being and autonomy, it is therefore crucial to understand and to contrast the causal factors of inadequate energy intake. This review focuses on the mechanisms of the so-called ‘anorexia of aging’. In recent years, it has been shown that elderly subjects have abnormal peripheral signal patterns and alterations in central hypothalamic control relays. Negative feedback from impaired gastric motility, exaggerated long-term adiposity signals (leptin, insulin) and postprandial anorexigenic signals (CCK, PYY) seem to prevail over the central feeding drive. If nutritional strategies of intervention are to be improved, these data need to be taken into account.

Body composition and pulmonary function in the elderly: a 7-year longitudinal study.

Objective:To evaluate over a 7-year follow-up period the relationships between changes in body composition, fat distribution and pulmonary function in a sample of elderly men and women.Design:Longitudinal clinical study.Subjects:A total of 47 women and 30 men aged 71.6±2.3 and 71.7±2.2 years, respectively, at baseline with body mass index (BMI) values of 24.96±3.28 and 27.04±3.35 kg m−2 were followed for 7 years.Measurements:Body weight, waist circumference, sagittal abdominal diameter (SAD), fat-free mass (FFM) and fat mass as measured by dual energy X-ray absorptiometry (DXA) and forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) by spirometry were evaluated at baseline and after a 7-year mean follow-up.Results:In women as in men there were no significant changes in weight, SAD and BMI. A significant decrease in height and FFM was observed in both women and men. Height-adjusted FEV1 and FVC decreased significantly in women and men over the 7-year follow-up. Changes in SAD were the most powerful predictors of 7-year follow-up of FEV1 and FVC after taking into account, respectively, baseline FEV1 and FVC. Linear regression analysis, performed by using 7-year follow-up lung function variables as dependent variables and changes in body composition variables as independent variables, showed that 1 cm SAD increase predicted a decrease in FEV1 and FVC of 31 and 46 ml, respectively, and 1 kg FFM decrease predicted a decrease in FVC of 38 ml. After subdividing our study population into four categories of change in FFM and SAD, patients with decreased FFM and increased SAD showed the highest probability of having a worsening in FEV1 and FVC.Conclusion:Increase in abdominal fat and FFM decline are significant predictors of lung function decline in the elderly. Old subjects developing both abdominal fat gain and FFM loss show the highest probability of developing worsening in lung function.