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When Thinner Isn't Better

Extra pounds may keep some people healthier after a certain age

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While the obesity epidemic rages on — with about 40 percent of American adults meeting the criteria for being seriously overweight — there's a lesser known flip side to weight and health concerns. And it starts around age 80.

"While obesity is the number one risk factor for people in middle age to early old age, adults over 80 face a different set of challenges,” explains Barbara Nicklas, professor of internal medicine at Wake Forest School of Medicine.

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As she explains it, obesity-related conditions including heart disease, stroke, type 2 diabetes and certain types of cancer are some of the leading causes of preventable premature death for those in middle age. But those who survive to age 80, such risk factors start to go down.

And so, too, may the number you're seeing on the scale. While people naturally tend to gain weight up until age 75 or 80, over age 80 they tend to decrease in weight, Nicklas explains.

The ideal body mass index (BMI) for people over 64, experts agree, is between 24 to 29. “But the mortality curve certainly shows the advantage to being at the top of that range,” Nicklas says, or even slightly over a BMI of 30 — defined as obese — once you hit age 80.

"The BMI curve shifts to the right as you age,” Nicklas explains, “meaning higher weight is better in older age.” Those extra pounds buffer against unintended weight loss due to digestive system conditions (or things like dental issues) that prevent people from eating enough. They can also offer protection from heart failure or COPD (chronic obstructive pulmonary disease). And extra padding can help prevent life-threatening fractures if an older old person falls.

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What's more, “if you're really thin, then you lose weight in your 80s, you are at risk of becoming frail,” says David Reuben, a specialist in geriatric internal medicine at UCLA Medical Center in Santa Monica, Calif. (Frailty is a clinical syndrome in which three or more of the following criteria are present: unintentional weight loss of 10 pounds in a year; self-reported exhaustion; weakness; slow walking speed; and low physical activity). If you're over 80 and have a BMI below 20, Reuben says, you're in the frailty zone.

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But there may, in some cases, be a little nuance involved in defining what's too thin. Erin Michos, associate professor of medicine at Johns Hopkins University School of Medicine, followed 6,000 patients over 13 years and found that it's important to look at the entire lifetime trajectory of weight in order to assess incremental risk. For example, significant unintentional weight loss at later ages needs to be evaluated regardless of a person's starting weight.

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Body composition is also important. Nicklas explains that the normal lifetime weight gain and loss trajectory is somewhat bell-shaped, but that this same gradual curve doesn't apply to the loss and gain of muscle and fat. We naturally lose muscle continuously as we age. And gain fat. So our body composition as we age becomes worse, “and that isn't likely to shift back.”

In fact, as we start to lose weight in our 80s, muscle loss may even accelerate. That condition is called sarcopenia — the loss of muscle mass and muscle quality, coupled with a decrease in bone density. And it puts people over 80 at increased risk of functional limitations, fractures from falls and disabilities. Women are at a higher risk of such disability than men, probably because they have a lower percentage of muscle mass and higher percentage of body fat to begin with.

That's why most scientists advise against putting people over 80 with normal or slightly obese BMIs on calorie-restricted diets. They may suffer loss of muscle mass and bone density that they may not be able to restore. “This is a big driver of age-associated disability,” says Douglas Seals, a professor in the Department of Integrative Physiology at the University of Colorado.

Many scientists are studying how the older old age body synthesizes protein, and the best way for those over 80 to maximize protein intake to minimize muscle loss. But, Seals says, there are no ready answers yet.

The best prescription we now have to preserve muscle mass in older adults, Seals adds, is to eat at least three meals a day that provide 30 grams of protein each, and to do two or three weekly sessions of resistance training that taxes all the large muscle groups. “That might be a circuit-based resistance training program where the person does 10 to 12 repetitions per set, over two or three sets.” Beyond that, experts advise walking to maintain mobility.

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