A geriatrician's approach to managing the complex older adult with obesity.

Study Importance

What is already known?

Evidence to treat obesity in older adults has been accumulating since 2016, and it had previously been debatable.

Intensive lifestyle intervention (ILI) remains foundational, with pharmacotherapy and bariatric surgery as adjuncts to weight loss as part of a comprehensive obesity treatment plan.

Management in older adults requires the co‐management of multiple obesity‐related chronic conditions, as well as functional and mobility impairment, while addressing obesity.

What does this review add?

Older adults with obesity need an age‐ and obesity‐friendly “What Matters, Medication, Mentation, and Mobility” (4Ms) approach across care settings.

Obesity accelerates aging, which highlights the need for a tailored, personalized, and holistic approach when done sequentially with ILI for an initial period followed by antiobesity medications in individuals in whom they are deemed appropriate.

How might these results change the direction of the research or the focus of clinical practice?

This review will serve as a clinical reference to practitioners who are providing care to this growing segment of older adults with obesity.

This will enable clinicians to help older adults achieve clinically meaningful weight‐loss goals to reduce comorbidity burden and improve function and quality of life.

INTRODUCTION

Obesity is rising among older adults and has reached a prevalence of 41% among adults aged 60 years and older [ 1 ]. Obesity is a chronic, relapsing, progressive, neurobehavioral, and degenerative multisystem disease [ 2 ] linked to more than 200 chronic conditions such as hypertension, dyslipidemia, cardiovascular and pulmonary diseases, diabetes, stroke, cancer, osteoarthritis (OA), and psychosocial conditions [ 3 ]. Obesity also accelerates the aging process, impacting quality of life and exaggerating the loss of muscle mass and strength, which leads to disability, impaired function, and decreased life expectancy [ 4 , 5 ]. Cumulative disease burden worsens with aging, posing a challenge to the aging community and its health care providers. Older adults with obesity would benefit from an age‐friendly, patient‐aligned, obesity‐centered approach, as studies show that obesity care among patients with multiple chronic conditions is suboptimal [ 6 ].

Obesity is diagnosed using body mass index (BMI), despite its impreciseness, due to its ease as a practical measure compared to body composition. BMI is calculated as weight in kilograms divided by height in meters squared. BMI is a less accurate indicator in older individuals due to loss of height and muscle mass, as well as its limitations in identifying visceral adiposity and alteration in body composition [ 7 ]. Waist circumference is a more sensitive indicator of visceral adiposity signifying cardiovascular risk in older adults [ 8 ]. The specific BMI categories as per the World Health Organization are shown in Table 1 . The surgical community further classifies obesity into “super obesity” for BMI > 50 kg/m 2 and "super‐super obesity" for BMI > 60 kg/m 2 .

Current evidence to support weight loss in older adults with BMI ≥ 30 started to emerge in 2016 when a systematic review revealed that weight‐loss interventions in older adults help improve physical function and quality of life [ 9 ]. This was followed by a clinical trial showing that lifestyle interventions, i.e., interventions that combined aerobic and resistance exercise with a balanced energy‐deficit diet, help mitigate muscle loss and bone loss while targeting weight loss [ 10 ]. For individuals with BMI < 30, there is considerable evidence supporting weight stability rather than weight loss. This could be achieved by intensive lifestyle intervention (ILI) without a need for pharmacological interventions in most scenarios. Any weight‐loss intervention in older adults should follow the geriatric principles of a “start low, go slow” approach and incorporate the inclusion of other disciplines such as physical therapists and exercise physiologists, based on functional impairments [ 11 , 12 ]. Pragmatic clinical trials for obesity interventions and guidelines to direct obesity care in the older populations are still lacking, but clinicians are faced with the care complexities of this growing older population. With the fast‐changing landscape of obesity pharmacotherapy and while awaiting long‐term data on the effect of antiobesity medications (AOMs) on body composition, this review highlights geriatric‐focused obesity care based on an age‐friendly framework of counseling on lifestyle interventions (diet/physical activity) and addressing multiple comorbid conditions, with a goal to improve mobility and function while targeting personalized weight loss in a nonaggressive manner that is centered on patient‐priority‐aligned goals.

Obesity care in older adults is complex due to multiple chronic medical conditions, with some reaching end‐stage disease, resulting in functional impairments and mobility disability with or without psychosocial concerns [ 13 , 14 ]. Given the complexity due to comorbidities and onset of disability, patients may have individual health priorities. Thus, understanding “what matters most” and aligning care interventions to their values and preferences, as well as understanding patient risk aversion toward physical activity, medications, or overall behavior change, would be vital to achieve successful weight‐management goals. A weight‐loss goal of >10% is commonly needed to improve most chronic health conditions. Therefore, management of obesity in this group requires a multicomponent intervention with a focus on identifying and optimizing obesity‐related multimorbidity and addressing diet, physical activity, and polypharmacy (with deprescription of weight‐promoting medications) and improving mobility and function using a multidisciplinary team that includes dietitians, physical therapists, exercise physiologists, social workers, and pharmacists and specialists, including complementary and alternative medicine specialists. Additionally, societal‐level change is needed for a broader impact at the population level. The current built environment and obesogenic ecosystem, both in urban and rural settings, call for a change involving capacity building and macro‐policy changes that focus on a new built environment for older adults that would enable access to neighborhood parks, fitness centers, and age‐friendly fitness equipment for varying levels of physical impairments, as well as a need for environmental changes at senior centers and residential care settings. Older adults with obesity from vulnerable populations are likely to face obstacles in the form of adverse social determinants of health (SDOH, commonly food insecurity) and limited resources to accessing care [ 15 ]. The unmet needs due to increased prevalence of SDOH in this population of older adults with obesity could be predictably met by enabling the links to community resources through agencies such as the Area Agency on Aging and using the clinic social worker in the team‐based model to coordinate obesity care.

OBESITY‐RELATED MEDICAL CONDITIONS LEADING TO MULTISYSTEM DISEASE

Cardiovascular diseases

Obesity is an independent risk factor for cardiovascular diseases (CVD) such as hypertension, obesity cardiomyopathy, obesity‐related subclinical cardiac dysfunction, coronary heart disease, atrial fibrillation (AF), heart failure with preserved ejection fraction (HFpEF), and sudden cardiac death. Effective blood pressure control and weight loss of >5% to >15% are of paramount importance in this group, as uncontrolled hypertension causes maladaptive changes in the heart (Figure 1 ) [ 16 ].

The risk for heart failure increases by 5% for men and 7% for women for each increment in BMI [ 17 ]. Thus, targeting modest weight loss (6.6%) by caloric restriction and pharmacotherapy can result in improvement in functional status in patients with HFpEF [ 18 ]. The Semaglutide Effects on Heart Disease and Stroke in Patients with Overweight or Obesity (SELECT) trial on semaglutide has demonstrated a 20% reduction in the incidence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke among adults aged >45 years (38.2% of the study population was older than age 65 years) [ 19 ]. This outcome is of high clinical importance as CVD are the leading cause of death in this population. The SUMMIT phase 3 clinical trial evaluated the safety and efficacy of tirzepatide in patients with obesity and HFpEF with or without diabetes. It demonstrated 15.7% weight loss and 38% reduction in the risk of heart failure‐related urgent visits or hospitalization, oral diuretic intensification, or cardiovascular death. Tirzepatide significantly improved heart failure symptoms and physical limitations [ 20 ]. Other than cardiac occlusive disease, the most common arrythmia in this population is AF, as obesity is associated with a 59% higher risk for AF. Weight loss achieved by lifestyle interventions or bariatric surgery in adults with severe obesity has proven to improve AF‐free survival, reversal of AF, symptom relief, and ablation outcomes [ 21 ]. Moderate caloric restriction with aerobic exercise has been proven to improve cardiorespiratory capacity, glycemic control, fatigue, and disability [ 22 ].

Pulmonary disease

A link between obesity and chronic obstructive pulmonary disease exists due to possibly visceral fat mass, yet the causal relationship is not proven. Current studies on patients with combined obesity and chronic obstructive pulmonary disease have demonstrated poor outcomes [ 23 ]. Insulin resistance in patients with obesity could be a contributory factor for asthma, and, therefore, optimal glycemic control is recommended as opposed to systemic corticosteroids, which cause less desirable side effects such as worsening glycemic control, weight gain, and osteoporosis [ 24 ].

Metabolic dysfunction‐associated steatotic liver disease

Obesity is a known risk factor for metabolic dysfunction‐associated steatotic liver disease (MASLD). Older age and diabetes can potentiate the disease progression to advanced hepatic fibrosis and cirrhosis [ 25 ]. A recent study has supported a two‐step screening including Fibrosis‐4 (FIB‐4) scoring ≥ 1.3 followed by magnetic resonance elastography (i.e., “MEFIB”) as a promising approach in the clinical setting due to its high negative predictive value for adverse liver‐related outcomes at 5 years [ 26 ]. The FIB‐4 score is a noninvasive liver fibrosis assessment based on patient age, platelet count, and aspartate aminotransferase and alanine aminotransferase values and is used because of its simplicity. It is calculated using an online calculator ( https://www.mdcalc.com/calc/2200/fibrosis-4-fib-4-index-liver-fibrosis ) or, faster and more easily, using SmartPhrase in Epic (.fib4score). Incorporating the calculator in the care of older adults with obesity could potentially help identify well‐compensated yet advanced liver diseases, including cirrhosis, despite normal liver function tests. It would be highly recommended to check complete blood count and liver function test annually in older adults with obesity along with the use of the mentioned Epic SmartPhrase. Magnetic resonance elastography is an expensive imaging study with limited availability and is therefore not recommended, whereas ultrasound‐based FibroScans are widely available and have proven comparable results [ 27 ]. Lifestyle changes, with caloric and fructose restriction, Mediterranean diet, and moderate exercise, have been proven to improve steatosis in patients with MASLD [ 25 , 28 ]. In March 2024, the Food and Drug Administration (FDA) approved resmetirom, a thyroid hormone receptor‐β (THR‐β) agonist, to treat metabolic dysfunction‐associated steatohepatitis (MASH) F2‐F3 disease. MASH with advanced cirrhosis is now the leading indication of liver transplant in the United States, which changes the landscape of MASLD as early identification of patients for treatment considerations could potentially help prevent progression to cirrhosis [ 29 ]. In a retrospective study performed at Veterans Health Administration, glucagon‐like peptide‐1 (GLP‐1) agonists in patients with diabetes have been shown to reduce progression of MASLD to cirrhosis and death if the treatment is initiated earlier in the disease course [ 30 ]. A recent clinical trial completed in July 2024 demonstrated the effectiveness of pemvidutide, a GLP‐1/glucagon dual receptor agonist, on reduction of liver fat and inflammation while promoting weight loss [ 31 ]. Early clinical trials have revealed GLP‐1 receptor agonists as a promising treatment option for patients with chronic liver disease and diabetes. A systematic review revealed that GLP‐1 receptor agonists may play a protective role in hepatocellular carcinoma risk reduction, although more randomized control trials are needed that compare GLP‐1 receptor agonists with other antidiabetic therapies [ 32 ].

With the current projected rise in the incidence of hepatobiliary cancers among older adults largely attributed to rising obesity rates [ 33 ], there needs to be an increased emphasis on controlling diabetes, the burden of metabolic syndrome, and obesity with available and emerging interventions, including bariatric surgery and newer AOMs [ 25 , 34 ].

Chronic kidney disease

Chronic kidney disease (CKD) is highly prevalent due to age, obesity chronicity, and severity. Weight loss helps with reversal of disease progression in the early stages of kidney involvement when glomerular hyperfiltration and hyperperfusion occur, but when proteinuria and later stages of kidney injury set in, management of CKD poses a challenge. Furthermore, the results of the Evaluate Renal Function with Semaglutide Once Weekly (FLOW) trial have shown that semaglutide at a lower dose of 1 mg weekly reduced the risk of clinically important kidney outcomes by 24% while slowing the chronic disease progression [ 35 ]. At all stages of CKD, control of hypertension, dyslipidemia, metabolic syndrome, and diabetes remains crucial. These patients are at high risk for acute kidney injury (AKI) due to comorbid conditions such as heart failure, hypertension, and diabetes while also being treated with medications such as diuretics, angiotensin‐converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs), predisposing them to higher short‐ and long‐term mortality [ 36 ]. AKI increases the risk for developing worsening CKD, CVD, neurological sequalae such as delirium, executive dysfunction, and cognitive impairment [ 37 ]. This further emphasizes the role of primary care physicians in carefully monitoring the metabolic panel while coordinating care with multiple specialists.

Thrombosis, stasis, and lymphedema

Obesity increases the risk of thrombosis and CVD due to vascular compression, venous stasis, underlying obstructive sleep apnea (OSA), the inflammatory and hypercoagulable state, and insulin resistance [ 38 ]. Clinical presentations such as deep vein thrombosis, pulmonary embolism, chronic venous stasis, varicose veins, superficial thrombophlebitis, lipodermatosclerosis, chronic thromboembolic pulmonary hypertension, iliofemoral venous obstruction, pelvic venous disorder, post‐thrombotic syndrome, and lymphedema and lipedema are often seen in older adults with obesity. Chronic thromboembolic pulmonary hypertension manifests in older adults with exertional shortness of breath, fatigue, decline in exercise tolerance, and, sometimes, chest pain. This condition may necessitate anticoagulation and endarterectomy.

Lipodermatosclerosis arising due to hyperpigmentation resulting from venous stasis would require compression stockings, leg elevation, and weight loss. Lymphedema requires a multidisciplinary treatment involving lymphedema therapists along with physical therapists, as effective management can improve quality of life, self‐esteem, and mobility.

Obesity‐related cancer

There is sufficient evidence that obesity has been linked to the following 13 cancers: cancer of the esophagus (adenocarcinoma); gastric cardia; colon and rectum; liver; gallbladder; pancreas; meningioma; postmenopausal breast; endometrium; ovary; kidney; thyroid; and multiple myeloma. The plausible explanation is obesity‐related inflammation, insulin resistance, adipokines, and altered gut microbiome [ 39 ]. This further highlights importance of recommending healthy body weight and screening for cancers such as colon and breast, which are often under‐screened in adults with obesity [ 40 , 41 ], while also highlighting the need for higher vigilance for other obesity‐related cancers. Adiposity, physical activity, diet, and alcohol intake can further influence cancer recurrence and overall survival, highlighting the importance of addressing obesity and alcohol use among cancer survivors. This is particularly important among postmenopausal breast cancer survivors, as excess adiposity affects cancer recurrence and increases cardiovascular mortality [ 42 ].

Mental health conditions

Obesity is associated with a range of mental health disorders, including depression, post‐traumatic stress disorder, anxiety, and cognitive impairment. This is more pronounced among racial and ethnic minority older adults [ 43 ]. The association of obesity and clinically relevant depression was stronger among female individuals and non‐Hispanic White individuals from the Health and Retirement study, a nationally representative longitudinal survey of US middle‐aged and older adults who were followed up for 16 years [ 44 ]. The relationship between obesity and depression is bidirectional and thereby merits treatment of both conditions for effective intervention. Clinical decision‐making regarding the choice of antidepressants by clinicians play a critical role in mitigating medication‐related weight gain. The Women's Health Initiative study showed that prescription medications with combination of antidepressants with either insulin or β‐blockers raised BMI values significantly [ 45 ]. Careful selection of antidepressants by choosing weight‐neutral or weight‐reducing medications while attempting to deprescribe weight‐promoting medications is highly recommended.

Sleep disorders

Obesity contributes to a plethora of sleep‐disordered breathing, most prevalent among them being OSA. Other sleep disorders range from insomnia, primary snoring, and restless leg syndrome [ 46 ]. Recognition and treatment of these conditions in older adults is imperative, as untreated sleep disorders have clinical implications and can lead to worsening cardiometabolic conditions such as hypertension, type 2 diabetes mellitus, congestive heart failure, AF, nocturnal dysrhythmias, pulmonary hypertension, and stroke [ 47 ]. The symptomatology could be myriad, including snoring, insomnia, restless sleep, sudden wakening with choking or gasping, headaches, daytime sleepiness, fatigue, nocturia, motor vehicle accidents, forgetfulness, mood changes, lack of interest in sexual behavior, or gastroesophageal reflux disease. Screening questionnaires such as the Epworth Sleepiness Scale, STOP‐Bang Questionnaire, and the Berlin Sleep Questionnaire could aid in the screening and referral for sleep testing. The treatment of OSA includes weight reduction and positive airway pressure (PAP) therapy. There is high prevalence of nonadherence to PAP therapy despite studies have shown an association of high adherence with reduced 30‐day readmission rates in patients with OSA and CVD [ 46 ]. A 10‐year longitudinal study showed that ILI improves OSA severity [ 48 ] and OSA‐related outcomes and cardiometabolic comorbidities when combined with continuous PAP therapy [ 49 ]. Other sleep disorders deserve attention to treatment, as the altered circadian rhythm can worsen cardiometabolic risk factors and outcomes due to the unhealthy effects on body composition, glycemic status, lipid panel, and blood pressure, further increasing risk for heart disease and stroke. Sleep deprivation could worsen hunger, decrease physical activity, and worsen body fat while worsening lean mass loss.

Cognitive impairment

Low‐quality diet, obesity, and sarcopenic obesity predispose individuals to cognitive impairment via systemic and central inflammatory pathway possibly initiated by the gut microbiome with or without alteration of blood brain barrier [ 50 , 51 ]. A diet with predominantly ultraprocessed foods has been associated with cognitive decline [ 52 ]. The “What Matters, Medication, Mentation, and Mobility” (4Ms) approach to care, with a lower threshold for suspicion of mild‐to‐moderate cognitive impairment, would help in the understanding of barriers to behavior change with weight‐loss intervention, which will enable clinicians to better understand adherence issues to lifestyle recommendations and should prompt use of care partners in the weight‐management efforts of older adults in the appropriate clinical setting. Although some knowledge gaps still exist regarding effective pharmacotherapeutics, sodium‐glucose cotransporter‐2 (SGLT2) inhibitors have been shown to improve cognition in this population in clinical trials [ 53 ]. Early evidence has revealed that tirzepatide may have a role to help prevent neurodegeneration through multiple molecular pathways and may play a role in neuroprotection and prevention of neurodegenerative disorders [ 54 ].

OA and chronic pain, falls, mobility disability, and functional impairment

Obesity predisposes individuals to OA in the weight‐bearing and non‐weight‐bearing joints. The joints most commonly affected are knee, hip, back, spine, shoulder, hands, and feet. The effect of OA is due to both mechanical loading and inflammatory effects of adipose tissue on most joints [ 55 ], particularly the knee, and is a major contributor for mobility disability. The high prevalence of pain and accompanying loss of muscle strength restrict physical activity and function [ 56 ].

Obesity is also associated with increased fall risk in older adults, further leading to activities of daily living impairment after a fall [ 57 ]. These individuals are eight times more likely to experience a fall than individuals without obesity when adjusted for age, gender, and gait speed [ 58 ]. In a smaller study comparing younger and older women with both healthy weight and obesity, older women with obesity walked with greater relative effort, explaining the gait difficulty observed in this population [ 59 ]. Abdominal adiposity contributes to gait impairment, which is further worsened by foot disorders such as flat foot and foot pain, as have been observed in this population [ 60 , 61 ].

Older adults with obesity have varying levels of mobility disability interfering with their ability to participate in ILI and perform activities of daily living, leading to increased use of assistive devices [ 12 , 62 ]. Adiposity and its deleterious effects on muscle composition lead to low muscle strength, which further leads to functional impairment and mobility disability [ 62 , 63 , 64 ]. Increasing obesity severity has been shown to be associated with worsening pain, functional limitation, and disability, predisposing individuals to homebound status [ 65 , 66 ]. Enhancing access to care by extending options for both in‐person and telehealth visits to patients with increasing mobility disability but with normal cognition could be a meaningful age‐ and obesity‐friendly approach. This has been successfully demonstrated in a feasibility study on a rural, underserved population [ 67 ]. Focusing on the mobility component of the 4Ms approach to care for this group would require an evidence‐based rehabilitation program with early referral to physical therapy or an exercise physiologist, as well as pain management with pharmacological and/or nonpharmacological strategies [ 68 , 69 ]. Clinical decision‐making regarding the choice of pain medication should take into consideration the weight‐promoting, detrimental effect of the neuropathic agents such as gabapentin and pregabalin, further leading to worsening OA and exacerbating the vicious cycle.

The importance of weight loss to improve OA in both the knees and hips warrants emphasis, as 1% weight loss can reduce the risk of knee replacement by 2% and hip replacement by 3% [ 70 ]. Weight loss also helps improve OA pain and function and reduce disability [ 71 ]. There is evidence that GLP‐1 agents may play a role in slowing degenerative arthritis by modulating inflammation and promoting cartilage repair [ 72 ]. An interesting yet conflicting scenario is that patients with severe obesity, i.e., BMI > 40, awaiting total knee arthroplasty are prescribed a weight‐loss goal of BMI < 40 or <35 as a prerequisite for surgery, which is often unattainable with ILI alone. Enabling patients to embark on a multicomponent comprehensive obesity intervention, encompassing management of pain and psychosocial conditions along with AOMs if appropriate, could help patients undergo long‐awaited major joint surgeries for conditions that have been impacting their mobility and function, thereby helping to improve quality of life [ 73 ].

Fall risk mitigation should take into consideration the underlying orthopedic and foot issues and consider appropriate referral to orthopedics and podiatry [ 74 ]. The emphasis should be on resistance and strength training exercise, balance, and aerobic fitness [ 75 ].

Social participation, social isolation, and SDOH needs

The mobility impairment associated with aging with multimorbidity raises the risk for social isolation in older adults with sensory issues (i.e., vision and hearing) and declining physical and mental health, as well as, often, lack of a supportive relationship due to loss of spouse or lack of caregiver. This varies in neighborhoods but is more highly prevalent among older adults living in rural areas, inner‐city areas, minority and low‐income neighborhoods, and residential environments such as nursing facilities and assisted living facilities. Social isolation leads to increased sedentary time and reduced leisure‐time physical activity [ 76 ], a precursor to worsening obesity that is worse in residential settings. Furthermore, mobility impairment limits social participation due to physical disability, with further impingement on driving, necessitating that individuals rely on alternate transportation or a caregiver. Obesity prevalence increases with SDOH burden [ 77 ], and, therefore, screening for SDOH in the primary care setting is strongly recommended. SDOH screening and documentation in electronic medical records in structured fields with utmost consistency are key steps that should be followed by embedding tools and alerts for positive SDOH screen to guide interventions, such as referrals to community‐based programs, community health workers, and nutrition services. Incorporating SDOH screening for food, housing, and transportation needs would serve as a focused scoping lens to view the gaps for older adults with obesity. However, universal screening for SDOH is recommended to identify unmet needs, which would require adequate infrastructure. Under the “Food is Medicine” movement, food and nutrition programs such as medically tailored meals are delivered to patients with chronic system‐specific, highly prevalent conditions such as kidney disease and heart disease. This program also offers medically tailored groceries and fresh produce prescription programs to benefit “at‐risk” individuals or individuals with diet‐related diseases. However, we currently do not witness widespread adoption of these programs. Meals on Wheels is a much more widely available community program in the United States aimed at helping older adults with food insecurity and risk for malnutrition, but its effectiveness for older adults with obesity to help promote weight loss is questionable. Using the team‐based model of care by involving clinical team social workers to establish the links to community resources for diet, exercise, transportation, and housing needs would help mitigate the underlying barriers to address the concerns and effectively treat obesity and disability.

Geriatric syndrome

Per Tran and Leonard, “Geriatric syndrome is a term used to describe unique health conditions in elderly patients that are multifactorial in cause and do not fit into discrete organ‐based categories” [ 78 ]. Owing to the confluence of the obesity and aging epidemics, the prevalence of sarcopenic obesity is predicted to rise [ 79 ]. Sarcopenia due to age‐related loss of muscle mass and strength with co‐occurrence of obesity and multimorbidity leads to impairment in muscle function, predisposing individuals to geriatric syndrome [ 80 ]. This leads to a cascade of decreased physical activity level, functional limitation, disability, fatigue, prefrailty and frailty, osteoporosis, cognitive impairment, depressive symptoms, dementia, and sleep disturbances [ 81 ]. Patients with geriatric syndrome also experience urinary incontinence and are at increased risk for falls, further adding to the complexity of the syndrome [ 82 ]. Geriatric syndrome could be the final common pathway to frailty, onset of disability, caregiver dependency, and institutionalization. The co‐occurrence of functional impairments and geriatric syndrome drives adverse health outcomes; therefore, a comprehensive geriatric assessment (Table 2 ) would be valuable to screen for geriatric syndrome in this population. This would serve as an instrument to provide a cognitive, functional, and psychosocial baseline of older adults to identify the subgroup of at‐risk older adults with obesity and recommend tailored nutrition and physical activity and screening for appropriateness for AOMs. Grip strength and dual‐energy x‐ray absorptiometry (DXA) scanning are currently not utilized as standards of clinical care due to lack of standardized cutoffs for grip strength and nonavailability of DXA for assessment of body composition for clinical practice. Therefore, clinicians would need to rely on a comprehensive geriatric assessment to provide insights to the prevailing impairments until more widespread tools are available to measure body composition. A bioelectrical impedance analysis device has shown high validity across settings, including clinics, research and wellness centers, and home use. The utility of these devices has gained more attention due to the increased need to track body composition as we step into the era of a wider adoption of incretin mimetics. The prevailing geriatric syndrome in older adults leads to unpredictable and undesirable changes on body composition, and inappropriate prescription of incretin mimetics without a geriatric assessment or adoption of a “start low, go slow” approach can lead to functional decline, metabolic derangements, weight cycling, and diminished quality of life.

MULTICOMPONENT INTERVENTION AND TEAM‐BASED CARE

Evidence‐based approach

Weight‐loss approaches in adults require a comprehensive evidence‐based approach involving behavioral intervention, nutrition, physical activity, pharmacotherapy, and surgery/bariatric procedures (Figure 2 ). Owing to the clinical and biological heterogeneity in older adults that is further exacerbated by obesity, this subset of older adults would benefit from a patient‐centered and geriatric‐focused weight‐loss approach with attention to mobility and functional impairment and polypharmacy.

Lifestyle interventions that include nutrition and exercise are components of comprehensive evidence‐based behavioral management and can help adults attain 5% to 10% weight loss [ 83 ]. Recent studies have highlighted the foundational role of ILI to achieve an additive weight‐loss benefit when used sequentially with AOMs, as opposed to concurrently [ 84 ]. This is a pivotal step in a weight‐loss interventional approach in older adults, as the resistance exercise and adherence to a protein‐enriched diet help to prevent the anticipated muscle loss associated with AOMs [ 85 ] A segment of the older adult population with increased chronic disease burden, adverse quality of life, cognitive dysfunction and depression, isolation, loneliness, widowhood, caregiver dependency, and residence in residential settings will have significant challenges to adopt lifestyle interventions [ 86 ].

Behavioral intervention

Evidence‐based approaches include goal setting, self‐monitoring (of food intake, activity tracking, and weight), stimulus control, relapse prevention, stress management, and cognitive therapy [ 87 , 88 ]. This is often accomplished by an offering within primary care or an outside referral to commercial programs. In the Veterans Affairs health system, veterans with obesity may be referred to the MOVE! population‐based behavioral weight‐management program. In 2011, the Centers for Medicare and Medicaid Services (CMS) approved a behavioral counseling code for intensive behavioral therapy (IBT) to help address obesity among Medicare beneficiaries. Furthermore, in 2018, the US Preventive Services Task Force recommended that clinicians offer multicomponent IBT for adults of all ages with BMI ≥ 30. The uptake of these services in the outpatient setting has been extremely low according to a cross‐sectional study on Medicare claims data between 2012 and 2015 [ 89 ] and further confirmed by a study that looked at an extended period of 2013 to 2019 [ 90 ]. The time burden of 15‐min sessions for a total of 22 sessions per year was likely a major reason for low uptake in younger adults, and low uptake in older adults was attributed to competing medical priorities and transportation barriers. In 2020, following the COVID‐19 pandemic, telehealth modality of IBT sessions was approved with the goal of reducing the barriers due to transportation and access. The data on the effectiveness of behavioral intervention in older adults still remain weak [ 91 ].

Nutrition

Weight loss in older adults by prescription of a hypocaloric diet can be challenging due to concern for loss of muscle mass and bone density [ 92 , 93 ]. A referral to a registered dietitian/nutritionist with additional referral to a nutrition support group would need to be part of the comprehensive obesity treatment plan. This could provide an opportunity for the patient to work 1:1 or in a group setting. The registered dietitian's effectiveness on nutritional intervention could be further enhanced if he or she is certified in obesity and weight management. A sensitive and customized approach to nutrition counseling would need to include cultural appropriateness and affordability to enhance accountability and adherence. Because older adults vastly differ on the level of calorie knowledge and confidence, which remains a disparity, education on nutrition needs to be tailored. A calorie‐restricted diet should be combined with both aerobic and resistance exercise to help preserve muscle strength, metabolic health, and cognition in order to maintain functional independence [ 94 ]. A hypocaloric, 500‐ to 750‐kcal‐deficit diet could be recommended with intake of balanced protein of 0.8 to 1.2 g/kg of body weight per day and micronutrients. Ensuring an intake of 20 to 30 g of protein with each meal along with a protein snack following exercise can help cut down elevated unhealthy caloric needs during those times [ 95 ]. Supplemental calcium up to 1200 mg/day and 800 to 1000 IU of vitamin D are recommended to prevent weight loss‐induced bone density reduction.

A Mediterranean diet is one pattern that has proven to be effective in older adults to help prevent muscle and bone loss and prevent age‐related decline in immune system, cognition, and sexual capacity [ 96 , 97 ]. Others have found that time‐restricted eating (8–10 h) combined with modest caloric restriction, modest increase in protein consumption, and resistance exercise can help achieve weight loss with improved cardiometabolic health and functional capacity [ 98 ]. Time‐restricted eating can be combined with meal replacement for effective caloric restriction. Educational handouts on protein‐ and fiber‐rich foods and emphasis on intake of 20 to 30 g of protein while highlighting the limitation of ultraprocessed snacks and meals would help guide patients of varying nutritional backgrounds and enhance adherence. This would also help tailor nutritional counseling, as it is a step‐by‐step process with a lead‐in period for patients who indulge in predominantly ultraprocessed foods to switch to home‐style cooking and gain adherence to a healthy diet. Clinicians caring for older adults in residential settings can advocate for serving small portion sizes with quality servings (i.e., with a focus on whole grains, low‐caloric density, protein‐ and fiber‐rich meals, and reducing calorie dense snacks) and educating and counseling patients and caregivers.

Physical activity

Physical activity recommendation is a key component of weight management as it influences health benefits but its effect on weight loss remains moderate [ 99 ]. Aerobic and resistance exercise combined with caloric restriction is essential to reduce adiposity and improve physical and metabolic health [ 100 ]. The Physical Activity Guidelines for Americans recommends a multicomponent regimen involving aerobic, muscle‐strengthening, and balance exercises in older adults to address obesity‐induced postural imbalance. Robust studies have recommended moderate‐to‐high‐intensity aerobic exercise to promote weight loss, which is less achievable in older adults. The International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines suggests achieving this by alternate methods such as intermittent intensity with resistance or interval training. The American College of Sports Medicine consensus statement for adults with obesity states that light‐intensity physical activity could be an alternative approach to high intensity provided it helps sufficient energy expenditure [ 101 ]. Although adherence to traditional exercise is low, recent evidence has suggested minimal‐dose resistance training as alternate effective approaches. This could be brief sessions of resistance training performed at either moderate‐high loads done infrequently, referred to as low‐volume, high‐load resistance training, or lower loads performed at higher frequencies and also with minimal to no equipment, referred to as resistance exercise snacking, which can be used in patients with sedentary behavior [ 102 ]. Exercise counseling could be recommended as a medicine prescription wherein the prescription needs to be tailored to the patient's exercise preference, amount of exercise agreed upon, and readiness (when and how often, i.e., days per week) and slowly increase the intensity (prescription dose) of physical activity and resistance training with a trusted partnership and shared decision‐making. Using office‐based tools such as a handgrip dynamometer to assess grip strength as a surrogate measure of muscle strength also serves as a motivator for older adults to improve resistance training. Exercise adherence in older adults with obesity and multiple chronic conditions is a challenge due to multiple limiting factors such as pain from OA leading to unpleasant experiences, embarrassment of one's own appearance, rapid exhaustion due to functional limitation due to inactivity, safety concerns, and lack of enjoyment with movement, leading to lack of motivation [ 103 ]. The extent of risk aversion due to the mentioned factors should be taken into consideration. A patient handout or an after‐visit summary outlining the behavior plan for physical activity as an exercise prescription will help improve adherence. This could be supplemented with additional resource links from validated websites such as the National Institute on Aging ( https://www.nia.nih.gov/health/exercise‐and‐physical‐activity/exercising‐chronic‐conditions ), Rethink Obesity ( https://www.rethinkobesity.com/advocacy‐resources/obesity‐resource‐library.html ), American College of Physicians ( https://www.acponline.org/sites/default/files/documents/cme_moc/olc/patient_education/obesity_lifestyle_nutrition.pdf ), and video‐based resources to help improve adherence. Effectiveness of behavioral counseling could be enhanced when clinicians review the exercise and physical activity discussed and outlined at the prior visit and assess change, discuss barriers, and advise strategies to overcome struggles and change the exercise dose as appropriate. This would also help gauge adherence between visits and reinforce accountability. Modalities such as interpersonal support (using a health coach), digital support, tracking, provider check‐in, and health care guidance and recommendations could help ensure adherence to physical activity and reduction of sedentary time, although we currently lack prospective studies to show effectiveness. Sedentary behavior increases with aging, leading to a high prevalence among older adults with >8.5 h/day spent sitting, which is more commonly seen in residential settings [ 104 ]. A strong association of increased sedentary behavior and physical inactivity with obesity in older adults exists [ 105 ]. Older adults with obesity often perceive exercise as a challenge; therefore, recommendations to improve light‐intensity physical activity with a goal of reducing sedentary time may derive health benefits.

Pharmacotherapy

Lifestyle interventions, including nutrition and physical activity, remain the mainstay for obesity intervention across all ages. However, these behavioral interventions help achieve only a modest weight loss (5%–10%) and are often less achievable by older adults [ 83 ]. Further long‐term maintenance of weight loss remains a challenge due to the compensatory biological mechanisms that decrease energy expenditure and increase appetite. These compensatory mechanisms are ameliorated by AOMs, which enable patients who cannot achieve weight‐loss goals by ILI alone or those who are experiencing challenges with weight‐loss maintenance to lose weight. Superimposed on this is the need for larger weight loss (≥10%) to achieve a medical benefit to optimize multiple obesity‐related comorbidities and complications [ 106 ]. This is achievable with the newer generation of AOMs (incretin mimetics) and GLP‐1 and dual glucose‐dependent insulinotropic polypeptide (GIP)/GLP‐1 agonists. There still exists a role for the prior generation of AOMs such as orlistat (8.4% weight loss) and phentermine‐topiramate (7.8%–9.4% weight loss). Phentermine is avoided in patients aged >60 years due to increased prevalence of subclinical CVD and the side effects of dizziness, which predispose individuals to fall risk. Other options include metformin as a first‐line (off‐label) treatment for weight loss. Low‐dose topiramate standalone, without phentermine, can also be used in this age group. Studies have been limited on older adults on naltrexone‐bupropion use, which raises concern on the use of this medication. There currently remains insufficient evidence to recommend AOMs in older adults based on the American Association of Clinical Endocrinologists and the American College of Endocrinology guidelines (2016). An updated algorithm based on evidence for management of obesity in older adults recommends pharmacological management with newer generation AOMs (i.e., semaglutide, liraglutide, tirzepatide), or orlistat and phentermine‐topiramate after a trial of semaglutide, for individuals with BMI > 30 or ≥27 and cardiometabolic comorbidities who are refractory to ILI [ 107 ]. There are still limited data on the therapeutic experience on older adults aged ≥75 years. Available evidence is based on short‐term data that have shown similar safety and efficacy compared to that in younger adults. There is still a paucity of safety, effectiveness, and long‐term outcomes data on older adults due to limited clinical trials in this population and less than 4 years having elapsed since approval. Although the major policy shift by the CMS to approve coverage of semaglutide for adults with established CVD events (i.e., coronary artery disease, stroke, peripheral artery disease) was prompted by the improved cardiovascular outcomes of the SELECT trial, continued advocacy efforts are needed to expand this coverage to patients with high atherosclerotic heart disease risk for primary prevention.

When prescribing AOMs, the geriatric principles should be followed with a careful review of polypharmacy for weight‐promoting medications, with recommendations for resistance training and a calorie‐deficit diet with increased protein quality to mitigate muscle and bone loss [ 107 ].

The old adage of “start low, go slow,” i.e., “start at the lowest starting dose and titrate slow,” needs to be a guiding principle when prescribing the incretin mimetics in older adults. The risk for gastrointestinal side effects and risk for dehydration leading to AKI are higher compared with the general population due to the increased prevalence of CKD. The lowest effective dose is meaningful as GLP‐1 and GIP agents often delay gastric emptying [ 108 ], thereby causing less of an impact on the absorption of other clinically relevant medications [ 109 ]. Furthermore, the current clinical model of care does not allow the longitudinal monitoring of the accompanied loss of muscle and bone with intentional weight‐loss intervention, as a 25% loss of lean muscle mass for every 75% loss to effect a pound of weight loss occurs [ 110 ]. Current clinical trials revealing ≥10% loss of muscle mass during the study duration of 68 to 72 weeks equivalent to 20 years of age‐related muscle loss raise significant concern [ 111 ]. Therefore, a slower and more watchful approach with a less aggressive weight‐loss goal following a sequential lifestyle intervention approach is needed.

In patients with moderate and severe obesity, specialist teams such as those composed of surgical and orthopedic specialists often have set prequalifying target weight‐loss goals (goals vary with practice, such as BMI of 40 or 35) for surgeries such as knee, hip, back, or other nonorthopedic surgeries. These preset weight‐loss goals have been historically nearly impossible to achieve for older adults with pain and functional impairment before the advent of the newer AOMs. The medications’ effect on the appetite control centers of the hypothalamus, brain stem, gut, and energy expenditure shows promising control on satiety, satiation, and hunger in patients with moderate‐to‐severe obesity and helps promote weight loss needed to successfully achieve weight goals to qualify for surgical procedures.

Deprescription of weight‐promoting medications

Older adults with obesity and the resultant multiple chronic conditions are predisposed to be on a high number of prescription medications, leading to polypharmacy burden with a high number of weight‐promoting medications (Table 3 ) [ 45 , 112 ]. Unfortunately, older adults with obesity have associated comorbid medical and psychiatric conditions such as diabetes with or without neuropathic pain, mood disorders with or without psychosis, hypertension, sleep disorders, including restless leg syndrome, and obesity‐related and non‐obesity‐related cancers, which benefit from medical management. These conditions are often treated by primary care physicians and specialists via an array of medications, including insulin, sulfonylureas, pain medications (gabapentin and pregabalin), antidepressants, antipsychotics, β‐blockers, sleep medications, and chemotherapeutic agents. There is an unmet need among both primary care physicians and specialists to be mindful of the weight‐promoting cumulative effect of these medications, which leads to substantial weight gain. A systematic 4Ms approach to review the medications with a deprescription plan involving a switch to a comparable medication that is associated with less weight gain, is weight‐neutral, or promotes weight loss should be a key initial step when attempting to achieve weight loss in older adults [ 12 ].

Bariatric surgery

Older adults are at high risk for any surgical procedure due to the advanced age, associated risk due to atherosclerotic heart disease, risk of respiratory failure, and frailty. With the increasing obesity rates and obesity severity in the older adult population and refractoriness to ILI, bariatric or metabolic surgery is a consideration. Bariatric surgery helps with weight loss and comorbidity remission in older adults; however, the extent of weight loss and remission of chronic disease is lesser compared to younger adults [ 113 ]. The consensus remains that age is not a limiting factor, and a recent study that evaluated the safety of bariatric surgery in older adults has shown that robotic‐assisted sleeve gastrectomy (SG) is safer than laparoscopic SG and laparoscopic and robotic Roux‐en‐Y‐gastric bypass [ 114 ]. This landscape has been rapidly changing in the last 3 years with the introduction of newer generation AOMs (more to come in the pipeline), as the newer incretin mimetics could help achieve weight loss that is comparable with that achieved with bariatric surgery, but the long‐term safety data are pending. There is still the potential for bariatric surgery to act as an adjunct with AOMs in cases of extreme obesity.

Challenges due the heterogeneity of older adults and need for team‐based care

Older adults are heterogenous due to age‐related biological changes and cumulative disease burden, leading to dynamic accumulation of biological changes that eventually surpasses the capacity to maintain homeostasis [ 115 ]. Obesity further accelerates this aging process and amplifies heterogeneity [ 4 ]. Older adults with obesity as defined by chronological age may deviate from the their age‐matched counterparts due to the onset of chronic diseases, risk factors, structural inequities, and other social influences due to aging [ 116 ]. The functional or physiological age should be taken into consideration to perform a comprehensive assessment and provide a tailored and personalized approach to care. Obesity is a chronic disease, according to the American Medical Association in 2013, associated with multiple chronic conditions, functional impairment, disability, and disadvantaged SDOH, and a team‐based model of care, which is being increasingly used in the presence of chronic diseases such as dementia, heart failure, and falls, will need to be incorporated [ 117 ]. This would involve disciplines such as social workers and dietitians and community outreach to link health system‐based and community‐based weight‐management programs for the care of the complex older adult with obesity. This is achievable when the geriatric assessment captures the complex medical and psychosocial issues with a syndromic presentation, prompting a plan to collectively address health literacy, food, activity, environment, and other SDOH, as they are often barriers for effective intervention. Approaching with “what matters most” and actively engaging older adults in their care with patient‐priority goals would help in approaching weight loss in a meaningful way. Using synopsis, which is an efficient and pragmatic graphic display tool in the electronic health record, can help identify meaningful correlations among life events leading to weight loss, weight gain, intentional weight‐loss efforts, and the weight regain pattern, as well as the association with weight‐promoting medications start dates and dosing. This can provide insightful information on the patient's weight‐gain trajectory to develop a meaningful interventional plan in a shared decision‐making process. This graphic display could also serve as an effective tool to share with patients and help understand the correlations with all of the aforementioned factors and track the weight‐loss trajectory when patients embark on ILI with or without AOMs.

OBESITY CARE ACROSS HEALTH CARE SETTINGS

The older population with functional impairment due to obesity is predicted to increase, and models of care such as Community Aging in Place Advancing Better Living for Elders (CAPABLE) and Program of All‐inclusive Care of the Elderly (PACE) could serve as potential options for this subgroup to continue living in the community. When the threshold of disability exceeds the level of support offered by these services, nursing homes would be the final residential setting. Understandably, the prevalence of obesity among nursing home residents has increased from 22% to 28% between 2005 and 2015, along with a proportional increase in moderate‐to‐severe obesity [ 118 ]. This early entry to nursing homes has implications on the increased cost of resident care and care complexity for the staff and management in nursing homes. Intermediate care facilities such as assisted living and independent living have rapidly grown across the nation and overseas due to the “aging in place” philosophy and Continuing Care Retirement Communities (CCRC) care model. These often have a broader option for physical activity but may still lack age‐friendly exercise equipment and require guidance and supervision with the onset of geriatric syndrome. The dietary choices limit the ability of these care facilities to adhere to a quality diet, as they are targeted toward a broader range of residents, which necessitates a focus on improving overall nutrition. Thus, residential settings induce an obesogenic environment, limiting access to a hypocaloric diet. Clinicians providing obesity care to this residential care population need to understand that almost 79% of awake time is spent as being sedentary [ 119 ]. This highlights that recommendations for dietary and exercise changes to patients in alternate living environments need to take into account the limitations in these care facilities.

FUTURE OF OBESITY MANAGEMENT: NOVEL OBESITY PHENOTYPES AND PRECISION MEDICINE APPROACH

Novel obesity classification based on the four obesity phenotypes, namely abnormal satiation (hungry brain), abnormal hedonic eating (emotional hunger), abnormal satiety (hungry gut), and low predicted energy expenditure (slow burn), will pave the way for targeted therapies [ 120 ]. This approach may help achieve a better overall response to various therapies and help achieve metabolic targets by integrating genetic, phenotypic, and lifestyle factors combined with better assessment of changes in body composition (currently unavailable). However, the complexity of older adults with obesity and functional impairments leading to geriatric syndrome calls for a precision gerontology approach [ 121 ]. With our better understanding of pharmacogenomics, which is likely to be integrated into clinical care more broadly in the near future, clinicians may have the advantage of using an obesity‐centered chronic disease management algorithm that targets both obesity and its comorbidities using precision medicine. This may change the landscape of obesity care in older adults with multiple comorbidities.

CONCLUSION

The management of obesity in older adults is complex and requires a comprehensive approach, taking into consideration the prevailing medical, physical, functional, psychosocial health, and age‐related and obesity‐influenced SDOH factors. A comprehensive geriatric assessment would provide insightful approaches to provide care for this multimorbid and functionally impaired subset of older adults while the landscape for functional assessments, monitoring, and targeted therapies is still evolving. A tailored, slow, and closely monitored multicomponent weight‐loss approach involving an interdisciplinary team and specialists with effective care coordination with a 4Ms approach would be an effective strategy to provide care across all settings for this growing population.

CONFLICT OF INTEREST STATEMENT

The author declared no conflicts of interest.

Dewar S. A geriatrician's approach to managing the complex older adult with obesity. Obesity (Silver Spring). 2025;33(Suppl. 1):41‐56. doi: 10.1002/oby.24267

DATA AVAILABILITY STATEMENT

Data sharing not applicable‐no new data generated, or the article describes entirely theoretical research.

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(16):1723‐1725. doi: 10.1001/jama.2018.3060

2. Bray GA, Kim KK, Wilding JPH. Obesity: a chronic relapsing progressive disease process. A position statement of the world obesity federation. Obes Rev. 2017;18(7):715‐723. doi: 10.1111/obr.12551

3. Centers for Disease Control and Prevention. Consequences of obesity. Updated July 15, 2022. Accessed July 21, 2024. https://www.cdc.gov/obesity/basics/consequences.html#Conditions

4. Villareal DT. Obesity and accelerated aging. J Nutr Health Aging. 2023;27(5):312‐313. doi: 10.1007/s12603-023-1922-0

5. Capodaglio P, Vismara L, Menegoni F, Cavigioli M. Obesity and disability. Int J Rehabil Res. 2009;32(suppl 1):S8. Abstract. doi: 10.1097/00004356-200908001-00011

6. Patton I, Salas XR, Hussey B, et al. Patient perceptions about obesity management in the context of concomitant care for other chronic diseases. Obes Pillars. 2023;8:100089. doi: 10.1016/j.obpill.2023.100089

7. 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(5):761‐767. doi: 10.1038/ijo.2015.243

8. Ross R, Neeland IJ, Yamashita S, et al. Waist circumference as a vital sign in clinical practice: a consensus statement from the IAS and ICCR working group on visceral obesity. Nat Rev Endocrinol. 2020;16(3):177‐189. doi: 10.1038/s41574-019-0310-7

9. Batsis JA, Gill LE, Masutani RK, et al. Weight loss interventions in older adults with obesity: a systematic review of randomized controlled trials since 2005. J Am Geriatr Soc. 2017;65(2):257‐268. doi: 10.1111/jgs.14514

10. 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(20):1943‐1955. doi: 10.1056/NEJMoa1616338

11. DiMilia PR, Mittman AC, Batsis JA. Benefit‐to‐risk balance of weight loss interventions in older adults with obesity. Curr Diab Rep. 2019;19(11):114. doi: 10.1007/s11892-019-1249-8

12. Dewar S, Janevic MR, Batsis JA, Alexander NB. Older adults with obesity: need for 4Ms age‐friendly approach to care. J Am Geriatr Soc. 2025;73(5):1621‐1623. doi: 10.1111/jgs.19353

13. Shirazi D, Haudenschild C, Lynch DH, et al. Obesity, multiple chronic conditions, and the relationship with physical function: data from the national health and aging trends survey. Arch Gerontol Geriatr. 2023;107:104913. doi: 10.1016/j.archger.2022.104913

14. Lynch DH, Petersen CL, Fanous MM, et al. The relationship between multimorbidity, obesity and functional impairment in older adults. J Am Geriatr Soc. 2022;70(5):1442‐1449. doi: 10.1111/jgs.17683

15. Robert SA, Reither EN. A multilevel analysis of race, community disadvantage, and body mass index among adults in the US. Soc Sci Med. 2004;59(12):2421‐2434. doi: 10.1016/j.socscimed.2004.03.034

16. Dasilva‐Deabreu A, Alhafez BA, Lavie CJ, Milani RV, Ventura HO. Interactions of hypertension, obesity, left ventricular hypertrophy, and heart failure. Curr Opin Cardiol. 2021;36(4):453‐460. doi: 10.1097/HCO.0000000000000868

17. Kenchaliah S, Evans J, Levy D, Wilson P. Obesity and the risk of heart failure. N Engl J Med. 2002;347(5):307‐313. doi: 10.1056/nejmoa020245

18. Aryee EK, Ozkan B, Ndumele CE. Heart failure and obesity: the latest pandemic. Prog Cardiovasc Dis. 2023;78:43‐48. doi: 10.1016/j.pcad.2023.05.003

19. Ryan DH, Lingvay I, Deanfield J, et al. Long‐term weight loss effects of semaglutide in obesity without diabetes in the SELECT trial. Nat Med. 2024;30(7):2049‐2057. doi: 10.1038/s41591-024-02996-7

20. Lilly's tirzepatide successful in phase 3 study showing benefit in adults with heart failure with preserved ejection fraction and obesity. Published August 1, 2024. Accessed October 28, 2024. https://investor.lilly.com/node/51151/pdf

21. Middeldorp ME, Kamsani SH, Sanders P. Obesity and atrial fibrillation: prevalence, pathogenesis, and prognosis. Prog Cardiovasc Dis. 2023;78:34‐42. doi: 10.1016/j.pcad.2023.04.010

22. Nicklas BJ, Brinkley TE, Houston DK, et al. Effects of caloric restriction on cardiorespiratory fitness, fatigue, and disability responses to aerobic exercise in older adults with obesity: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2019;74(7):1084‐1090. doi: 10.1093/gerona/gly159

23. Hanson C, LeVan T. Obesity and chronic obstructive pulmonary disease: recent knowledge and future directions. Curr Opin Pulm Med. 2017;23(2):149‐153. doi: 10.1097/MCP.0000000000000354

24. Carpaij OA, Van Den Berge M. The asthma‐obesity relationship: underlying mechanisms and treatment implications. Curr Opin Pulm Med. 2018;24(1):42‐49. doi: 10.1097/MCP.0000000000000446

25. Sheka AC, Adeyi O, Thompson J, Hameed B, Crawford PA, Ikramuddin S. Nonalcoholic steatohepatitis: a review. JAMA. 2020;323(12):1175‐1183. doi: 10.1001/jama.2020.2298

26. Tamaki N, Imajo K, Sharpton SR, et al. Two‐step strategy, FIB‐4 followed by magnetic resonance elastography, for detecting advanced fibrosis in NAFLD. Clin Gastroenterol Hepatol. 2023;21(2):380‐387.e3. doi: 10.1016/j.cgh.2022.01.023

27. Sanyal AJ, Foucquier J, Younossi ZM, et al. Enhanced diagnosis of advanced fibrosis and cirrhosis in individuals with NAFLD using FibroScan‐based agile scores. J Hepatol. 2023;78(2):247‐259. doi: 10.1016/j.jhep.2022.10.034

28. Montemayor S, Mascaró CM, Ugarriza L, et al. Adherence to Mediterranean diet and NAFLD in patients with metabolic syndrome: the FLIPAN study. Nutrients. 2022;14(15):3186. doi: 10.3390/nu14153186

29. Guirguis E, Dougherty J, Thornby K, Grace Y, Mack K. Resmetirom: the first Food and Drug Administration–approved medication for nonalcoholic steatohepatitis (NASH). Ann Pharmacother. 2024;59(2):162‐173. doi: 10.1177/10600280241259528

30. Kanwal F, Kramer JR, Li L, et al. GLP‐1 receptor agonists and risk for cirrhosis and related complications in patients with metabolic dysfunction‐associated steatotic liver disease. JAMA Intern Med. 2024;184(11):1314‐1323. doi: 10.1001/jamainternmed.2024.4661

31. Harrison SA, Browne SK, Suschak JJ, et al. Effect of pemvidutide, a GLP‐1/glucagon dual receptor agonist, on MASLD: a randomized, double‐blind, placebo‐controlled study. J Hepatol. 2025;82:7‐17. doi: 10.1016/j.jhep.2024.07.006

32. Shabil M, Khatib MN, Ballal S, et al. Risk of hepatocellular carcinoma with glucagon‐like peptide‐1 receptor agonist treatment in patients: a systematic review and meta‐analysis. BMC Endocr Disord. 2024;24(1):246. doi: 10.1186/s12902-024-01775-2

33. Storandt MH, Tella SH, Wieczorek MA, et al. Projected incidence of hepatobiliary cancers and trends based on age, race, and gender in the United States. Cancers (Basel). 2024;16(4):684. doi: 10.3390/cancers16040684

34. Kounatidis D, Vallianou NG, Geladari E, et al. NAFLD in the 21st century: current knowledge regarding its pathogenesis, diagnosis and therapeutics. Biomedicines. 2024;12(4):826. doi: 10.3390/biomedicines12040826

35. Perkovic V, Tuttle KR, Rossing P, et al. Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. N Engl J Med. 2024;391(2):109‐121. doi: 10.1056/nejmoa2403347

36. Danziger J, Chen KP, Lee J, et al. Obesity, acute kidney injury, and mortality in critical illness. Crit Care Med. 2016;44(2):328‐334. doi: 10.1097/CCM.0000000000001398

37. Wang J, Xu X, Wang C, et al. Association of acute kidney injury with the risk of cognitive impairment or dementia: a systematic review and meta‐analysis. Ren Fail. 2023;45(2):2279647. doi: 10.1080/0886022X.2023.2279647

38. Bindlish S, Ng J, Ghusn W, Fitch A, Bays HE. Obesity, thrombosis, venous disease, lymphatic disease, and lipedema: An Obesity Medicine Association (OMA) clinical practice statement (CPS) 2023. Obes Pillars. 2023;8:100092. doi: 10.1016/j.obpill.2023.100092

39. Avgerinos KI, Spyrou N, Mantzoros CS, Dalamaga M. Obesity and cancer risk: emerging biological mechanisms and perspectives. Metabolism. 2019;92:121‐135. doi: 10.1016/j.metabol.2018.11.001

40. Rosen AB, Schneider EC. Colorectal cancer screening disparities related to obesity and gender. J Gen Intern Med. 2004;19(4):332‐338. doi: 10.1111/j.1525-1497.2004.30339.x

41. Cohen SS, Palmieri RT, Nyante SJ, et al. A review: obesity and screening for breast, cervical, and colorectal cancer in women. Cancer. 2008;112(9):1892‐1904. doi: 10.1002/cncr.23408

42. Hurtado MD, Tama E, D'Andre S, Shufelt CL. The relation between excess adiposity and breast cancer in women: clinical implications and management. Crit Rev Oncol Hematol. 2024;193:104213. doi: 10.1016/j.critrevonc.2023.104213

43. Lincoln KD. Race, obesity, and mental health among older adults in the United States: a literature review. Innov Aging. 2020;4(5):igaa031. doi: 10.1093/geroni/igaa031

44. Xiang X, An R. Obesity and onset of depression among U.S. middle‐aged and older adults. J Psychosom Res. 2015;78(3):242‐248. doi: 10.1016/j.jpsychores.2014.12.008

45. Stanford FC, Cena H, Biino G, et al. The association between weight‐promoting medication use and weight gain in postmenopausal women: findings from the Women's Health Initiative. Menopause. 2020;27(10):1117‐1125. doi: 10.1097/GME.0000000000001589

46. Pennings N, Golden L, Yashi K, Tondt J, Bays HE. Sleep‐disordered breathing, sleep apnea, and other obesity‐related sleep disorders: An Obesity Medicine Association (OMA) clinical practice statement (CPS) 2022. Obes Pillars. 2022;4:100043. doi: 10.1016/j.obpill.2022.100043

47. Gu C, Younas H, Jun JC. Sleep apnea: An overlooked cause of lipotoxicity? Med Hypotheses. 2017;108:161‐165. doi: 10.1016/j.mehy.2017.09.007

48. Kuna ST, Reboussin DM, Strotmeyer ES, et al. Effects of weight loss on obstructive sleep apnea severity ten‐year results of the Sleep AHEAD study. Am J Respir Crit Care Med. 2021;203(2):221‐229. doi: 10.1164/rccm.201912-2511OC

49. Carneiro‐Barrera A, Amaro‐Gahete FJ, Guillén‐Riquelme A, et al. Effect of an interdisciplinary weight loss and lifestyle intervention on obstructive sleep apnea severity: the INTERAPNEA randomized clinical trial. JAMA Netw Open. 2022;5(4):E228212. doi: 10.1001/jamanetworkopen.2022.8212

50. Someya Y, Tamura Y, Kaga H, Sugimoto D. Sarcopenic obesity is associated with cognitive impairment in community‐dwelling older adults: the Bunkyo health study. Clin Nutr. 2025;41(5):1046‐1051. doi: 10.1016/j.clnu.2022.03.017

51. Leigh SJ, Morris MJ. Diet, inflammation and the gut microbiome: mechanisms for obesity‐associated cognitive impairment. Biochim Biophys Acta Mol Basis Dis. 2020;1866(6):165767. doi: 10.1016/j.bbadis.2020.165767

52. Gomes Gonçalves N, Vidal Ferreira N, Khandpur N, et al. Association between consumption of ultraprocessed foods and cognitive decline. JAMA Neurol. 2023;80(2):142‐150. doi: 10.1001/jamaneurol.2022.4397

53. Mei J, Li Y, Niu L, et al. SGLT2 inhibitors: a novel therapy for cognitive impairment via multifaceted effects on the nervous system. Transl Neurodegener. 2024;13:41. doi: 10.1186/s40035-024-00431-y

54. Fontanella RA, Ghosh P, Pesapane A, et al. Tirzepatide prevents neurodegeneration through multiple molecular pathways. J Transl Med. 2024;22(1):114. doi: 10.1186/s12967-024-04927-z

55. Nedunchezhiyan U, Varughese I, Sun ARJ, Wu X, Crawford R, Prasadam I. Obesity, inflammation, and immune system in osteoarthritis. Front Immunol. 2022;13:907750. doi: 10.3389/fimmu.2022.907750

56. Batsis JA, Zbehlik AJ, Barre LK, Bynum JPW, Pidgeon D, Bartels SJ. Impact of obesity on disability, function, and physical activity: data from the Osteoarthritis Initiative. Scand J Rheumatol. 2015;44(6):495‐502. doi: 10.3109/03009742.2015.1021376

57. Himes CL, Reynolds SL. Effect of obesity on falls, injury, and disability. J Am Geriatr Soc. 2012;60(1):124‐129. doi: 10.1111/j.1532-5415.2011.03767.x

58. Allin LJ, Wu X, Nussbaum MA, Madigan ML. Falls resulting from a laboratory‐induced slip occur at a higher rate among individuals who are obese. J Biomech. 2016;49(5):678‐683. doi: 10.1016/j.jbiomech.2016.01.018

59. Koushyar H, Anderson DE, Nussbaum MA, Madigan ML. Relative effort while walking is higher among women who are obese, and older women. Med Sci Sports Exerc. 2020;52(1):105‐111. doi: 10.1249/MSS.0000000000002093

60. Dufour AB, Losina E, Menz HB, LaValley MP, Hannan MT. Obesity, foot pain and foot disorders in older men and women. Obes Res Clin Pract. 2017;11(4):445‐453. doi: 10.1016/j.orcp.2016.11.001

61. Meng H, Gorniak SL. Obesity is associated with gait alterations and gait asymmetry in older adults. Motor Control. 2022;27(1):6‐19. doi: 10.1123/mc.2021-0125

62. Vincent HK, Vincent KR, Lamb KM. Obesity and mobility disability in the older adult. Obes Rev. 2010;11(8):568‐579. doi: 10.1111/j.1467-789X.2009.00703.x

63. Schaap LA, Koster A, Visser M. Adiposity, muscle mass, and muscle strength in relation to functional decline in older persons. Epidemiol Rev. 2013;35(1):51‐65. doi: 10.1093/epirev/mxs006

64. Batsis JA, Sahakyan KR, Rodriguez‐Escudero JP, Bartels SJ, Lopez‐Jimenez F. Normal weight obesity and functional outcomes in older adults. Eur J Intern Med. 2014;25(6):517‐522. doi: 10.1016/j.ejim.2014.05.008

65. Raud B, Gay C, Guiguet‐Auclair C, et al. Level of obesity is directly associated with the clinical and functional consequences of knee osteoarthritis. Sci Rep. 2020;10(1):3601. doi: 10.1038/s41598-020-60587-1

66. Jensen GL, Silver HJ, Roy MA, Callahan E, Still C, Dupont W. Obesity is a risk factor for reporting homebound status among community‐dwelling older persons. Obesity (Silver Spring). 2006;14(3):509‐517. doi: 10.1038/oby.2006.66

67. Khairat S, Haithcoat T, Liu S, et al. Advancing health equity and access using telemedicine: a geospatial assessment. J Am Med Inform Assoc. 2019;26(8–9):796‐805. doi: 10.1093/jamia/ocz108

68. Qian M, Shi Y, Yu M. The association between obesity and chronic pain among community‐dwelling older adults: a systematic review and meta‐analysis. Geriatr Nurs. 2021;42(1):8‐15. doi: 10.1016/j.gerinurse.2020.10.017

69. Janke EA, Fritz M, Hopkins C, Haltzman B, Sautter JM, Ramirez ML. A randomized clinical trial of an integrated behavioral self‐management intervention Simultaneously Targeting Obesity and Pain: the STOP trial. BMC Public Health. 2014;14:1‐10. doi: 10.1186/1471-2458-14-621

70. Salis Z, Sainsbury A, Keen IH, Gallego B, Jin X. Weight loss is associated with reduced risk of knee and hip replacement: a survival analysis using Osteoarthritis Initiative data. Int J Obes (Lond). 2022;46(4):874‐884. doi: 10.1038/s41366-021-01046-3

71. Anandacoomarasamy A, Leibman S, Smith G, et al. Weight loss in obese people has structure‐modifying effects on medial but not on lateral knee articular cartilage. Ann Rheum Dis. 2012;71(1):26‐32. doi: 10.1136/ard.2010.144725

72. Halabitska I, Babinets L, Oksenych V, Kamyshnyi O. Diabetes and osteoarthritis: exploring the interactions and therapeutic implications of insulin, metformin, and GLP‐1‐based interventions. Biomedicines. 2024;12(8):1630. doi: 10.3390/biomedicines12081630

73. Seward MW, Briggs LG, Bain PA, Chen AF. Preoperative nonsurgical weight loss interventions before total hip and knee arthroplasty: a systematic review. J Arthroplasty. 2021;36(11):3796‐3806.e8. doi: 10.1016/j.arth.2021.06.021

74. Neri SGR, Harvey LA, Tiedemann A, Gadelha AB, Lima RM. Obesity and falls in older women: mediating effects of muscle quality, foot loads and postural control. Gait Posture. 2020;77:138‐143. doi: 10.1016/j.gaitpost.2020.01.025

75. Dantas LO, de Fátima Salvini, McAlindon TE. Knee osteoarthritis: key treatments and implications for physical therapy. Braz J Phys Ther. 2021;25(2):135‐146. doi: 10.1016/j.bjpt.2020.08.004

76. Smith GL, Banting L, Eime R, O'Sullivan G, van Uffelen JGZ. The association between social support and physical activity in older adults: a systematic review. Int J Behav Nutr Phys Act. 2017;14(1):56. doi: 10.1186/s12966-017-0509-8

77. Javed Z, Valero‐Elizondo J, Maqsood MH, et al. Social determinants of health and obesity: findings from a national study of US adults. Obesity (Silver Spring). 2022;30(2):491‐502. doi: 10.1002/oby.23336

78. Tran HT, Leonard SD. Geriatric assessment for primary care providers. Prim Care. 2024;44(3):399‐411. doi: 10.1016/j.pop.2017.05.001

79. Roubenoff R. Sarcopenic obesity: the confluence of two epidemics. Obes Res. 2004;12(6):887‐888. doi: 10.1038/oby.2004.107

80. Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14(9):513‐537. doi: 10.1038/s41574-018-0062-9

81. Prado CM, Batsis JA, Donini LM, Gonzalez MC, Siervo M. Sarcopenic obesity in older adults: a clinical overview. Nat Rev Endocrinol. 2024;20(5):261‐277. doi: 10.1038/s41574-023-00943-z

82. Marcelissen T, Anding R, Averbeck M, Hanna‐Mitchell A, Rahnama'i S, Cardozo L. Exploring the relation between obesity and urinary incontinence: pathophysiology, clinical implications, and the effect of weight reduction, ICI‐RS 2018. Neurourol Urodyn. 2019;38(suppl 5):S18‐S24. doi: 10.1002/nau.24072

83. Elmaleh‐Sachs A, Schwartz JL, Bramante CT, Nicklas JM, Gudzune KA, Jay M. Obesity management in adults: a review. JAMA. 2023;330(20):2000‐2015. doi: 10.1001/jama.2023.19897

84. Wadden TA, Chao AM, Moore M, et al. The role of lifestyle modification with second‐generation anti‐obesity medications: comparisons, questions, and clinical opportunities. Curr Obes Rep. 2023;12(4):453‐473. doi: 10.1007/s13679-023-00534-z

85. Wadden TA, Chao AM, Machineni S, et al. Tirzepatide after intensive lifestyle intervention in adults with overweight or obesity: the SURMOUNT‐3 phase 3 trial. Nat Med. 2023;29(11):2909‐2918. doi: 10.1038/s41591-023-02597-w

86. Mathus‐Vliegen EMH. Obesity and the elderly. J Clin Gastroenterol. 2012;46(7):533‐544. doi: 10.1097/MCG.0b013e31825692ce

87. Curry SJ, Krist AH, Owens DK, et al. Behavioral weight loss interventions to prevent obesity‐related morbidity and mortality in adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(11):1163‐1171. doi: 10.1001/jama.2018.13022

88. MOVE! Weight Management Program . Accessed July 21, 2024. https://www.move.va.gov/MOVE/QandA.asp

89. Dewar S, Bynum J, Batsis JA. Uptake of obesity intensive behavioral treatment codes in Medicare beneficiaries, 2012–2015. J Gen Intern Med. 2019;35(1):368‐370. doi: 10.1007/s11606-019-05437-1

90. Ozoor M, Gritz M, Dolor RJ, Holtrop JS, Luo Z. Primary care provider uptake of intensive behavioral therapy for obesity in Medicare patients, 2013–2019. PLoS One. 2023;18(3):e0266217. doi: 10.1371/journal.pone.0266217

91. Rejeski WJ, Fanning J. Models and theories of health behavior and clinical interventions in aging: a contemporary, integrative approach. Clin Interv Aging. 2019;14:1007‐1019. doi: 10.2147/CIA.S206974

92. Chaston TB, Dixon JB, O'Brien PE. Changes in fat‐free mass during significant weight loss: a systematic review. Int J Obes (Lond). 2007;31(5):743‐750. doi: 10.1038/sj.ijo.0803483

93. Jiang BC, Villareal DT. Weight loss‐induced reduction of bone mineral density in older adults with obesity. J Nutr Gerontol Geriatr. 2019;38(1):100‐114. doi: 10.1080/21551197.2018.1564721

94. Colleluori G, Villareal DT. Weight strategy in older adults with obesity: calorie restriction or not? Curr Opin Clin Nutr Metab Care. 2023;26(1):17‐22. doi: 10.1097/MCO.0000000000000879

95. Al‐Nimr RI. Optimal protein intake during weight loss interventions in older adults with obesity. J Nutr Gerontol Geriatr. 2019;38(1):50‐68. doi: 10.1080/21551197.2018.1544533

96. Hanna AMR. Solving the obesity crisis in older adults with the Mediterranean diet: policy brief. J Nutr Health Aging. 2023;27(11):966‐971. doi: 10.1007/s12603-023-1995-9

97. Mazza E, Ferro Y, Pujia R, et al. Mediterranean diet in healthy aging. J Nutr Health Aging. 2021;25(9):1076‐1083. doi: 10.1007/s12603-021-1675-6

98. Panda S, Maier G, Villareal DT. Targeting energy intake and circadian biology to engage mechanisms of aging in older adults with obesity: calorie restriction and time‐restricted eating. J Gerontol A Biol Sci Med Sci. 2023;78:79‐85. doi: 10.1093/gerona/glad069

99. Oppert JM, Ciangura C, Bellicha A. Physical activity and exercise for weight loss and maintenance in people living with obesity. Rev Endocr Metab Disord. 2023;24(5):937‐949. doi: 10.1007/s11154-023-09805-5

100. Waters DL, Aguirre L, Gurney B, et al. Effect of aerobic or resistance exercise, or both, on intermuscular and visceral fat and physical and metabolic function in older adults with obesity while dieting. J Gerontol A Biol Sci Med Sci. 2022;77(1):131‐139. doi: 10.1093/gerona/glab111

101. Jakicic JM, Apovian CM, Barr‐Anderson DJ, et al. Physical activity and excess body weight and adiposity for adults. American College of Sports Medicine consensus statement. Transl J Am Coll Sports Med. 2024;9(4):e000266. doi: 10.1249/TJX.0000000000000266

102. Fyfe JJ, Hamilton DL, Daly RM. Minimal‐dose resistance training for improving muscle mass, strength, and function: a narrative review of current evidence and practical considerations. Sports Med. 2022;52(3):463‐479. doi: 10.1007/s40279-021-01605-8

103. Collado‐Mateo D, Lavín‐Pérez AM, Peñacoba C, et al. Key factors associated with adherence to physical exercise in patients with chronic diseases and older adults: An umbrella review. Int J Environ Res Public Health. 2021;18(4):2023. doi: 10.3390/ijerph18042023

104. Harvey JA, Chastin SFM, Skelton DA. Prevalence of sedentary behavior in older adults: a systematic review. Int J Environ Res Public Health. 2013;10(12):6645‐6661. doi: 10.3390/ijerph10126645

105. Silveira EA, Mendonça CR, Delpino FM, et al. Sedentary behavior, physical inactivity, abdominal obesity and obesity in adults and older adults: a systematic review and meta‐analysis. Clin Nutr ESPEN. 2022;50:63‐73. doi: 10.1016/j.clnesp.2022.06.001

106. Tahrani AA, Morton J. Benefits of weight loss of 10% or more in patients with overweight or obesity: a review. Obesity (Silver Spring). 2022;30(4):802‐840. doi: 10.1002/oby.23371

107. Henney AE, Wilding JPH, Alam U, Cuthbertson DJ. Obesity pharmacotherapy in older adults: a narrative review of evidence. Int J Obes (Lond). 2025;49(3):369‐380. doi: 10.1038/s41366-024-01529-z

108. Perna S, Guido D, Bologna C, et al. Liraglutide and obesity in elderly: efficacy in fat loss and safety in order to prevent sarcopenia. A perspective case series study. Aging Clin Exp Res. 2016;28(6):1251‐1257. doi: 10.1007/s40520-015-0525-y

109. Drucker DJ. Mechanisms of action and therapeutic application of glucagon‐like peptide‐1. Cell Metab. 2018;27(4):740‐756. doi: 10.1016/j.cmet.2018.03.001

110. Heymsfield SB, Gonzalez MCC, Shen W, Redman L, Thomas D. Weight loss composition is one‐fourth fat‐free mass: a critical review and critique of this widely cited rule. Obes Rev. 2014;15(4):310‐321. doi: 10.1111/obr.12143

111. Mechanick JI, Butsch WS, Christensen SM, et al. Strategies for minimizing muscle loss during use of incretin‐mimetic drugs for treatment of obesity. Obes Rev. 2025;26(1):e13841. doi: 10.1111/obr.13841

112. Hales CM, Gu Q, Ogden CL, Yanovski SZ. Use of prescription medications associated with weight gain among US adults, 1999‐2018: a nationally representative survey. Obesity (Silver Spring). 2022;30(1):229‐239. doi: 10.1002/oby.23299

113. Pfefferkorn U, Hort S, Beluli M, La Vista M, Züger T. Weight loss after bariatric surgery in different age groups. Obes Surg. 2023;33(4):1154‐1159. doi: 10.1007/s11695-023-06488-4

114. Rahimi AO, Ashouri Y, Maegawa F, Hsu CH, Ghaderi I. Robotic bariatric surgery in older adults, is it safer than the laparoscopic approach? A 7‐year analysis of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database. Obes Surg. 2023;33(9):2671‐2678. doi: 10.1007/s11695-023-06720-1

115. Ferrucci L, Kuchel GA. Heterogeneity of aging: individual risk factors, mechanisms, patient priorities, and outcomes. J Am Geriatr Soc. 2021;69(3):610‐612. doi: 10.1111/jgs.17011

116. Callahan EA, Vafiadis DK, Cameron KA, Stanford FC. A call for solutions for healthy aging through a systems‐based, equitable approach to obesity. J Am Geriatr Soc. 2022;70(5):1599‐1604. doi: 10.1111/jgs.17732

117. Kuchel G, Fortinsky R, Ferrucci L. Heterogeneity of aging: implications for team care and team science. Innov Aging. 2020;4(suppl 1):854. GSA abstract. doi: 10.1093/geroni/igaa057.3144

118. Zhang N, Field T, Mazor KM, Zhou Y, Lapane KL, Gurwitz JH. The increasing prevalence of obesity in residents of U.S. nursing homes: 2005–2015. J Gerontol A Biol Sci Med Sci. 2019;74(12):1929‐1936. doi: 10.1093/gerona/gly265

119. Barber SE, Forster A, Birch KM. Levels and patterns of daily physical activity and sedentary behavior measured objectively in older care home residents in the United Kingdom. J Aging Phys Act. 2015;23(1):133‐143. doi: 10.1123/japa.2013-0091

120. Sacoto D, Hurtado MD, Acosta A. Precision medicine and obesity. Handb Exp Pharmacol. 2022;274:467‐485. doi: 10.1007/164_2021_566

121. Kuchel GA. Function begets function and resilience in old age: is precision gerontology possible? J Am Geriatr Soc. 2017;65(6):1141‐1144. doi: 10.1111/jgs.14901

Associated Data

Data Availability Statement

Data sharing not applicable‐no new data generated, or the article describes entirely theoretical research.