Obesity in Older Adults

1. Obesity in Older Adults Terry Son PharmD Candidate, 2012 Mercer University November 6, 2011

2. Obesity in Older Adultshttp://www.youtube.com/watch?v=uonXKiLZ9AE Terry Son PharmD Candidate, 2012 Mercer University November 6, 2011

3. Dietary Management for Older Subjects with ObesityChernoff R. Clin Geriatr Med 2005; 21: 725-733 http://www.learnwell.org/nutri.htm

4. Background • Older adults have a decreased in lean body mass, total body water and bone density, and an increased proportion of total body fat • Intra-abdominal fat makes up a greater proportion of body composition in older adults • Increased in morbidity and mortality • Efficacy of interventions involving surgery, exercise, diet, and medications have not been adequately evaluated in this age group • There are heterogeneity of the older population, so weight management in older adults requires individualization

5. Essential Nutrient Requirement • Caloric restriction without structure or plan may contribute to an inadequate intake of essential nutrients and a loss of lean body tissue and may compromise the reserve capacity • Reduced calorie diets must meet essential nutrient requirements • protein, vitamin D, vitamin B¹², fiber, and fluid

6. Protein • Recommended daily intake (should be high):0.8-1.5 g/kg/d • Extra protein is needed for healing or if chair or bedbound • If a caloric reducing diet does not provide enough protein, muscle wasting occurs, immune function may be compromised, healing is slow, and new tissue is of poor quality

7. Vitamin D • Recommended daily intake: • 19-70 years—600 IU • >70 years—800 IU • Needed for bone health and immune function • Primary dietary source—fortified milk • If milk product intolerance—choose over the counter supplements

8. Vitamin B¹² • Recommended daily intake: 2.4mcg • Nutrient that is at risk for older adults due to reduced consumption of red meat and organ meats, decreased in intrinsic factor production, an increased prevalence of atrophic gastritis, and a potential for bacterial overgrowth • Oral supplements are in crystalline form which does not need gastric acid for absorption

9. Fiber • Provides bulk in a diet and promotes peristalsis, and GI function • Fiber in older adults decreased due to reduced consumption in complex carbohydrate, vegetables, and fruits • Dietary fiber is often used by older adults for bowel regulation and peristalsis • Commercially available products: bran fiber, psyllium, chemical stimulants

10. Fluid • Recommended daily intake: 30ml/kg with a minimum of 1500 ml • Challenge: thirst sensitivity decreases and encouragement of consumption may be difficult

11. Weight Reduction Strategies • Should not compromise nutritional status, meet nutritional requirements, and contribute to a healthy, sustained declined in weight • Should result in small changes and focus on reduction in fat intake • Increase HDL, decrease cholesterol, and triglycerides • Better functioning in patients with OA • Decrease glucose intolerance • Should not be a low carbohydrate diet, protein liquid diet, or a high fat diet

12. Recommendations: • Weight loss programs for older adults should focus on maintaining adequate intake of essential nutrients, while reducing caloric intake by controlling dietary fat intake • The DASH (Dietary Approaches to Stop Hypertension) diet is an option for older adults • Rich in fruits/vegetables • High in lean meats, poultry, and fish • Low fat diary products • Whole-grain breads and cereals • At least six 8-oz glasses of fluid • Older adults are encouraged to seek help of nutrition professionals such as registered dietitians for advice on how to modify their diets

13. Physician-Assisted Weight Loss and Maintenance in the ElderlyKiehn JM, Ghormley CO, Williams EB. Clin Geriatr Med 2005;21:713-723 http://www.wvva.com/category/218455/medical-weight-loss-skin-care-clinic

14. Background • Older individuals are living longer now and are at greater risk for excess weight gain and obesity • It has been suggested that body-weight set point may be increased with age, therefore increase the challenge for older adults to maintain young adult weight • Obesity’s high prevalence and strong influence on increased risk for a variety of health problems has become a challenge to clinicians in the primary care settings • Intentional weight loss benefit older adults but unintentional weight loss resulting in low BMI may be related to increased mortality • There is limited information available that focuses on weight-loss interventions in older adults

15. Lack of Physician Intervention • Many overweight patients never receive advice from their primary care physicians about their need for weight loss or how to appropriately achieve a healthy weight • Only about 34% of individuals with obesity reported receiving any type of weight loss management counseling • Less than ½ of patients with cardiovascular risk factors reported being counseled to lose weight • Individuals with diabetes and BMI greater than 35 were two-three times more likely to receive such advice • Rates of weight-counseling intervention by a health care provider were higher for women, those with higher education, and those of higher socioeconomic status

16. Barriers to Physician Intervention • Lack of reimbursement from insurance companies for weight management services • Limited time availability during office visits • Low physicians confidence • Lack of training in weight-management counseling • Pessimism as to whether counseling produces actual behavior change • Physicians and patients take different approaches to discussing weight management

17. The Role of the Physician • Assess obesity risk • American College of Preventative Medicine: All adults should be regularly received counseling about healthy eating and exercise • The US Preventative Services Task Force: Physicians are recommended to take periodic height and weight measurements to track body fat over time • BMI calculation: weight (kg)/height squared (m²) • BMI<24 and >27: increased nutritional risk in elderly • Assess readiness to change • Inquire about patient weight history, previous attempts to lose weight, reasons for wanting to lose weight, social support, barriers to lose weight, and major stressors • Assist in discussing consequences of not changing and helping patients establish their own reasons for change

18. The Role of the Physician • Assist in developing a weight-management program • Unique to the individual • The patient should be involved in the development of the weight-loss program: • Realistic weight-loss goals (3.5-5 kg or 10%-15% of body weight), • Financial cost, • Time frame, and • Need for long-term weight maintenance

19. Role of the Physician • Establishing appropriate interventions • Healthy diet • Diet that incorporates all essential nutrients, lower in fat, with higher percentages of carbohydrate and protein • Diet that decreases sugar and alcohol • Exercise • Start slow and gradually increase to accommodate the patient’s current conditioning level • Regular exercise q30min/d x 5 d/w • Gardening, housekeeping, golfing • Combining aerobics and strengthening exercises prevent functional declines, improve QOL

20. Role of the Physician • Establishing appropriate interventions (continued) • Commercial weight loss programs • Include individual or group plans • Include the program or physician-prescribed eating plans • Incorporate exercise, behavior modification, frequent follow-up, and methods for maintenance of weight loss • Examples: Weight Watchers, Jenny Craig, LA Weight Loss Centers, Take Off Pounds Sensibly (TOPs), Overeater’s Anonymous (OA)

21. Role of the Physician • Establishing appropriate interventions (continued) • Other interventions • Behavioral-therapy strategies • Self-monitor weight, food intake, and exercise • Identify and control stimuli that trigger overeating • Physician-initiated consultation with dietitians, exercise physiologists, and psychologists • Provide follow-up care • Review current weight-loss strategies and goals • Implement positive reinforcement of patient effort • Long-term support and ongoing communications

22. Barriers to Success • Absence of sustained reinforcement • Patient discouragement • Lack of social support • Depression • Physicians should acknowledge and address potential barriers before initiating a weight-loss plan • When appropriate, referrals should be made to specialists in other disciplines who can assist in successful weight loss and maintenance

23. Summary • Growing epidemic of obesity constitutes one of the most serious and widespread public challenges that has impact on disease and mortality • Encouragement, support, and guidance related to diet and exercise only takes about 3-5 minutes per office visit to influence an individual’s behavior • Patients who were told by their physicians to lose weight were three times more likely to attempt to lose weight than those patients who never received advice • Modest weight loss has positive effect on patient gaining control of obesity-related illnesses

24. Pharmacologic Agents for the Treatment of ObesityMathys M; Clin Geriatr 2005;21:735-746 http://www.weightlossdietwatch.com/diet-pills-and-supplements/can-phentermine-diet-pills-really-help-you-to-lose-weight/

25. When should pharmacotherapy be initiated? • Patients who failed to lose at least 10% of body weight within 6 months and make lifestyle change (diet, exercise, and behavior modification) • Patients with BMI ≥30 with no obesity-related conditions. • Patients with BMI ≥ 27with obesity-related conditions, such as diabetes or high blood pressure.

26. Phentermine (Adipex-P) Sibutramine (Meridia) Orlistat (Alli, Xenical) http://phentermine-hcl.info/ http://www.sibutramineonline.org/ http://www.nhplus.com/product_detail_e.cfm?ID=16111

30. Summary • 1/4 to 1/3 of the elderly are classified as obese • Many older adults benefit from safe weight-loss regimen that includes reduced-calorie diet, exercise, and behavior modification • Pharmacologic therapy has not been sufficiently studied in adults > 65 yo • Pharmacotherapy is usually not recommended • Orlistat may be a better choice over phentermine

31. Obesity in Older Adults Terry Son PharmD Candidate, 2012 Mercer University November 6, 2011