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Obesity in Older Adults Terry Son PharmD Candidate, 2012 Mercer University November 6, 2011 Obesity in Older Adults http://www.youtube.com/watch?v=uonXKiLZ9AE Terry Son PharmD Candidate, 2012 Mercer University November 6, 2011 Dietary Management for Older Subjects with Obesity Chernoff R. Clin Geriatr Med 2005; 21: 725-733 http://www.learnwell.org/nutri.htm 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 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 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 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 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 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 Fluid Recommended daily intake: 30ml/kg with a minimum of 1500 ml Challenge: thirst sensitivity decreases and encouragement of consumption may be difficult 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 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 Physician-Assisted Weight Loss and Maintenance in the Elderly Kiehn JM, Ghormley CO, Williams EB. Clin Geriatr Med 2005;21:713-723 http://www.wvva.com/category/218455/medical-weight-loss-skin-care-clinic 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 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 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 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 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 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 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) 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 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 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 Pharmacologic Agents for the Treatment of Obesity Mathys M; Clin Geriatr 2005;21:735-746 http://www.weightlossdietwatch.com/diet-pills-andsupplements/can-phentermine-diet-pills-really-help-you-tolose-weight/ 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 ≥ 27 with obesity-related conditions, such as diabetes or high blood pressure. Phentermine (Adipex-P) http://phentermine-hcl.info/ Sibutramine (Meridia) http://www.sibutramineonline.org/ Orlistat (Alli, Xenical) http://www.nhplus.com/product_detail_e.cfm?I D=16111 Phentermine Approved for • Short-term • BMI ≥ 30, or • BMI ≥27 with Comorbidities • In combo w/reduced calorie diet, exercise,& behavior modification MOA Inhibits reuptake of NE & DA Adverse Events • Overstimulation • Dizziness • Euphoria/dysphoria • Sympathomimetic side effects Sibutramine Orlistat • Wt loss and maintenance • In combo with reduced calorie diet, exercise and behavior modification • • BMI ≥ 30, or BMI ≥27 w/at least one cardiac risk factor Inhibits reuptake of NE, 5-HT, DA (minimal) • • Sympathomimetic side effects Occurrence of HTN 5-8% of pts • Wt loss and maintenance • In combo with reduced calorie diet, exercise and behavior modification • • BMI ≥ 30, or BMI ≥27 w/at least one cardiac risk factor Inhibits lipase enzymes of the GI tract • No systemic AEs • Oily stools • Flatulence • Incr defecation • Fecal incontinence Phentermine Sibutramine D-D interactions contraindications Comments Orlistat • MAOIs (monoamine oxidase inhibitors • MAOIs (monoamine oxidase inhibitors • TCAs, sibutramine, bupropion, SSRIs • • Anti-hypertensive medications TCAs, SSRIs, pseudoephedrine, phentermine • Moderate to severe HTN • Poorly controlled HTN • Malabsorption syndrome • Hyperthyroidism • cholestasis • Cardiovascular diseases • Coronary artery disease Development of tolerance in few months • Warfarin • Fat soluble vitamins • History of arrhythmias, HF, stroke Withdrawn from market in 2010 due to cardiovascular events Has few drug interactions Phentermine Dose Orlistat 15-37.5 Xenical: 120 mg tablet/capsule po in capsule po tid 1-2 divided doses w/each main meal containing fat (during or up to 1 hr after meal) Alli (OTC): 60 mg capsule po tid Comments Safer b/c of fewer side effects and drug interactions 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 Obesity in Older Adults Terry Son PharmD Candidate, 2012 Mercer University November 6, 2011
