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-and-supplements/can-phentermine-diet-pills-really-help-you-to-lose-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) Sibutramine (Meridia)

http://www.nhplus.com/product_detail_e.cfm?ID=16111

http://www.sibutramineonline.org/

Orlistat (Alli, Xenical)

http://phentermine-hcl.info/

Phentermine Sibutramine OrlistatApproved for

• Short-term • BMI ≥ 30, or• BMI ≥27 with

Comorbidities

• In combo w/reduced calorie diet, exercise,& behavior modification

• 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

• 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

MOA Inhibits reuptake of NE & DA

Inhibits reuptake of NE, 5-HT, DA (minimal)

Inhibits lipase enzymes of the GI tract

Adverse Events

• Overstimulation

• Dizziness

• Euphoria/dysphoria

• Sympathomimetic side effects

• Sympathomimetic side effects

• Occurrence of HTN 5-8% of pts

• No systemic AEs

• Oily stools

• Flatulence

• Incr defecation

• Fecal incontinence

Phentermine Sibutramine Orlistat

D-D interactions • MAOIs (monoamine oxidase inhibitors

• TCAs, sibutramine, bupropion, SSRIs

• Anti-hypertensive medications

• MAOIs (monoamine oxidase inhibitors

• TCAs, SSRIs, pseudoephedrine, phentermine

• Warfarin• Fat soluble

vitamins

contraindications • Moderate to severe HTN

• Hyperthyroidism

• Cardiovascular diseases

• Poorly controlled HTN

• Coronary artery disease

• History of arrhythmias, HF, stroke

• Malabsorption syndrome

• cholestasis

Comments Development of tolerance in few months

Withdrawn from market in 2010 due to cardiovascular events

Has few drug interactions

Phentermine OrlistatDose 15-37.5

tablet/capsule po in 1-2 divided doses

Xenical: 120 mg capsule po tid 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