Transcript Obesity in Older Adults

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