obesity in older adults terry son pharmd candidate, 2012 mercer university november 6, 2011
TRANSCRIPT
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