Mr. H is a 73-year-old male with obesity who has been overweight for most of his life. He has numerous comorbid conditions, including major depression, a 20-year history of hypertension, and chronic obstructive pulmonary disease. Three years ago, he was diagnosed with obstructive sleep apnea. His history includes hyperlipidemia and coronary artery disease with a myocardial infarction and stent placement in 1998.
Mr. H has a longstanding history of osteoarthritis and has been on disability since 1995 when he had an unprovoked fall. He underwent surgery for a displaced left patella fracture but never regained full function in his left leg. He uses a cane for support when ambulating. Although Mr. H's gait is somewhat unsteady and his mobility limited, he has no limitations performing activities of daily living (ADL).
Over the past few years, Mr. H's weight has gradually increased from a baseline of 258 lb (117 kg) to 324 lb (147 kg) with a body mass index (BMI) of 47.6 kg/m 2 . He dismissed repeated recommendations from his primary care NP to alter his diet, increase physical activity according to his capabilities, and lose weight until routine lab work revealed an increase in fasting blood glucose (FBG) level from 98 mg/dL to 239 mg/dL and an increase in his A1C from 6.7% to 10.1%. Mr. H was diagnosed with type 2 diabetes mellitus (T2DM) and prescribed metformin. It was at this point that fear motivated him to lose weight. He recalled his mother, who was obese and had a leg amputated due to T2DM, vowing that he did “not want to lose his leg.”
Data from the National Health and Nutrition Examination Survey indicate today's baby boomers have significantly higher rates of chronic disease, obesity, disability, and functional limitations compared with previous generations.3,4 Considering today's increased lifespan, more older adults will experience obesity-related disability in later life. Preventing and reducing disability has significant public health implications.
There is no clear consensus on a definition of obesity in older adults, although it is commonly defined as a weight greater than what is considered healthy for a given height. Surrogate measures such as BMI, waist-to-hip ratio, and waist circumference can be used to assess obesity. Of these, BMI is the most widely used and accepted measure and identifies ranges of weight shown to increase the likelihood of medical consequences. Using BMI, the World Health Organization defines normal weight as a BMI of 18.5 kg/m2 to 24.9 kg/m2; overweight, a BMI of 25 kg/m2 to 29.9 kg/m2; and obese, a BMI of 30 kg/m2 or greater. Obesity may be further classified using BMI as class I (30.0 kg/m2 to 34.9 kg/m2), class II (35.0 kg/m2 to 39.9 kg/m2), and class III (40 kg/m2 or greater).5
BMI may not be the most appropriate measure for assessing obesity in older adults because it does not take into consideration normal age-related changes in body composition, including a loss of height, or more important, a loss of muscle mass and an increase in adiposity (intra-abdominal fat in particular). Loss of muscle mass often goes unrecognized in the obese older adult until functional loss of muscle strength is evident.6
Sarcopenia, or the decline of skeletal muscle tissue with age, frequently accelerates after age 80 and further promotes a loss of muscle strength, impairs mobility, and is associated with frailty, weakness, and functional decline. Additional age-related changes impacting musculoskeletal integrity include a gradual decrease in bone mass and density and joint deterioration. A history of injury and/or obesity may further impact joint function and stability, particularly related to the large weight-bearing joints of the body. Combined, these changes alter an older adult's center of gravity, posture, flexibility, and mobility.7
Comorbidity and disability
Obesity in older adults is associated directly or indirectly with a broad range of diseases and medical complications, most notably metabolic syndrome, diabetes mellitus, heart disease, stroke, arthritis, and several types of cancer (especially breast, colon, and prostate).6 Obesity is also associated with poor clinical outcomes, reduced quality of life, and increased healthcare utilization, and is an independent risk factor for disability.8
Disability is defined in various ways and can be assessed by the ability to perform ADL and instrumental ADL, physical function, mobility, or a combination of activity and functional measures. Obesity also reduces the likelihood of recovery from disability.9
The relationship between arthritis and obesity is particularly important.10 Obesity places an excessive burden on weight-bearing joints. As degenerative changes progress, pain intensifies and impairs mobility. Individuals tend to avoid physical activity and, in turn, adopt a less-painful, less-active lifestyle.
Although a sedentary lifestyle requires less energy expenditure, individuals often fail to recognize the need to reduce their dietary intake, which leads to additional weight gain and associated medical risks, social isolation, and risk for depression. Sarcopenia is further aggravated by physical inactivity.6
Benefits and risks of weight loss
Obesity is generally associated with increased morbidity and mortality, although controversy exists over the relative potential harms of excess weight in older adults. An “obesity paradox” often discussed in the literature reflects a body of data that suggest obesity may be protective against mortality in older adults and indicate obese older adults have lower mortality than their “lean” age-matched counterparts.11
Research has demonstrated the relationship between weight (measured by BMI) and disability in older adults as having a “U” shape, indicating the risk of disability is greatest in both the obese and underweight. A low BMI (less than 18.5 kg/m2) in older adults is associated with the highest mortality risk.11
There are numerous benefits to weight loss. A reduction of 5% to 10% improves cardiovascular risk profile, physical functioning, and quality of life. A loss of as few as 6.6 lb to 8.8 lb (3 kg to 4 kg) over a 1- to 3-year period improves blood glucose and hypertension control and reduces diabetes onset and cardiovascular risk.6 A combination of weight loss and exercise provides greater improvement in physical function than either intervention alone.12
Older adults may face numerous barriers when adopting a healthier lifestyle to effect weight loss. “Healthier” food selections are not always available in certain neighborhoods. If available, they may be cost-prohibitive for older adults on a fixed income. Securing transportation to buy food is a concern for many. Older adults who cannot prepare their own meals may not have a choice in meal selection. Physical activity options may be limited depending on the availability of safe walking areas and access to parks, exercise equipment, and facilities.
Despite many positive effects, weight loss can have adverse reactions on bone mineral density and lean body mass, further accelerating sarcopenia.6 Weight loss can also increase the risk of functional and mobility limitations.13 It is important that physical activity interventions include a combination of aerobic and resistance exercise (as tolerated) to preserve bone and muscle health.
When reducing dietary intake, it is essential to include foods that will provide adequate and balanced nutrition. Malnutrition, whether due to intentional or unintentional weight loss, further exacerbates sarcopenia and functional decline in this vulnerable population.
Should NPs routinely promote weight loss among obese older adult patients? Given the potential adverse reactions on bone and muscle, it is important to note that weight loss should be considered only for moderately to severely overweight older adults. General weight management for all older adults, including those with mild obesity, should focus on weight maintenance and the preservation of lean body mass to limit the impact of sarcopenia on disability risk.14
In addition to improving comorbid conditions, supervised, intentional weight loss and weight management can improve physical function, reduce disability, and improve quality of life. These are the main goals of treatment of obesity in older adults.15 A potential to reduce polypharmacy is an additional benefit.6
Managing obesity in older adults
The first step in managing obesity in older adults is to collaboratively develop a weight loss strategy in partnership with the patient. It is important to review the benefits and risks of weight loss and to emphasize that even modest increases in physical activity can lead to health benefits, reduced disability, and improved quality of life.
Treatment options include comprehensive lifestyle changes, pharmacotherapy, and/or bariatric procedures. In addition to benefits and risks, the NP must consider the costs of treatment and have an understanding of the obesity services available to Medicare beneficiaries. Because the majority of older adults in the United States utilize Medicare as their primary insurance, this discussion focuses on current Centers for Medicare and Medicaid Services guidelines.16
Lifestyle changes. Comprehensive lifestyle changes are the cornerstone of obesity treatment and are as effective in older adults as in younger individuals.6 The intensive behavioral therapy (IBT) for obesity benefit, which includes regularly scheduled patient-provider face-to-face visits, became a covered preventive service under Medicare in 2011 (see Medicare IBT for obesity benefit).
All beneficiaries with a BMI greater than 30 kg/m2 who are competent and alert are eligible for IBT for obesity counseling and education provided by a qualified primary care provider in a primary care setting for up to 12 months. Medicare coinsurance and Part B deductible are waived for this service.17
The goal of IBT is to promote sustained weight loss through high-intensity interventions on diet and exercise and should follow the 5-A framework (see The 5-A framework of IBT for obesity). The framework encourages collaboration between the NP and patient in setting goals and can guide the development of a weight-loss program and treatment strategies.
Dietary interventions are broadly categorized as low-calorie/reduced portion size or diets with different macronutrient compositions (low carbohydrate or fat, various proportions of carbohydrate/fat/protein). Evidence-based data on nonconventional diets in older adults are limited. A conventional diet (low calorie/reduced portion size), especially when combined with a physical activity program, is a reasonable and effective strategy.18
Many older adults find the relative simplicity of limiting portion size a more acceptable “diet” plan. Older adults on a reduced-calorie diet require close monitoring to ensure a balanced food intake to avoid reductions or expediting age-related declines in key vitamins and nutrients.19 Dietary recommendations should focus on making healthy choices and incorporating foods that can help decrease caloric intake while increasing satiety, such as high-fiber foods, nuts, and whole grains.14
Very low-energy or low-energy liquid diets, which can range from 400 to 800 kcal/day, are not typically recommended for older adults. Although they may promote rapid, short-term weight loss, long-term results are inferior to those of more moderate-calorie diets (1,000 kcal/day to 1,500 kcal/day), and they can lead to various adverse reactions, including gallstones.6
The American College of Sports Medicine and the American Heart Association provide recommendations for physical activity, modified to meet the needs of older adults and adults ages 50 to 64 who have clinically significant chronic diseases and/or functional limitations that affect exercise ability.20 The exercise component of a weight loss plan should specify how, when, and where each exercise should take place. The plan should emphasize a stepwise approach to gradually increase exercise with short bouts (10 minutes or more) of physical activity at a time and should incorporate aerobic activity, muscle-strengthening, flexibility, and balance exercises.20
Ideally, patients should try to perform 30 minutes of moderate-intensity exercise at least 5 days per week or vigorous-intensity exercise for 20 minutes at least 3 days per week. Strength and endurance exercises targeting the major muscle groups (10 to 15 repetitions of 8 to 10 exercises) and flexibility exercises (10 minutes minimum) should be encouraged at least twice a week. All older adults at increased risk for falls should participate in balance exercises.20
Optimal outcomes are observed using a combination of dietary changes and exercise, which incorporate aerobic, resistance, and flexibility maneuvers.13,21,22 A modest calorie restriction combined with exercise is the best way to reduce body fat while preserving lean muscle mass.18
Pharmacotherapy. A limited amount of FDA-approved antiobesity agents are currently available for short- and long-term use and work by suppressing appetite and reducing dietary intake, impairing dietary absorption, and/or increasing energy expenditure.23 With significant advances in knowledge of the pathogenesis of obesity in recent years, four new agents have received FDA approval since 2012, with several more currently in development. Medicare Part D (prescription drug program) currently prohibits coverage of FDA-approved obesity drugs. The impact of this lack of coverage on access to these agents is not known.24
As older adults either have not been targeted in clinical drug trials or study analyses did not isolate this group, outcome data on the efficacy, safety, and tolerability in this population are lacking.19,25 All antiobesity agents have considerable adverse reactions. When considering use in older adults, the risks and benefits of these agents must be thoroughly and critically examined, especially considering the high prevalence of comorbidities and geriatric syndromes, polypharmacy, and the potential for drug-disease interactions.26
Bariatric procedures. Several types of bariatric procedures are available, although surgery for obesity alone is not a covered benefit. Medicare does, however, currently cover select procedures for the treatment of comorbid conditions for beneficiaries who have a BMI of 35 kg/m2 or greater and meet specific criteria (see Bariatric treatment for Medicare beneficiaries). When weight loss is required prior to surgery to reduce patient's risk for complications caused by obesity, Medicare will make a case-by-case determination of coverage.
Outcomes of bariatric surgery in older adults include improvements in hypertension, diabetes mellitus, and dyslipidemia, reduction in medication use, and improved quality of life.27,28 However, postoperative nutrient and vitamin deficiencies combined with food intolerances may predispose patients undergoing bariatric procedures to osteoporosis and anemia. These deficiencies negatively impact quality of life due to increased healthcare visits for vitamin supplementation (B12) and iron infusions.25,29
Although extant data indicate surgery may be a safe and effective treatment option, the mortality and morbidity associated with bariatric surgery in older adults is controversial; additional methodologically robust research is needed.19 To date, no randomized controlled trials, systematic analysis, or meta-analysis have been conducted in older adults. Interpretation of the available literature is confounded by inconsistent definitions of “older adult” and small sample sizes.
Variability among the type of bariatric procedure performed, patient comorbidities, and high- versus low-volume surgical centers further limits comparison of available data. Although bariatric surgery may be more effective for weight loss than nonsurgical options, the long-term success in older adults is unknown.19
Case management and outcome
As a Medicare beneficiary, Mr. H qualified for the IBT for obesity benefit and committed to routine visits over the next 6 months with a goal of losing 20 lb (9 kg). He was asked to list the reasons why he wanted to lose weight in decreasing importance on a 3×5 card, which he was instructed to keep in a convenient place. He would then have the card readily available to him when he would begin to “wander off” his plan to encourage him to refocus on his commitment. Following the 5-A framework, a treatment plan of dietary portion control and physical activity was developed that incorporated Mr. H's preferences, abilities, and resources to facilitate his success.
He was asked to keep a daily log of everything he ate and drank (with portion size), and of all exercise, noting the type and duration of each activity. Weight and vital signs were recorded at each visit, and a different topic was presented to incorporate into treatment. Topics included a review of daily food recommendations, reading food labels, portion size, eating when dining out, and a stepwise approach to incorporating exercise into his sedentary lifestyle. Mr. H left each visit with a brief, individualized information sheet to review at home. Each subsequent encounter included a review of the previous visit and discussion on his ability to implement each activity.
The 6-month visit revealed a weight loss of 18 lb (8 kg; BMI 44.9 kg/m 2, A1C 8.2%). Motivated by a fear of diabetes complications, Mr. H never missed a scheduled visit. As he met the 6-month weight-loss requirement, IBT was continued for an additional 6 months. At the end of 12 months, Mr. H had experienced a 13.5% weight loss (weight 280 lb [127 kg]; BMI 41.1 kg/m 2 , FBG 133 mg/dL, A1C 7.8%). Although Mr. H continues taking metformin, he has less chronic pain and is more active than he has been in the past 20 years. He has not had any additional falls.
Implications for practice
Obesity and obesity-related disability among the rapidly growing older adult population is a significant concern. With potential adverse reactions on bone and muscle health, a decision to promote weight loss in older adults must be individualized and in general should be reserved for the moderately or severely obese. A weight-loss treatment plan that combines exercise with modest caloric restriction is often the most appropriate.
Clinicians should avoid placing great emphasis on weight loss and focus attention on lifestyle changes to improve physical function, reduce disability, and improve quality of life. Careful supervision is required to ensure a balanced dietary intake and to prevent nutritional deficiencies. Weight loss strategies should promote activities that preserve lean muscle mass and strengthen muscle and bone. Optimal outcomes are observed using a combination of dietary changes and exercise that incorporates aerobic, resistance, and flexibility maneuvers.
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