Managing Obesity in Long-Term Care

Affiliation:

Friedrich Nutrition Counseling, Salisbury, NC

Article series summary: This is the second article in a continuing series on nutrition issues in long-term care. The first article in the series was published in the May 2013 issue and discussed evidence-based organizational strategies to prevent weight loss in frail elders. Subsequent articles in the series, which will be published in future issues of Annals of Long-Term Care: Clinical Care and Aging, will review end-of-life nutrition and other related topics.

Abstract: More than one-third of adults in the United States are considered obese. As the obese population ages, one can assume the number of obese elderly persons requiring long-term care (LTC) services will also increase. Most of the research on obesity has been conducted on younger adults and, more recently, on childhood obesity. As a result, many questions regarding the assessment and treatment of obesity in those aged 65 years and older remain unanswered. Obesity carries many well-known health risks, including increased risk of hypertension and type 2 diabetes, but it may also carry some health benefits in older adults. Some elderly LTC residents who are obese have comorbidities that make them poor candidates for planned weight loss. Each resident who is obese should be evaluated individually for the safety and efficacy of weight loss before a weight loss plan is implemented.

Key words: Obesity, quality of life, planned weight loss, residents’ rights, body mass index, caloric needs, nutrition assessment. 
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According to the Centers for Disease Control and Prevention (CDC), between 2007 and 2010 more than one-third of adults in the United States were considered obese.¹ Older adults are not immune to the obesity epidemic; in fact, this same report revealed that 8 million obese adults (40.8%) are between the ages of 65 and 74 years, and nearly 5 million obese adults (27.8%) are aged 75 years and older. The CDC also observed the trend that older adults are more likely to be obese than their younger counterparts. Figure 1 summarizes the percentages of older adults who are obese by age and sex.¹

It is difficult to find reliable statistics regarding the number of skilled nursing facility residents who are obese, but many long-term care (LTC) providers have observed an increase in the number of patients who are obese being admitted to their facilities.² As a result, facilities are seeking guidance for the nutritional care of these patients; however, the treatment of overweight and obese individuals in LTC is fraught with conflicting information and difficult decisions for both patients and healthcare providers. Many questions surround the identification of obesity, selection of appropriate nutrition assessment tools, and determination of obesity-related health risks and of the safety and efficacy of prescribing weight loss diets in older LTC residents who are obese. The following sections review these issues related to obesity in elderly individuals.

Identification of Obesity and Assessment of Caloric Needs 

The controversial aspects of obesity management in LTC begin with the identification of obesity. Obesity is commonly classified according to body mass index (BMI), which is a measurement of weight adjusted for height, calculated as weight in kilograms divided by the square of height in meters (kg/m²).³ A BMI of 25 to 29.9 kg/m² classifies a patient as overweight, whereas a BMI of ≥30 kg/m² indicates obesity (Table).⁴ Because BMI does not distinguish between excess fat, muscle, or bone mass, and older adults tend to have more body fat than younger adults with an equivalent BMI, the CDC advises caution when interpreting BMI in older adults,³ leading many healthcare practitioners to question whether BMI is a useful tool for measuring obesity in older adults at all. Nevertheless, BMI is commonly used as one of many measures of nutritional status per the Minimum Data Set 3.0 (MDS 3.0), the assessment tool used in Medicare- and Medicaid-certified nursing homes as mandated by the Centers for Medicare & Medicaid Services. A BMI of >24.9 kg/m² is considered a trigger on the MDS, alerting care staff to a potential nutritional problem that necessitates undertaking a Care Area Assessment.⁵

In addition to BMI, some practitioners focus on ideal body weight (IBW), which takes a person’s sex and age into account. IBW charts are readily available in nutrition care manuals and medical pocket guides. However, for older adults, a patient’s usual body weight (UBW; defined as that individual’s most frequent body weight) may be a more appropriate indicator of weight status because it can reveal undesirable or unintentional weight gain or loss. Weight loss may not be achievable or desired by the person whose UBW is well above his or her IBW. Furthermore, basing weight loss interventions on an individual’s IBW can be misleading because IBW has not been definitively established for the frail elderly and for those with chronic illnesses and disabilities.⁶ In addition, it is not always realistic or necessary to encourage a resident to achieve his or her IBW.

Estimating the caloric needs of older adults who are obese is also problematic. For years, there were no clear guidelines on which of the many available mathematical formulas dietitians should use to estimate resting energy expenditure (REE) and total caloric needs of an individual. In recent years, however, the Academy of Nutrition and Dietetics (formerly known as the American Dietetic Association) determined that the Mifflin-St Jeor equation (Figure 2), which uses a patient’s actual body weight rather than his or her adjusted body weight, results in the most accurate estimation of REE for most individuals.^7,8 It is not clear, however, whether that standard also applies to older adults. There are a number of other formulas and “quick and dirty” methods that are used to estimate an individual’s caloric needs. Registered dietitians (RDs) continue to struggle with which method provides the most accurate estimate, often using their own clinical judgment as a guide. 

Health Risks Associated With Obesity and the Debate Over Weight Loss 

Most healthcare professionals are aware that adults who are obese have a greater risk of developing diabetes, hypertension, cardiovascular disease, and several types of cancer.^9,10 These individuals also have an increased rate of debility related to the effect of excess weight on joints, such as the knees. Advanced age and abdominal obesity are both independent risk factors for chronic health conditions, such as hypertension and type 2 diabetes mellitus¹¹; however, it is often difficult to determine for certain whether the obesity contributed to the development of these conditions or if it is a coexisting condition.⁹ Regardless, excess weight is a contributor to disability in aging individuals, as it can exacerbate age-related physical decline and lead to frailty, difficulty with performing activities of daily living, and limit independent ambulation.¹⁰ Evidence also suggests that being overweight or obese is associated with an increased decline in cognitive status and dementia.^9,11

When an individual is obese, weight loss is usually recommended to improve his or her health. Data suggest that even a moderate weight loss can raise high-density lipoprotein cholesterol levels, while lowering blood pressure and blood serum levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, and blood glucose.¹² There is some evidence to suggest that weight loss in healthier older adults (≥65 years) can lead to some of these benefits,¹² but most research on the health risks of obesity has focused on younger adults (<65 years).

Another issue complicating the health benefits of weight loss is the “obesity paradox.” Research shows that obese persons fare as well as or better than low- or normal-weight patients in terms of mortality rates in the context of several comorbidities, including chronic kidney disease, congestive heart failure, hemodialysis, and coronary artery disease with hypertension.¹¹ It is unclear how older age interacts with these protective benefits.¹¹ In addition, individuals who are obese may also have lower rates of hip fracture with falls, possibly related to higher bone mineral density or better cushioning.¹¹ Thus, the need for weight loss to improve the health of older adults may seem logical, but the evidence on the benefits to one’s health and longevity is mixed.    

Health Risks Associated With Weight Loss in Older Adults 

The evidence that weight loss in older adults can be associated with significant health risks complicates treatment decisions. Older adults are already subject to sarcopenia (ie, age-related loss of skeletal muscle mass).¹³ When caloric and protein intake are reduced too drastically to facilitate weight loss, the body uses dietary protein for energy and eventually can break down lean body mass (muscle) rather than stored fat for energy.¹⁴ This results in an additional loss of lean body mass above and beyond sarcopenia, placing the patient at an increased risk for weakness and skin breakdown. Weight loss is also associated with a loss of bone mineral density⁹ and, in older adults, increased mortality.¹⁰

Identifying Candidates for Weight Loss Interventions 

According to both the American Society for Nutrition and the Obesity Society, weight-loss therapy that minimizes muscle and bone loss is recommended for older adults who are obese and have functional impairments or medical complications that can be improved by weight loss.¹⁰ However, a weight loss program must be individualized for each patient. Every individual residing in an LTC facility should have his or her weight status defined and caloric needs estimated as part of a routine nutrition assessment; however, the plan of care that results from the assessment is not always clear. Planned weight loss requires input from the patient and the careful evaluation of his or her risks and benefits. If a resident is overweight or obese, he or she along with the interdisciplinary team should consider whether weight loss is an appropriate goal. To determine this, numerous questions need to be addressed. For example, will the health benefits of weight loss outweigh the risks? If weight loss results in a reduced blood cholesterol level or blood glucose level, will there be long-term benefits? Will weight loss prolong the resident’s life? Will weight loss improve his or her functional status and/or quality of life? Will a restrictive diet reduce the resident’s ability to consume enough nutrients to maintain his or her health?

It is critical to remember that LTC residents with multiple chronic medical conditions, cognitive decline, and/or a limited lifespan are often at risk for unintended weight loss; thus, planned weight loss is generally inappropriate for these residents.¹⁵ In addition, unless an improvement in quality of life is expected, planned weight loss is usually not appropriate for obese patients with dementia.¹⁶ Unintended weight loss is usually an unavoidable consequence of end-stage dementia, although experts are not clear as to why this occurs. As a rule, maintaining a dementia patient’s UBW should be the plan of care. Initiating a weight loss program in dementia patients is not generally recommended because even planned weight loss could contribute to their decline. Unless a dementia patient is able to express a clear desire to lose weight, the focus of nutrition care should be maximizing food and fluid intake, encouraging pleasant mealtimes, and providing the highest possible quality of life.

Decisions on planned weight loss should be made with the knowledge, consent, and input of the resident—not just the interdisciplinary team. Regardless of medical recommendations, weight loss is not appropriate unless the resident wants to lose weight. Many individuals who reside in skilled nursing facilities believe that quality of life takes precedence over health and longevity and prefer to enjoy food and activities without restriction. Short-term rehabilitation patients have varying weight goals. Many rehabilitation patients are younger, more active, and have fewer health concerns than LTC residents. Some use their brief stay in the skilled nursing facility to practice portion control and attempt to lose a few pounds before returning home. Others use their stay as an opportunity to enjoy the benefits of having good food provided to them three times a day and choose to indulge freely. Regardless of the resident’s length of stay, after counseling him or her on the risks and benefits of weight loss, a refusal of interventions should be respected by the medical team as part of each resident’s right to make choices about his or her lifestyle, routines, and treatments.

Implementing Planned Weight Loss 

If a resident chooses to move forward with planned weight loss, the facility’s RD should be a key part of the plan of care.^7,10 Each individual will require a different diet prescription, but often a regular diet with a few key modifications will result in slow weight loss. Meal intake should be closely monitored to ensure that adequate protein, calories, nutrients, and fluids are consumed to maintain good health. If the patient is able to participate, weight-bearing exercise is helpful to help prevent breakdown of lean body mass.¹⁰ Participation in therapy, restorative nursing, or facility exercise programs and other activities can help a patient expend more calories to help facilitate weight loss.

If a resident wishes to move forward with planned weight loss, facility staff should consult the evidence-based recommendations for adult weight management outlined by the Academy of Nutrition and Dietetics, remembering that questions remain as to the safety and effectiveness of these recommendations for the elderly.⁷ A facility’s RD should be a key partner in a resident’s care plan,¹⁰ as diets should be individualized to the patient’s needs. Often, a regular diet that has been modified to reduce calorie intake will result in gradual weight loss. Nutrition education and close monitoring and documentation are advised as part of a long-term comprehensive weight loss program for residents.⁷

Although physical activity is encouraged for weight loss, it should be tailored to the abilities and goals of the resident. Weight-bearing exercise is shown to prevent breakdown of lean body mass,¹⁰ but in residents for whom this approach is not feasible, staff can simply encourage residents to participate in other low-impact physical activities (eg, walking, games) to help expend more calories and maintain muscle mass. There is also strong evidence suggesting that behavioral therapy, such as self-monitoring, stimulus control, and social support, is successful for weight loss when combined with other dietary and physical strategies to help prevent regression to baseline weight.⁷

Conclusion 

As the number of LTC facility residents with obesity increases, and since many factors must be considered when deciding on a weight loss plan (eg, the benefits and risks of obesity and weight loss), facilities will need to address each obese patient’s weight loss goals individually. Further research is needed to determine the safety and efficacy of planned weight loss in older adults and the appropriate strategies to avoid the adverse effects of weight loss on muscle mass and bone density. Weight loss should only be implemented with the knowledge and consent of each individual. Collaboration with an RD is needed to ensure that the plan of care is appropriate.

References

1. Fakhouri TH, Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity Among Older Adults in the United States, 2007-2010. NCHS data brief, no. 106. Hyattsville, MD: Centers for Health Statistics, 2012. www.cdc.gov/nchs/data/databriefs/db106.pdf. Accessed June 24, 2013.

2.  Lapane KL, Resnik L. Obesity in nursing homes: an escalating problem. J Am Geriatr Soc. 2005;53(8):1386-1391.

3.  Centers for Disease Control and Prevention. Body mass index: considerations for practitioners. www.cdc.gov/obesity/downloads/BMIforPactitioners.pdf. Accessed June 20, 2013.

4.  Centers for Disease Control and Prevention. Healthy weight—it’s not a diet, it’s a lifestyle! About BMI for adults. www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html. Accessed June 9, 2013.

5.  Care area assessment (CAA) process and care planning. In: Long-Term Care Facility Resident Assessment Instrument User’s Manual MDS 3.0. Baltimore, MD: Centers for Medicare & Medicaid Services; 2012.

6.  Centers for Medicare and Medicaid Services. State Operations Manual Appendix PP: Guidance to Surveyors for Long Term Care Facilities. Revision 70. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Published January 7, 2011. Accessed June 21, 2013.

7.  Academy of Nutrition and Dietetics. Adult weight management evidence-based nutrition practice guideline: executive summary of recommendations. Accessed June 25, 2013.

8.  Mifflin MD, St Jeor ST, Hill LA, Scott BJ, Daughtery SA, Koh YO. A new predictive equation for resting energy expenditure in healthy individuals. Am J Clin Nutr. 1990;51(2):241-247.

9.  Houston DK, Nicklas BJ, Zizza CA. Weighty concerns: the growing prevalence of obesity among older adults. J Am Diet Assoc. 2009;109(11):1886-1895.

10. Villareal DT, Apovian CM, Kusher RF, Kline S. Obesity in older adults: technical review and position statement of the American Society for Nutrition and NASSO, the Obesity Society. Am J Clin Nutr. 2005;82(5):923-924.

11. Osher E, Stern N. Obesity in elderly subjects: in sheep’s clothing perhaps, but still a wolf! Diabetes Care. 2009;32(suppl 2):S398-S402.

12. National Institutes of Health: National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. https://www.ncbi.nlm.nih.gov/books/NBK2003/pdf/TOC.pdf. Published September 1998. Accessed June 24, 2013.

13. Evans WJ. Skeletal muscle loss: cachexia, sarcopenia, and inactivity. Am J Clin Nutr. 2010;91(4):11235-11275.

14. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Saunders; 2011:474, 886.

15. Dorner B. The Obesity Challenge: Weight Management for Older Adults. Fairlawn, OH: Becky Dorner and Associates; 2012.

16. Vidal K, Jackovatz S. Obesity in older adults of skilled nursing facilities: let them eat cake! Weight Management Newsletter. 2007;5(2):6-8. Accessed June 24, 2013.

Disclosures: The author has received speaker honoraria from Abbott Nutrition and has served as a consultant or paid advisory member for
Abbott Nutrition.

Address correspondence to: Liz Friedrich, MPH, RD, CSG, LDN, 110 West Colonial Drive, Salisbury, NC 28144; ekf@carolina.rr.com

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