​​​​​​​Managing Obesity in the Older Adult

National Harbor—Providers are often unclear, reluctant, and unprepared in treating older adults with obesity. During a session at the AGS meeting, a panel of speakers discussed the importance and methods of counseling this patient population in clinical practice.

John A. Batsis, MD, assistant professor of medicine, The Dartmouth Institute for Health Policy & Clinical Practice, opened the session by describing the epidemiology of an older population with obesity and its impact on function and morbidity. Studies have shown that obesity is associated with increased risks of cardiovascular disease, diabetes, and some cancers, as well as other chronic conditions. Further, obesity in middle-aged and older adults also increases the risk of physical disability.

Data from the National Health and Nutrition Examination Survey 2011 to 2012, published in National Center for Health Statistics Data Brief in 2013, found that more than one-third (34.9%) of adults were classified as obese (body mass index [BMI] ≥30 kg/m2). The prevalence of obesity among individuals age 60 and older was higher among women compared with men (38.1% vs 32%, respectively). Overall, the report found that the prevalence of obesity among US adults remains above the Healthy People 2020 goal of 30.5%.

Dr Batsis highlighted several studies that looked at the correlation of obesity with disability and muscle loss. Using data from the Health, Aging, and Body Composition Study, Houston and colleagues examined the association of overweight and/or obesity in young, middle, and late adulthood, as well as the cumulative effect of overweight and/or obesity across all 3 timepoints (age 25, 50, and 70-79), with incident mobility limitation in men and women in their 70s and 80s. The findings published in American Journal of Epidemiology in 2009 found that onset of overweight and obesity in earlier life contributes to an increased risk of mobility limitation in old age.

In a separate study, Stenholm and colleagues reported on obesity and muscle impairment in older adults in International Journal of Obesity in 2009. Community-dwelling adults age ≥65 years participating in the population-based In CHIANTI study were followed for 6 years. Walking speed and self-reported mobility disability (ability to walk 400 m or climb 1 flight of stairs) were assessed at baseline and at 3- and 6-year follow-up. Obese participants with low muscle strength had steeper decline in walking speed and high risk of developing new mobility disability over the 6-year follow-up compared with those without obesity or low muscle strength.

Sarcopenic obesity is also more prevalent among older individuals. Sarcopenia plus obesity is a “lose–lose combination,” said Dr Batsis. High fat mass plus low muscle mass leads to increased functional limitations and metabolic problems. Many studies have examined these entities separately. The synergistic effect of the 2 has not been well-examined, he said.

A study by Baumgartner and colleagues published in Obesity Research in 2004 looked at the association of sarcopenic obesity with the onset of Instrumental Activities of Daily Living (IADL) disability in a cohort of 451 elderly individuals followed for up to 8 years. The study found that sarcopenic obesity is independently associated with and preceded the onset of IADL. After adjusting for age, sex, physical activity level, length of follow-up, and prevalent morbidity, the relative risk for incident disability in sarcopenic obese participants was 2.63.Dr Batsis also reviewed the benefits and limitations of using BMI as a measure of obesity in older adults. While it is easy to use in a clinical setting and inexpensive, there are several drawbacks, he said. These include poor sensitivity as demonstrated in a study published in International Journal of Obesity in 2008. Romero-Corraland colleagues found that using BMI in diagnosing obesity missed approximately 50% of adults that otherwise would have been classified as obese. Other limitations include that ethnic-specific values may exist, cutoffs have impact for public health policy, and measuring fatis not cost-effective nor practical.

The best therapeutic approach for losing fat but retaining/gaining muscle function to prevent functional decline and disability in obese older adults is a 3-pronged approach involving a dietary program, physical activity, and behavior modification, he said.

PHYSICAL ACTIVITY

Exercise improves function, according to Dawna Pidgeon, PT, Dartmouth Hitchcock Medical Center, who discussed physical activity in older adults. Studies have demonstrated that lifestyle intervention incorporating weight loss and multicomponent exercise is optimal for managing sarcopenic obesity; resistance training is useful for attenuating muscle loss; and moderate intensity activity programs reduce major mobility disability invulnerable older adults. 

Various organizations have published exercise guidelines including the American College of Sports Medicine, American Physical Therapy Association, and National Institute of Aging. See the Table for exercise resources for older adults.

She said adverse cardiac events and musculoskeletal injury are potential risks associated with exercise in older adults. Medical screening, recommendations, and clearance from the individual’s clinician for exercise related to coronary heart disease can decrease risk. Gradual progression of exercise with warm-up and cooldown can decrease musculoskeletal risk. Ms Pidgeon also recommended a physical therapy referral for older adults with mobility limitations, decreased strength, and balance difficulties.

BEHAVIORAL CHANGE

Weight loss can be achieved with diet and exercise. However, getting patients to engage in behavioral change strategies to achieve this goal is a challenge. Gretchen E. Ames, PhD, ABPP, assistant professor of psychology, Mayo Clinic College of Medicine, identified key strategies that can be utilized in clinical practice to promote behavioral change.

One strategy is motivational interviewing (MI), defined as “a patient-centered guiding method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” This collaboration between the health care provider and patient is associated with increased patient satisfaction, increased trust in the health care provider, improved adherence, and improved health status. She reviewed patient barriers to changing patterns of behavior:

• Patients have other priorities
• Patients do not see the importance of change
• Patients do not have confidence to change
• Patients feel change will not make a difference

The spirit of MI involves compassion, collaboration, autonomy, and empathy, according to Dr Ames, who discussed the 4 processes of MI outlined in Miller and colleagues 2013 book Motivational Interviewing Helping People Change. These include engaging, focusing, evoking, and planning. A fundamental aim of MI is for the health care provider to engage with the patient. She referenced the OARS mnemonic to help facilitate engagement:

• Open-ended questions help to understand the patient’s perspective and motivation (ie, What are some things you would like to be doing but your weight is holding you back? Where do you see yourself 6 months from now with exercise?)
• Affirmation is recognizing the patient’s efforts and strengths
• Reflections allows the patient to hear the thoughts and feelings he or she are expressing and ponder them
• Summaries pull together the information that the patient has shared at each visit; they may suggest a link between present material and what has been discussed previously

Engaging the patient leads to a focus on a particular concern. For example, “What do you think needs to happen to turn your weight gain around?” Evoking is building motivation. The planning process encompasses both developing commitment to change and formulating a plan of action. The general principles and techniques of MI is a strategy that can be applied by clinicians to talk to patients about weight loss and guide them to make a commitment to change.