The Obesity Challenge: Aging, Obesity and Long Term Health Care Becky Dorner, RD, LD

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1 The Obesity Challenge: Aging, Obesity & Long Term Care NIH Obesity Definitions BMI = Overweight BMI >30 = Obese BMI >40 = Extremely Obese Obesity: A National Crisis? Percent of US adults >20 that are obese exceeds those that are just overweight 34.3% Obese (BMI >30) 32.7% Overweight (BMI ) Almost 6% of US adults are extremely obese (BMI of >40) Comparing 2000 to 2005, there was a 24% increase in number of people with a BMI >30 50% increase in number of people with a BMI >40 86% of Americans Could be Overweight or Obese by 2030 Most adults in the US will be overweight or obese by 2030, with related healthcare spending projected to be as much as $956.9 billion, according to the July 2008 issue of Obesity. ADA Times Sept/Oct 2008 US Obesity Rates Continue to Rise The proportion of US adults who reported being obese in 2007 rose to a record 25.6% Men (26.4 %); Women (24.8%) Lowest for years; Highest for Obesity highest for non-hispanic black women (39%) followed by non-hispanic black men (32%) Higher in the South (27.3%) & Midwest (26.5%) Lower in the Northeast (24.4%) & West (23.1%) 2007 Behavioral Risk Factor Surveillance System survey 1

2 Waist Circumference Excess abdominal fat out of proportion to total body fat is an independent predictor of risk factors and morbidity Gender-specific cutoffs identify increased relative risk for development of obesity-associated risk factors in most adults with a BMI of 25 to 34.9 kg/m2: Men >40 inches Women >35 inches Lose incremental predictive power in patients with a BMI >35 because these patients exceed the cut points noted above Obesity Increases Disease Risk hypertension; dyslipidemia; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; endometrial, breast, prostate, & colon cancers Higher body weights are also associated with increases in all-cause mortality. Waist Circumference Diabetes Incidence A large belly in mid-life has been shown to increase the risk of diabetes, stroke, and coronary heart disease dementia The number of US residents with diabetes has doubled to more than 20 million since 1980 & is expected to double again by 2025 One-third of diabetes cases are not diagnosed ADA On the Pulse What About Seniors in Particular? Obesity s Impact On Health and Health Care Costs What s Driving Medicare Spending? Obesity rates among Medicare beneficiaries more than doubled between 1987 and % of the increases in spending attributed to people entering the program with diabetes, metabolic syndrome & other diseases associated with obesity Almost half the Medicare population meets the clinical definition of "metabolic syndrome Medicare cost of treating these patients nearly tripled from 1987 to 2002 Number of patients receiving treatment for 5 or more medical conditions rose to more than half in 2002 These patients used up more than 3/4 of Medicare spending by 2002 Emory University study published in Health Affairs 2

3 Obesity at 70 and Beyond An obese person will cost Medicare $149,000 (35% higher or $38,000 more than normal weight person over lifetime) The effects of disability from obesity will be even more of a toll on the system (not to mention the incredible social burden) Rand Health: Future Health & Medical Spending of the Elderly Obesity Rates in Older Adults Age >70 Percentage of Obesity in % 11.4% Percentage of Obesity in % 15.5% Rate of Increase from 1991 to % 36% Lakdawalla DN, Goldman DP, Shang B, The Health And Cost Consequences Of Obesity Among The Future Elderly, Health Aff (Millwood), 2005 Sep 26; [Epub ahead of print], Accessed December 10, Note: More recent CDC data shows 19.4% of people >70 are now obese (2008) Leading Causes of Death for Seniors: Heart disease, cancer & stroke CVD Mortality In 2004 CVD accounted for 36.3% of deaths in the US Coronary disease, stroke, high BP, heart failure, and congenital cardiovascular defects 12/29/06 Circulation and U.S. Census Bureau, "65+ in the United States: 2005." News release, National Institute on Aging, NIH Obese Seniors Disabled Longer Obesity Leads to More Hospital Admissions, Longer Stays 70 Years of Age Men, Non-obese Men, Obese Women, Non-obese Women, Obese Life Expectancy, Years Disabled Years ,574 adults, >41 over 20 years (>1971) Obese: ~3.22 hospital stays vs 2.47 for normal wt LOS: days for obese vs 9.4 days Higher prevalence of conditions such as hypertension was a major reason why obese adults had more hospitalizations The longer a person has been obese, the more hospital resources they will need Early adulthood is a crucial time for addressing weight problems, and will quite likely pay dividends in reducing healthcare consumption when these adults are in their 50s, 60s, 70s and even 80s. December 2007 Journal of Health and Social Behavior 3

4 Diabetes Diagnosis Rates Soaring The number of seniors with diabetes jumped ~23% between and Death rate for patients diagnosed with diabetes decreased by 8.3 Archives of Internal Medicine 2-08 Diabetes Presents Growing Problem for Nursing Homes 1 out of every 4 residents >65 is diagnosed with diabetes Non-white residents were twice as likely to have diabetes as white residents Diabetic residents were Younger than their non-diabetic counterparts More likely to take more meds & arrive at a NH with pre-existing circulatory problems 56% more likely to have a pressure ulcer upon admittance February 2008 issue of Diabetes Care: McKnight's Daily Update [LTCN-Webmaster@mltcn.com] Metabolic Syndrome Almost 1 in 4 adults have metabolic syndrome Almost half the Medicare population meets the clinical definition of "metabolic syndrome (Emory U) Increases chance for CVD and other health problems such as diabetes and stroke 12/29/06 Circulation and Metabolic Syndrome Diagnosed when a person has at least 3 of these heart disease risk factors: 1.Waist Circumference: >40 men/>35 women 2.Triglycerides: >150 mg/dl (or on medication to treat high triglycerides) 3.HDL Cholesterol: <40mg/dL men/<50mg/dl women (or on medication to treat low HDL) 4.HBP: >130 systolic or >85 diastolic (or on medication to treat HBP) 5.Fasting BG: >100mg/dL (or on medication to treat elevated BG) Metabolic Syndrome People with Met S are twice as likely to develop CHD and 5X as likely to develop diabetes The more risk factors, the greater the chance of developing CHD, diabetes or stroke Risk Factors: Overweight/obesity & lack of physical activity Insulin resistance which can lead to high BG levels (also closely linked with being overweight or obese) Genetics (ethnicity, family history) & older age are other important underlying causes Middle-age Lifestyle Factors Foretell LTC Need 20 years of data indicate a strong correlation between NH admission & presence of unhealthy lifestyle-related factors in middle age The same factors that increase risk of disease and early death also increase risk of requiring NH care later in life Smoking, HTN, physical inactivity, obesity and diabetes McKnight's LTC News Daily Update 5/12/

5 Think About the Impact Obesity Will Have on Long Term Health Care Bariatric Care in LTC Treat medical conditions related to obesity: HTN, CVD, DM, stroke, respiratory problems, mobility restrictions (ex fractures due to falls), skin problems Special equipment needs: as much as 50% higher cost without additional reimbursement W/C, beds, lifts, scales, walkers, shower chairs, furniture Staff training: Sensitivity, behavioral, lifting, skin care (folds) Broad based interdisciplinary approach: nursing, RD/DTR, psychological, PT, etc. Bariatric Care in LTC RD/DTR counseling, coaching, diet approach, behavioral, family education, P&Ps (resident s rights related to food, etc.) With compliance comes rapid weight loss for some (from 10-12,000 calories a day to 2500; from no exercise to daily exercise) Medication changes needed Advantages Of Weight Loss Evidence Supports Weight loss for individuals who are overweight or obese to reduce: Risk factors for diabetes & CVD BP in both hypertensive & pre-hypertensive individuals BG in persons with diabetes & pre-diabetes HgbA1C in persons with type 2 diabetes Serum triglycerides Total serum cholesterol LDL cholesterol ADA Weight Management Toolkit Advantages Of Weight Loss Weight loss may Help decrease the likelihood of developing diseases or Help to control diseases worsened by obesity: Hypertension Hyperlipidemia Hyperglycemia (NIH) 5

6 What About Older Adults? Is Weight Loss Appropriate for Every Obese Older Adult? Answer these questions to determine whether weight loss is safe & appropriate: 1. Will weight loss reduce risk factors for other complications? 2. Will weight loss prolong life? 3. What are the risks associated with obesity treatment? 4. Will a restricted diet reduce the individual s ability to consume adequate nutrients to maintain health? Carefully weigh the risks versus benefits of obesity treatment in older adults. Is Weight Loss Appropriate for Every Obese Older Adult? Benefits of weight loss for healthy older adults: Reduced risk of cardiovascular episodes, Reduction in blood cholesterol, lipids & glucose levels There is some evidence that weight reduction in obese people >65 has similar health benefits to those at younger ages primarily related to the reduction of CVD risk factors. NHLBI, Clinical Guidelines on the Identification, Evaluation & Treatment of Overweight and Obesity in Adults Safety of Weight Reduction in Older Adults The safety of weight reduction must be of utmost priority to avoid PEM, vitamin/mineral deficiencies and other complications Carefully planned and supervised Proper nutritional counseling Close monitoring of body weight and other nutritional parameters Weight loss is NOT appropriate for fragile older adults with PrU or other serious medical conditions that threaten mortality Weight Management Those who need to lose weight: Aim for a slow, steady weight loss by decreasing calorie intake, maintaining an adequate nutrient intake and increasing physical activity Overweight people with chronic diseases and/or on medication: Consult a healthcare provider prior to starting a program to ensure appropriate management of health conditions US Dietary Guidelines Goals: Weight Loss & Management Reduce BW 10% within 6 months (ADA 5-10%) Most weight loss occurs because of caloric intake Further weight loss can be attempted, if indicated BMI 27 to 35: Decrease calories / day to lose ~1/2-1 lb/week (10% loss/6 mos) BMI >35: Decrease calories 500-1,000 kcal/ day to lose 1-2 lb/week (10% loss/6 months) This rate of weight loss commonly occurs for up to 6 months (then weight loss declines) Weight will likely regained without dietary therapy, physical activity, & behavior therapy 6

7 What Does the Evidence Support? Meal Replacements For people who have difficulty with self selection and/or portion control, meal replacements (eg liquid meals, meal bars, calorie controlled packaged meals) may be used as part of the diet component of a comprehensive weight management program Substituting 1 or 2 meals or snacks with meal replacements is a successful weight maintenance strategy Rating: Strong Comprehensive WM Program Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet, physical activity, and behavior therapy. The combination therapy is more successful than using any one intervention alone Rating: Strong Physical Activity Physical activity should be part of a comprehensive weight management program Physical activity level should be assessed and individualized long term goals established to accumulate at least 30 min or more of moderate intensity physical activity on most, if not all days of the week, unless medically contraindicated Physical activity contributes to weight loss, may decrease abdominal fat, and may help with maintenance of weight loss. Rating: Strong Medications FDA approved weight loss medications may be part of a comprehensive weight management program Dietitians should collaborate with other members of the health care team regarding the use of FDA approved weight loss medications for people who meet the NHLBI criteria (BMI>30 with no obesity related risk factors or diseases; Or BMI with obesity related risk factors and diseases) Research indicates that pharmacotherapy may enhance weight loss in some overweight and obese adults Rating: Strong Bariatric Surgery Dietitians should collaborate with other members of the health care team regarding the appropriateness of bariatric surgery for people who have not achieved weight loss goals with less invasive weight loss methods and who meet the NHLBI criteria (BMI>40; w/co-morbidities) Separate ADA evidence based guidelines are being developed on nutrition care in bariatric surgery Rating: Strong 7

8 Behavior Therapy A comprehensive weight management program should make maximum use of multiple strategies for behavior therapy (eg self monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support) Behavior therapy in addition to diet and physical activity leads to additional weight loss Continued behavioral interventions may be necessary to prevent a return to baseline weight Rating: Strong Portion Control Portion control should be included as part of a comprehensive weight management program Portion control at meals and snacks results in reduced energy intake and weight loss Rating: Fair Macronutrient Composition Having patients focus on reducing carbohydrates rather than reducing calories and/or fat may be a short term strategy for some individuals Research indicates that focusing on reducing carbohydrate intake (<35% of kcals from CHO) results in reduced energy intake Consumption of a low-cho diet is associated with a greater weight and fat lass than traditional reduced calorie diets during the first 6 months, but these differences are not significant after 1 year Rating: Fair Macronutrient Composition A low glycemic index diet is NOT recommended for weight loss or weight maintenance as part of a comprehensive weight management program A low glycemic index diet has not been shown to be effective in weight loss or weight loss maintenance, although some studies show improvements in other parameters such as hunger and body fat mass Rating: Fair Diet Content: Dairy In order to meet current nutritional recommendations, incorporate 3-4 servings of low fat dairy foods a day as part of the diet component of a comprehensive weight management program Research suggests that calcium intake lower than recommended levels is associated with increased body weight. However, the effect of dairy and/or calcium at or above recommended levels on weight management is unclear Rating: Fair Nutrition Education Nutrition education should be individualized and included as part of the diet component of a comprehensive weight management program Short term studies show that nutrition education (eg reading nutrition labels, recipe modification, cooking classes) increases knowledge and may lead to improved food choices Rating: Fair 8

9 Strategies: Weight Loss & Maintenance Diet: Reduce the total amount of calories & control carbohydrates <30% Total calories as fat ( saturated fat: 7% AHA) Increase physical activity (will not lead to substantially greater weight loss over 6 months) Sustained physical activity is most helpful in prevention of weight regain Reduces CV & diabetes risks beyond that produced by weight loss alone Calculation of Nutritional Needs Not enough evidence-based research to suggest that one method of calculations will meet the estimated needs for all obese individuals The recommendations for needs calculations will continue to evolve as EBR evolves Reassess for any significant change in status including: Significant change in weight (>5% in one month, 7.5% in 3 months or 10% in 6 months) Calories Indirect calorimetry is considered the gold standard for determining resting energy expenditures (REE) Mifflin St. Jeor equation has been found to be the most reliable mathematical calculation of RMR in healthy adults (using actual BW & adjusting for physical activity) However, there is little research available to indicate accuracy of prediction for obese older adults Protein Limited research is available to provide specific guidelines for the obese individual General recommendation: 1.0 gm/kg for older adults Protein needs may vary depending on a number of factors, including: Renal status Presence of a pressure ulcer or wound Albumin or pre-albumin level Presence of hepatic (liver) disease Fluids Limited research is available to provide specific guidelines for the obese individual General recommendation 30 ml/kg Fluid needs may vary depending on a number of factors: Hydration status (dehydration or overhydration) Renal status Presence of hepatic disease Presence of severe edema or ascites Basic Guidance Until more research is available, each practitioner should: 1. Be aware of the current information available and choose the formulas they believe to be most accurate 2. Be consistent in the choice of formula as applied to each different population 3. Follow a standardized protocol for nutrient needs calculations Be aware that other nutrients may be needed due to deficiencies or medical conditions 9

10 What Can You Do to Help? Provide a Healthy Diet Plan Create Awareness 1. Provide information: US Dietary Guidelines, MyPyramid, other nutrition information Nutritional information on the items you serve 2. Provide some healthy options that are lower in Calories Fat Salt Sugar 3. Provide appropriate portion sizes Portion Sizes According to Jeffrey Prince of AICR, The easiest way to reduce intake is to very gradually reduce the size of the portions on our plates American Institute for Cancer Research Newsletter, Summer 2006 USDA Standard Portion Sizes ½ c Chopped vegetables, pasta, rice, cooked cereals or dried beans 1 c Raw leafy vegetables or 1 medium piece fresh fruit 3 oz. Meat, poultry or seafood 1/3 c Nuts ½ baseball or rounded handful for average adult 1 baseball or fist of an average adult Deck of cards Level handful for average adult 10

11 Offer Healthy Options that TASTE GOOD! Whole grain breads and cereals Fresh fruits and vegetables Low fat milk and milk products (cottage cheese, yogurt, etc.) Salad bar Low fat dressings Low sodium options (soups, vegetable juices, entrees, snacks) Replace Whole milk Whipped cream Sour cream Full-fat cheese Whole egg Healthy Substitutions With Skim, 1%, or 2% milk Chilled, whipped evaporated skim milk, nondairy whipped topping or FF Half & Half Plain low-fat yogurt, or ½ cup cottage cheese blended with 1½ tsp. lemon juice, or low- or nonfat sour cream Low-fat, skim-milk, or fatfree cheese (1 Tbsp flour) Two egg whites, or ½ cup egg product Replace Mayonnaise Cream Regular soups Canned vegetables Canned fruits Healthy Substitutions Regular salad dressing Regular vegetable and tomato juices With Low/no fat Mayonnaise Low/no fat salad dressing Low/no fat evaporated milk Lower sodium versions Lower sodium versions Fresh or frozen without added salt, fat Fresh or frozen without added sugar Menu Descriptors Can Help People Make the Right Choices Consumers want menu descriptions to help them make healthy choices: Low fat Specific nutrient values Heart healthy (Calories, fat, sodium) Lower sodium Low calorie Fresh Natural or organic Encourage Physical Activity Benefits of Physical Activity Helps maintain weight, healthy bones, muscles, joints Helps reduce body fat and increase muscle mass Improves mood Reduces risk of C-V disease, hypertension, diabetes Can reduce blood pressure, cholesterol (increase HDL) 11

12 Physical Activity US Dietary Guidelines Recommendations Regular physical activity 30/60/90 minutes of moderate physical activity most days Include cardiovascular, stretching and resistance exercises Older adults: Participate in regular physical activity to reduce functional declines associated with aging; and achieve other benefits of physical activity (C-V, strength, flexibility, balance) Physical Activity Initiate exercise slowly, build intensity gradually Can be done intermittently over the day Walking 30 min. 3 days/week; build to 45 min. of more intense walking 5 days/week (burn additional calories/day) Build to at least 30 min. of moderate-intensity physical activity most days of the week Increase "every day" activities (taking the stairs, reducing sedentary time) Promote Physical Activity Offer some healthy activities: Strength training, stationary bicycling or walking programs Employees & employers also benefit from healthy options (decrease insurance, absenteeism) Resources ADA Evidence Analysis Library Adult Weight Management Tool Kit Weight Management DPG NHLBI website Becky Dorner & Associates The Obesity Challenge Free Membership: Free E-zine Discounts on Publications Articles FAQs Helpful Links CEU Programs (self study online, teleseminars) Menus/Recipes Call to Action! Obesity will have a major impact on the US healthcare system Now is the time to get involved We can have a major impact in preventing and treating obesity in middle age and older adults 12