March/April 2014

Applying New Obesity Guidelines

By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 7 No. 2 P. 6

Physicians, including those who work with geriatric patients, are being challenged to step up their efforts to identify patients who are obese and counsel them regarding weight loss thanks to new guidelines released in November 2013 by the American Heart Association (AHA), the American College of Cardiology (ACC), and The Obesity Society.

“We need, as clinicians, to take ownership in advising overweight and obese adults and the geriatric community,” says Ralph Brindis, MD, past president of the ACC and a member of the ACC/AHA oversight task force for clinical practice guidelines.

To that end, the updated guidelines provide a road map for physicians to engage patients about weight and provide them with the skills they need to reach a healthier weight.

Identifying Patients and Goals
The guidelines first address how to identify patients who need to lose weight. In reviewing the research, the panel that developed the guidelines found a strong evidence base for calculating each patient’s BMI at least once per year. “To be honest, many of our clinicians to date have not been [calculating BMI regularly],” Brindis says, adding that “if you don’t measure it, you can’t manage it.”

According to the panel’s recommendations, patients who are obese (having a BMI of 30 or above) require treatment on the merits of their BMI alone. But for those with a BMI of 25 and above, weight loss isn’t necessary unless the patient has at least one additional risk factor, such as elevated blood pressure, abnormal lipids, or type 2 diabetes.

Donna Ryan, MD, professor emeritus from Louisiana State University’s Pennington Biomedical Research Center and cochair of the writing committee for the new guidelines, says the message is that being overweight in itself isn’t sufficient to necessitate weight-loss interventions, especially for elderly patients. Instead, what matters is patients’ weight along with their individual health risks. Since weight loss inevitably entails losing both fat and some muscle mass, which is of particular concern in the older patients, Ryan encourages physicians to be judicious in determining when weight loss is truly important.

With respect to the extent of necessary weight loss for patients who are obese, the new recommendations stress that health benefits begin to appear even with a weight loss of only 3% to 5%. “Of course 5% to 10% weight loss produces even greater benefits,” Ryan says. “But I think the underlying message here is that you don’t need to get people to a BMI of 25. We don’t need to be aggressive in anybody, much less older patients, to achieve some real health benefits.”

Appropriate Diet
Where treatment is concerned, the guidelines purposefully don’t recommend a specific diet. “When we looked at all the diets in terms of weight-loss superiority, there was no benefit of one above the other; there was no one magic diet,” Ryan says. “So we can’t say everybody ought to be on the low–glycemic-index diet or the low–glycemic-load diet or the Atkins diet or the low-carbohydrate diet or the Ornish diet or a vegetarian diet or a vegan diet.”

Only calorie reduction is necessary for weight loss, but multiple diets achieve this end with equal success. Therefore, a specific diet plan should be determined by a patient’s health status and preferences, according to Ryan. If, for example, a patient has hypertension, the Dietary Approaches to Stop Hypertension eating pattern may be appropriate, while physicians may recommend a low–glycemic-index diet for a patient with prediabetes. Otherwise, physicians should encourage patients simply to choose a diet that appeals to them.

Lifestyle Modification
A new and significant aspect of the guidelines is that physicians should refer obese patients for intense, comprehensive lifestyle intervention counseling. In its research review, the panel found that patients lose weight most consistently when they have at least 14 sessions over a six-month period with a trained interventionist, such as a nutrition professional.

Such lifestyle interventions should target not only diet but also physical activity and behavioral patterns, such as sleep and stress management. “These types of intensive interventions with a trained interventionist actually work,” Brindis says. “They’re much more effective than me as a clinician seeing a patient once or twice a year and just admonishing them to lose weight.”

The physical activity component of an intensive lifestyle intervention may be the aspect that is most difficult for older patients to implement. Generally, Brindis says, recommendations encourage aerobic exercise of moderate to vigorous intensity three or four times per week, lasting 40 minutes per session. But such intensity often is difficult for patients with osteoarthritis, knee disease, or other physical limitations, and messages about physical activity must be tailored for older patients.

“We shouldn’t frustrate our geriatric community that they have to go run 5Ks or go to Spin classes,” Brindis says. “For a younger population, people talk about getting target heart rates for their age—typically, for a 40-year-old, 130 beats per minute. That’s not what we’re asking our geriatric community to do. We’re asking them to be moving; we’re asking them to go on walks; we’re asking them to be involved and not just … sitting around the home with the remote.”

Bariatric Surgery and Weight-Loss Drugs
Although the new guidelines more strongly endorse bariatric surgery than the previous version, this recommendation applies less to older adults, Ryan says. “Because it produces more extreme weight loss, [surgery] is something that I think should really be approached with extreme caution in the geriatric population,” she explains.

Ryan encourages similar caution regarding the use of weight-loss drugs for older patients. The guidelines themselves don’t specifically address weight-loss drugs because only one was available when the panel began its work in 2008. However, in Ryan’s opinion, such drugs aren’t ideal for use among older patients because they may promote too much weight loss. “You really have to look at the biology of the patients in front of you because the risk-benefit is a little shifted,” she says. With older patients, she notes, “The more weight loss you produce, the more fragility you’re likely to see.”

Strategies for Addressing Obesity
For practical help with approaching conversations with patients about weight, Ava Port, MD, an assistant professor of medicine at the University of Maryland School of Medicine, with expertise in treating adult obesity, offers the following strategies:

• Focus on the here and now. The concerns surrounding weight loss differ depending on the patient’s age. With younger patients, the goal of obesity treatment is the prevention of long-term complications and disease risk. But with elderly individuals, whose life expectancy is shorter, the focus shifts to improving quality of life in the present.

“We’re talking really about improving current disease states, maybe reducing the need for medication, and really improving quality of life,” Port says. “You want to try to convince your patients of the here-and-now value.”

• Learn what motivates patients. If a patient isn’t self-motivated, efforts to encourage weight loss likely will go nowhere. Accordingly, it’s crucial to connect with patients and discover their personal motivating factors.

Port recommends motivational interviewing, which involves asking patients reflective questions to try to engage them and understand what may drive them. In her experience, aches and pains tend to be the biggest motivator for weight loss in older patients; patients are attracted to the idea of feeling lighter, more mobile, and able to climb a flight of stairs without having back or knee pain.

“Have the patient build goals based on their own personal feelings,” she says.

• Stress diet more than exercise. Physical activity is a necessary and important part of weight management, even for the elderly, but it’s not where the main focus should lie in obesity counseling for older patients. “Everybody benefits from exercise,” Port says, but “the focus typically for weight loss in older individuals is on modifying the diet. That’s where you’re going to get the greatest bang for your buck.”

• Help patients focus on what they can do and not what they can’t do. When it comes to exercise, older patients easily get hung up on their limitations, but you can refocus patients on forms of exercise in which they can successfully participate. Simple activities such as walking are ideal, and aqua aerobics and chair aerobics particularly are suited for patients who can’t handle weight-bearing activities.

• Make conversations about weight a priority. With older patients, who often have a variety of medical conditions, it’s easy to skip over conversations about weight. However, this is misguided because obesity often is at the core of other problems, and even minimal weight loss can substantially improve function and mobility, and reduce the need for medication.

“Even if it’s something that seems like it’s not a primary focus of care, physicians, no matter how old a patient is, should really be encouraging their patients to lose weight, particularly patients who fall in the obese range, with a BMI greater than 30,” Port says. “It should be something that physicians should make a priority to talk to all of their patients about.”

— Jamie Santa Cruz is a freelance writer based in New York City.