Added weight: The challenge of obesity in older patients

The patient is a 78-year-old woman with severe osteoarthritis in her knees, hypercholesterolemia and hypertension. She is severely overweight. And her physician has been working with her to address her excess bulk.

Has the effort resulted in any success?

"Yes and no," said Melvyn Sterling, MD, an internist in Orange County, Calif. He has been able to stop the progressive rise in her weight. But as of yet, the scales haven't started registering downward momentum.

Like Dr. Sterling, many physicians are well aware of the hard-fought nature of such small victories when treating older, overweight patients who often present with a lifetime of bad habits and a range of complex chronic conditions. After all, the problems related to obesity are both widespread and insidious.

About two out of three Americans are overweight or obese. Incidence rates for older Americans follow close behind. According to the National Heart, Lung and Blood Institute, an estimated 18% of U.S. adults older than 65 are obese. Another 40% are overweight, putting them at substantially increased risk for diabetes, hypertension, heart disease and other illnesses.

In July, the Centers for Medicare & Medicaid Services announced a change in Medicare rules designed to remove barriers to covering anti-obesity treatments. The agency changed language that had stated that obesity was not a disease. As a result, coverage decisions now can be made on treatments, with the exception of weight loss drugs, if an advisory panel determines that enough evidence exists to demonstrate effectiveness in improving beneficiaries' health outcomes. Many doctors hope that this step ultimately will enable Medicare to be more proactive in paying for interventions before comorbidities take hold.

For now, though, the added attention doesn't ease the burdens physicians face as they struggle to develop strategies to make a difference.

"There are some things that are common sense when dealing with older people and weight issues," said Dr. Sterling, also chair of the AMA Council on Scientific Affairs. "But it can be much more difficult to change their behavior, and the stakes are much higher, because the secondary medical problems are more common."

More than one epidemic

Many experts talk about the problem in terms of twin epidemics: obesity and inactivity.

Between 28% to 34% of adults ages 65 to 74 and 35% to 44% of adults older than 75 engage in no leisure-time physical activity at all, according to the Centers for Disease Control and Prevention. This fact further complicates this demographic group's weight-control efforts. Not only are these patients more likely to be sedentary, but as people age, their metabolisms slow. Interventions, therefore, have to operate on two tracks.

"I don't just think in terms of weight loss anymore," said Howard Eisenson, MD, a family physician who is the director of the Duke Diet and Fitness Center in Durham, N.C. Instead, diet and nutrition as well as physical activity are two sides of the same coin, he said.

But the stumbling blocks are many. Physicians often recommend walking. However, wear-and-tear joint pain can limit a patient's ability to follow through, explained Denise Bruner, MD, a bariatrician in private practice in Arlington, Va., and a former president of the American Society of Bariatric Physicians. They might fear walking outside because of crime or a lack of sidewalks. People also sometimes have vision or balance problems that put them at risk of falling.

When it comes to eating habits, older patients can have diminished taste buds, which tend to lure them toward the sweet and salty. Their negative patterns are well-established. And often, they live on fixed incomes, and healthy food choices are usually more expensive.

And some patients are on medications that either drive their weight up or prevent losses. "In the bariatric world, we know that beta-blockers can cause weight gain," Dr. Bruner said. Steroids also fall into this category.

But the news isn't all bad, because some factors actually work in these patients' favor.

Many are retired, meaning they have time to commit to making changes. They also have a different state of mind.

Once patients are in their 40s or beyond, they've been on a multitude of diets and lost and gained a multitude of pounds, said Joel Posner, MD, an Audrey Meyer Mars Professor of Gerontologic Research at Drexel University College of Medicine in Philadelphia. "By laying out right at the beginning that we are talking about a two, three- or four-year process where we're really going to change behavior to make [the patient] more healthy, compliance actually tends to be pretty good, and unreasonable expectations usually aren't there."

Conventional wisdom about making necessary adjustments also has changed.

"The thinking used to be if you got to be 60, 70, or 80 and you were overweight, it wasn't going to hurt you," said Edward Saltzman, MD, chief of the division of nutrition at Tufts Medical Center in Boston. "That really isn't true."

Still, helping define a patient's notion of what he or she is working toward is no easy task.

According to Dr. Bruner, success in weight reduction is generally viewed as losing and maintaining a 5% to 10% reduction in body weight. For someone who weighs 300 lbs, that's only 30 lbs.

With her older patients, she tries to emphasize "the benefits that result instead of the discomfort of making a change." Younger people have more external motivation, she added. "In these people, it has to come from the heart."

But the cards seem stacked against older patients. It's the arthritis that makes it hard to exercise, the habits ingrained over many years that are difficult to break, and the reality that older folks simply tend to lose weight more slowly.

"One of the limitations to a weight-control effort -- particularly if it is non-surgical -- is people want to hop on the scale every few days and see the needle dropping. If they don't, it can derail their efforts," Dr. Eisenson said.

Thus, keeping these patients focused on the prize is critical.

"We have a number of older people who are really very overweight," Dr. Posner said. Though these patients slim down a bit, their main accomplishment is improved health. "You have to applaud that, even though you may never get the person down to the weight they want."

Dr. Eisenson thinks of it as moving their frame of reference beyond the scale. "I like to grab at the moment and say, 'Hey, hold on a second. How have you felt over this week? How are your clothes fitting? Are you starting to move better?' If you can get them to say, 'Oh yeah, that's better,' that can give them the motivation to stick with it."

Tips for doctors in the trenches

Physicians who either specialize in diet and nutrition or have significant experience dealing with older patients offer a number of specific tips.

"The first thing is to take heart -- don't write these people off," Dr. Eisenson said. "I would avoid assuming that older patients are either uninterested or unable to modify their eating habits or activity levels."

Once the issue is on the table, one of the most basic messages to convey to patients is not to gain more weight.

In terms of cutting calories, experts generally agree that patients should avoid radical diets and instead incorporate small changes sustainable over the long term. These include staying away from refined products, processed food, white sugars, white flours and white rice, as well as avoiding saturated fats and transfatty acids. Meanwhile, they should emphasize fruits, vegetables, whole grains and enough protein to build and maintain muscle.

In terms of exercise, the mantra is start low and go slow.

Goals should be geared to individual patients. "We have some people who are almost crippled, and we have some people who are in very good shape," Dr. Posner said. But it is always important to focus on flexibility; aerobic exercise, based on the patient's fitness; and muscle work to build strength and increase metabolism.

Specialists note the daunting time constraints primary care doctors face when trying to advance these kinds of lifestyle changes.

Being familiar with local resources and encouraging patients to take advantage of them can help. For instance, senior or community centers or YMCAs often have senior fitness classes, pool exercise -- great for those who have joint pain -- or walking groups.

"If somebody is limited, they can start with walking 10 minutes a day and add a few minutes a week to that regimen," Dr. Eisenson said. And if they are afraid or unable to go outside, they should still have an ultimate goal of 30 minutes of activity -- even if it is accomplished indoors on a stationary bike or by walking around the dining room table, said Barry Fabius, MD, medical director of geriatrics at the Holy Redeemer Health System in suburban Philadelphia. He also notes the importance of putting patients through some basic tests to ensure that they are medically ready.

Most also agree that referring patients with orthopedic issues to a physical therapist, which is often covered by insurance, can be helpful. Physicians also can send patients to diet and nutrition programs.

Dr. Sterling said his patients are most successful when involved in a program that meets a minimum of once every other week. Depending on the patient's financial resources, he recommends, for example, Overeaters Anonymous or Weight Watchers as affordable options. His patients have also been very successful working with a registered dietician.

Meanwhile, Dr. Bruner reminds physicians to review patient medications to ensure that they are "weight neutral" if possible. She also recommends advising patients to stay well-hydrated. "Dehydration can be mistaken for hunger." Another tip: Eat a main meal at the noon hour and eat lighter in the evening. "It's a metabolic rate issue," she said.

Bottom line: Experts agree that obesity is a long-term problem and should be treated as such. "Applying a chronic disease model makes a great deal of sense," Dr. Eisenson said. "Too often we don't do that."

He encourages physicians to bring up often the issues of weight, eating habits and exercise. And over time, patients will need encouragement, support and even problem solving. But healthier lifestyles are certainly within reach.

"I don't think there's an age limit on people's interest in improving their health, becoming more active, losing weight," Dr. Eisenson added. "Nor do I think the ability to be successful ends at a certain age."