August 2013 Issue

Older Adults and Obesity — Is Dieting the Answer?
By Lindsey Getz
Today’s Dietitian
Vol. 15 No. 8 P. 44

Weight loss in obese elder patients can be detrimental to their health, but dietitians can take certain steps to help them lose weight appropriately and healthfully to improve their quality of life.

The prevalence of obesity in the United States is increasing among all age groups, including adults aged 65 and older. The most recent findings from the National Health and Nutrition Examination Survey (NHANES) found that more than one-third of this population segment is obese.

While weight loss often is the best answer to obesity, reducing chronic disease risk, and promoting health in other populations, when it comes to older adults, it’s not that cut-and-dried. Weight loss can lead to additional lean muscle loss and decreased physical strength. Though losing weight certainly can benefit older adults who are obese or overweight, experts say it must be done safely and methodically.

Today’s Dietitian spoke to RDs who have experience working with elder patients who are overweight or obese. Here they discuss the perils of overweight and obesity in this population and share the safest and most effective treatment options to improve their quality of life.

Growing Prevalence
“Just like in the general population, the percent of older adults with obesity is increasing,” says Laura Newton, MA, RD, an assistant professor in the department of nutrition sciences at the University of Alabama at Birmingham. “The baby boomer generation is moving into that older age demographic and therefore increasing the number of individuals who are overweight or obese.”

By 2050, the number of US older adults is expected to more than double, rising from 40.2 million to 88.5 million, according to the US Census Bureau. One reason obesity in the older population is getting more attention is because aging and obesity contribute to the increased use of health care services, which compounds health care spending.

Older adults who are obese or overweight have many (if not more) of the same health risks as the rest of the population. In fact, obese elders have an increased risk of chronic diseases such as diabetes, hypertension, and heart disease. But with older adults, obesity also can play a role in how they function on a daily basis, Newton says, who notes that “it can contribute to joint pain and limited mobility.”

“It’s definitely a quality-of-life issue,” says Joan Salge Blake, MS, RD, LDN, a nutrition educator, clinical associate professor at Boston University, and spokesperson for the Academy of Nutrition and Dietetics (the Academy). “Those who are obese may have problems with their hips, or that extra weight can become a burden on the knees. Walking for an extended period of time becomes problematic, and that begins to impact daily living. Becoming less physically active also is problematic in managing blood glucose. So weight can really become a burden.”

That’s why losing weight has significant benefits. “With weight loss, they might be able to reduce medications, such as hypertension medication, and they may become more mobile,” Salge Blake says. “But it’s a very individualized process. You have to look at each case individually. Losing weight has to be done carefully in this population.”

There are several factors that contribute to obesity in the aging population. Some individuals always have been overweight or obese and have simply carried those extra pounds into their older years. But a key reason some individuals become overweight or obese as they age is the decrease of their caloric needs and physical activity. Vandana Sheth, RDN, CDE, a spokesperson for the Academy, says that in addition to decreased activity, reduced growth hormone and testosterone levels, poor nutrition, medications, hypothyroid disorders, and lower metabolic rates are some additional factors that can cause weight gain and contribute to obesity in older adults.

Weight-Loss Risks
While it may seem as though dramatic weight loss is the best answer for obesity, when it comes to older adults, weight loss can produce negative effects that must be taken into consideration. “With aging in general, we have [significant] muscle loss—the condition of sarcopenia—and obesity can complicate that,” Newton says. “They’re carrying around greater weight and don’t have much muscle, so the older obese population is at a higher risk for falls and frailty already. The controversy with weight loss is that the individual also may lose additional muscle mass. You already have muscle loss from aging, and when you couple that with muscle loss from weight loss, it can significantly affect functional status and bone density.”

“As muscle mass decreases, fat mass increases over time,” Sheth says. “In studies, older adults with a higher percentage of fat mass were shown to have increased risks of disability, mobility limitations, and decreased physical function. It also has been reported that women are at a greater risk than men with higher fat mass.”

Since weight loss typically leads to losing both fat and muscle, it’s critical for RDs to develop personalized diet plans for clients. “There are some very restrictive diets out there that would cause an older person to lose weight very quickly, but weight loss should be done gradually,” says Ruth Frechman, MA, RD, CPT, owner of On the Weigh in Burbank, California, and a national spokesperson for the Academy. “Many older adults also have specific medical conditions that will play a part in what type of diet they’re on. And the fact that most people don’t know how to lose weight in a healthful way is another factor and a reason why dietitian guidance is so important.”

Newton recommends “targeting the issue” for older adults. “For example, if they have hypertension, you may consider using the DASH diet. If it’s hyperlipidemia, then maybe it’s a low-fat diet you’d try. You want to target the metabolic condition.”

Older adults also tend to take more medications than younger adults, so it’s important to account for how weight loss may affect dosing. “For example, if your patient is on hypertension medications and starts losing a lot of weight, that medication may need to be readjusted,” Salge Blake says. “Or if your patient is taking a blood thinner like Coumadin, it’s important they keep their vitamin K stable or else it can interact with the medication. When the patient is on a weight-reducing diet, it’s likely they’re eating a lot more vegetables, but it’s important to be aware that green, leafy vegetables are packed with vitamin K. That may mean the medication needs to be adjusted.”

These potential scenarios are why it’s so important for dietitians to oversee a new weight-loss diet plan for older adults. “The diet needs to not only be nutritionally balanced but also in line with other things going on in the person’s life, such as their medication regimen,” Salge Blake says. “It’s important for more people to realize that they shouldn’t just pick a diet from a fad book but that they should seek the guidance of a dietitian who will look at the medical history and any medications the patient is on.”

Fitting in Fitness
Incorporating some exercise also is vital for older adults so they can prevent muscle loss, Newton says. “It’s important to emphasize weight-resistant exercises to minimize muscle loss,” she adds. “Recommend about 2 1/2 hours of moderate-intensity exercise and two hours of strength resistance [training] per week.”

Frechman says that even clients in their 70s, 80s, or 90s can start a strength training routine that’s safe and beneficial. “Resistance bands and light weights are great,” she says. “As they build muscle mass and get stronger, that will help with stability, which is very important for the aging population. They’ll get stronger and be surprised to find that everyday tasks, like getting out of a chair or carrying a bag of groceries, are suddenly easier to do.”

Newton says it’s imperative for dietitians to stress the exercise component when discussing weight loss with older clients since many hone in only on the diet plan. “Even though we may not be the one doing the fitness instruction, we still need to recommend it,” she says. “It helps to at least have a network of places you can refer clients to—where you know they can exercise safely. It’s not enough for a dietitian to just say, ‘Go to the gym.’ Instead, we actually should be recommending places where they can go. It’s in our scope of practice to make the recommendation that they need to be exercising and doing strengthening exercises.”

Jessica Crandall, RD, CDE, of Sodexo Wellness and Nutrition and a national spokesperson for the Academy, also is a fitness instructor and says there are some great exercises older adults can do without putting too much stress on bones and joints, including yoga, using an elliptical, and walking in a pool. “The key is exercising within one’s own limits,” she says. “When clients are trying to lose weight, it’s so critical that they incorporate exercise into that routine, but the exercises must be helpful and not hindering. Older adults can’t recover as quickly and injuries will set them back even further, so finding the right exercise is very important.”

Special Dietary Concerns
As dietitians begin developing weight-loss diet plans for elder clients, there are other special considerations that may come into play. As discussed, medication and medical history are two key concerns. But it’s also important to note that older adults occasionally have naturally occurring loss of taste or difficulty chewing that can make adhering to certain dietary recommendations challenging. This is significant because it can hinder the amount of protein they consume, particularly if they get most of their protein from meat. This is concerning because protein is critical for maintaining the immune system and rebuilding muscle mass. It’s essential to assess whether older clients have barriers to getting adequate protein and develop solutions.

“Proteins come from a variety of sources. Beans are a really great alternative to meat if the patient has trouble chewing,” Crandall says. “They also can get protein from eggs or some of the nut butters.”

The cost of protein sources is another concern for many older adults, which may be a reason they begin to eat less meat, Crandall says. Some clients may need assistance in finding less expensive protein sources, such as beans and eggs. Or if loss of taste is the reason they’re eating less protein, they may need helpful suggestions in making their protein options more flavorful.

Dietitians also can play a role in the type of supplements older adults take, Frechman says. “RDs should make sure older adults are getting enough calcium in their diets,” she says. “Vitamin D also becomes especially important over age 50. Of course it’s also possible that older adults may be spending money on supplements they don’t really need, so that’s an area where RDs can help as well.”

A recent report from Emory University, published in Advances in Nutrition, challenges the idea that older adults need plenty of extra vitamins. Emory researcher Donald B. McCormick, PhD, professor emeritus of biochemistry and the graduate program in nutrition and health sciences at Emory said, “A lot of money is wasted in providing unnecessary supplements to millions of people who don’t need them.”

Crandall says she frequently encounters this with clients. “I see a lot of oversupplementation with older adult patients,” she says. “Clients will have a long list of supplements they’re taking, but they don’t even know why sometimes. Oversupplementation can cause problems as well, so it’s important that RDs know what their clients are taking and why they’re taking it.”

Because older adults who are overweight or obese have unique nutrient and dietary needs, it’s important for dietitians to form partnerships with local physicians, Salge Blake says. If primary care physicians are recommending these patients lose weight, they also should recommend they seek the assistance of an RD.

“We, as dietitians, should be seeking physicians and health care providers that serve that age group and make sure they know this is our specialty,” Salge Blake says. “Physicians need to be aware of what can go wrong if patients tackle weight loss on their own. In the same way an orthopedic surgeon would refer a patient to a physical therapist, primary care physicians who want their elder patients to lose weight should be referring them to us.”

 Salge Blake sees tremendous opportunity with this population. “Baby boomers are still booming, and as more people age, we’re going to be dealing with more and more obesity among older adults,” she says. “We’re living longer than ever, and there’s unbelievable opportunity to really seize this population and not only help them live longer but live better, too.”

— Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.