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The Risks and Benefits of Weight Loss in Overweight Seniors: ACCN Day Three

By Sheela Sinharoy, Student Blogger

Is weight loss always recommended for obese persons, or are there some individuals for whom weight loss may not be necessary or may even be harmful? In a session on Saturday, Dr. Julie Locher looked at this question in relation to seniors. Given that 14% of Americans – or one in seven – are over age 65, and that this proportion is expected to increase to 20% by 2030, it is important to understand the needs and special requirements of this group.

As the proportion of Americans who are over age 65 increases, so too does the prevalence of overweight and obesity. According to Dr. Locher, approximately 35% of older persons are obese. Many of these individuals experience co-morbidities and functional limitations, which are often associated with or impacted by obesity. However, the effects of weight loss treatment in older adults have not been extensively studied.

The benefits of weight loss in older adults are similar to those found in the general population, including reduced markers of inflammation and improved cardiovascular health. As co-morbid conditions increase with age, weight loss may address some of these conditions. Especially when weight loss occurs through a combination of diet and exercise, research has shown that muscle quality and physical function also improve, as does global cognition.

At the same time, some studies have found being overweight to be potentially beneficial. For older adults in particular, a number of studies indicate that being overweight yields no extra risk of mortality, and in fact, may be associated with a lower risk of mortality than being normal weight. Obesity is also associated with increased bone mineral density and decreased osteoporosis as well as with decreased risk of hip fracture.

In addition, weight loss in overweight seniors carries certain risks. First, intentional weight loss is associated with a loss of bone mineral density. Also, weight cycling – when individuals lose and then regain weight – may be a more serious concern with older adults because of their different body composition. When seniors regain weight, it is disproportionately fat, especially abdominal fat, compared to lean muscle. This is associated with higher cardiometabolic risk and an increased risk of disability and mortality.

Even among older adults, needs may differ between sub-populations. For example, as the proportion of older adults continues to rise, the fastest-growing segment is those ages 85 and over. These individuals may require a different therapeutic approach than younger seniors, and improving physical function and quality of life may be more important than obesity treatment.

As some providers move increasingly toward personalized medicine, this may be one more way in which recommendations and a therapeutic approach may need to be tailored to the individual patient. Depending on their bone health, metabolic health, and a range of other factors, doctors may decide that weight loss is not always the best approach for obese older adults. For some seniors, the risks of weight loss may in fact not outweigh the benefits.

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Changes on the Horizon: Redefining Malnutrition Diagnoses in Older Adults

By Jonelle Agurs, ASN Intern

No one wants to get half a diagnosis from their doctor.

Unfortunately, that’s what tends to happen when diagnosing malnutrition in hospitalized adult patients in the United States. The present criteria for some malnutrition assessments, like the Malnutrition Screening Tool (MST), are under scrutiny because they only evaluate patients on symptoms of starvation, such as unintentional weight loss or poor appetite. However, new studies postulate that malnutrition should not be limited to food behaviors, but should be expanded to include inflammation resulting from chronic disease. The body’s inflammatory response can intensify the symptoms of starvation, and vice versa; poor eating habits may induce inflammation as well. The human body does an impeccable job of patching itself up using the inflammatory response, but this process often triggers symptoms strongly associated with malnutrition, such as weight loss. With approximately half of the U.S. adult population (117 million) suffering from at least one chronic condition, such as coronary heart disease and diabetes, it is no surprise that there is an increasing prevalence of malnutrition cases among hospitalized adult patients.

ASN supports the efforts of many of its partner organizations, such as the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics, which want to recognize the role of the inflammatory response when diagnosing malnutrition. They have proposed four standard criteria: insufficient energy intake, unintended weight loss, muscle mass and fat loss, and diminished physical function. These criteria will support a more etiological-based diagnosis of malnutrition; a diagnosis more closely linked to the chronic diseases that cause it. Misdiagnoses often result in patients being discharged early from hospital care, causing inpatients to return later for health issues made worse by the symptoms of poor nutrition.

The International Classification of Diseases, 10th Revision, or ICD-10, is a coding system under the Affordable Care Act of 2010, scheduled to be implemented after October 1, 2015. Designed to improve disease management, this revision will include coding using an updated definition of malnutrition. Absence of a standard screening system for this condition is like installing the proverbial cork in the leaky faucet; diagnoses without a simple malnutrition assessment may “plug” up the issue, but the pressure continues to build, waiting for a more thorough solution. The expansion of the ICD-10 coding system will provide a part of that solution by enhancing screening accuracy. With five times more descriptors than its ICD-9 predecessor, ICD-10 coding will include more conditions that could be linked to a range of malnutrition-related issues.

Hospitals across the nation are preparing for the ICD-10 updates, but it is imperative that hospital personnel fully understand how to recognize and diagnose malnutrition to code it properly. Despite shortages of nursing staff and other trained individuals, quality of patient care must be maintained in order to indicate their risk of malnutrition. Clinicians must be able to perform comprehensive assessments of the patient’s complete medical background, so that, along with the newly-proposed diagnostic construct, every patient will receive comprehensive care that will, ideally, lower the cost of their medical care expenses in the future.

Malnutrition, among other hospital-based nutrition topics will be discussed on Saturday, December 6 during the fourth annual Advances and Controversies in Clinical Nutrition conference. Dr. Gordon Jensen, ASN’s immediate past president, will give an address titled “Malnutrition and the Affordable Care Act.” The conference runs December 4-6 at the Gaylord National Resort & Convention Center in National Harbor, MD, and features a dynamic program with topics ranging from dietary supplements to nutrition and cancer. To learn more about this year’s conference, please visit the website.

Reference
Jensen, G, Compher, C, Sullivan, D, Mullin, G. (2013). Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach. Journal of Parenteral and Enteral Nutrition, 802-807.