US Pharm. 2009;34(9):20-24.
Pharmacists are in a unique position, as they often 1) are the most accessible health care professionals in the community; 2) monitor a patient's entire medication regimen prescribed by multiple clinicians; and 3) counsel patients on the most appropriate, convenient, and cost-effective medications. These pharmaceutical care services, in conjunction with guidance on nutritional and lifestyle modifications (see Patient Resource sidebar), constitute a more holistic approach to achieve therapeutic outcomes. Patients who are obese (TABLE 1) could potentially benefit from such an integration of counseling services. Furthermore, a pharmacist's referral for nutritional counseling with a registered dietitian and/or referral for medical evaluation to address how obesity may be impacting the patient's health and well-being may be warranted; lifestyle and exercise programs may require a medical evaluation prior to their incorporation into a daily regimen.
Steady Rise in Obesity
There has been a significant increase in obesity in the United States within the last 2 decades.1 For the majority of the 20th century, the obesity rates in the U.S. were stable, aside from a slight trend upwards at the end of the 1970s, after which there was a spike across all demographic groups; rates have risen steadily since.2 As The Wall Street Journal recently reported, the American population is heavier, and those who are the heaviest are much heavier.2 Data from 2008 indicate that Colorado had a prevalence of obesity less than 20%, 32 states had a prevalence equal to or greater than 25%, and Alabama, Mississippi, Oklahoma, South Carolina, Tennessee, and West Virginia had a prevalence of obesity equal to or greater than 30%.1 According to the Centers for Disease Control and Prevention (CDC), U.S. society has become "obesogenic" and is characterized by environments that promote behaviors such as increased food intake, consumption of nonhealthful foods, and physical inactivity.1
Relevance to Health Care
While obesity is relevant to health care, it is especially so in light of recently proposed health care legislation. Obesity contributes to medical problems (TABLE 2) including cardiovascular disorders, osteoarthritis (OA), and urinary incontinence (UI), especially seen in the elderly. Furthermore, morbidly obese patients present nutrition-related and other challenges including difficulty undergoing diagnostic tests and procedures; physical rehabilitation and performance of activities of daily living may be difficult as well.3 Functional ability may be impaired in morbidly obese seniors with cognitive impairment and multiple comorbidities (e.g., heart failure, chronic obstructive pulmonary disease). In postmenopausal women, obesity is associated with increased risk of de novo breast cancer.4 An increased prevalence of android obesity in senior women may explain, in part, the higher risk of breast cancer with age.3
Chronic obesity is rooted in lifestyle (e.g., inadequate exercise), environment (e.g., excess caloric intake, high-fat diets, refined carbohydrates), and inherited traits (e.g., genetic predisposition); minor contributors include genetic, metabolic, and other determinants.5,6 Overeating leads to obesity in some and not in others due to the following variables: race, age, gender, activity level, metabolic rate, smoking, and alcohol consumption.5 While obesity has been defined as severe excess body fat, it may be further explained by an increase in body weight beyond the limitation of skeletal and physical requirements as a result of excessive fat accumulation.6,7 Specific conditions (e.g., hypothyroidism, Cushing's syndrome, genetic alterations, neurologic disorders) and medications (e.g., prednisone) may occasionally cause secondary obesity.5
In adults, obesity is determined by body mass index (BMI) using the calculation of weight (kg) divided by height (m)2 (TABLE 1).6 BMI is race specific (e.g., Asians and many aboriginal populations have a lower BMI cutoff [i.e., 23 kg/m2]) and age specific with limited use in seniors.6 Pharmacists should note the distribution of body fat in a patient, since more often than the presence of fat elsewhere, a predominately abdominal distribution (i.e., waist-hip ratio >0.8) is associated with diabetes mellitus, hypertension, and cardiovascular disorders.6 In seniors, an increased waist circumference (WC) is a better predictor of morbidity and mortality risk than BMI.6 High-risk WC is greater than 40 inches in males and greater than 35 inches in females.8 Other potential complications of obesity can be found in TABLE 2.
Obesity and Functional Ability in Seniors
Functioning of the geriatric individual involves innate abilities of the patient and his or her environment; however, clinicians working with geriatric patients may misinterpret the need to direct clinical attention to a senior's functional status as well as to specific medical disorders.9 Kane et al note that functional status is not more important or more useful than diagnosis, but rather one is incomplete without the other; they recommend a twofold process of geriatrics: 1) a clinical assessment and management that carefully identifies all remediable problems; and 2) a functional assessment that is conducted as carefully and competently to determine how to maximize a senior's autonomy through human and mechanical assistance and environmental manipulation.9
Health care professionals are encouraged to identify a remediable problem; obesity is a prime example of a potentially remediable cause of symptoms and health conditions that may impair functional ability and cause a handicap. Obesity is considered one of the leading factors associated with functional limitations and is the strongest known modifiable risk factor for knee OA; a significant decrease in pain and improvement in function has been seen with weight loss in patients with established disease.10,11 Obesity is both an established and modifiable risk factor for UI; extra weight adds additional pressure on the bladder, causing or worsening stress incontinence.12,13
Treatment
Behavioral, diet, and exercise therapies are the mainstays of weight-reduction and maintenance programs; weight loss requires both dietary modification and increased physical activity, usually in conjunction with behavioral therapy.5,6 Overall, in an obese patient, even a 5% to 10% weight loss seems to improve health, increase longevity, and reduce the risk of complications.6 In seniors, the mortality risk increases as BMI decreases. 6 Therefore, unless a senior's mobility is restricted, an increase in physical activity is preferred to dietary restriction; strength training and endurance exercises result in improvement of muscle strength, endurance, and overall well-being in seniors.6
Pharmacotherapy with a centrally acting appetite suppressant (e.g., the noradrenergic/serotonergic agent sibutramine 10 mg once daily; maximum dose 15 mg/day) or the intestinal lipase inhibitor orlistat 120 mg (Rx) or 60 mg (OTC) 3 times/day during or up to 1 hour after each meal containing fat is indicated as an adjunct to behavior modification if BMI is 30 or greater or if BMI is 27 or greater in an obese patient with complications, to reduce morbidity and mortality risks.5,6 While medications are more useful for maintaining weight loss, they have not been evaluated in the elderly. 6 Short-term noradrenergic agents (e.g., phentermine, diethylpropion) cause predictable weight regain upon discontinuation and their use is difficult to justify.8 OTC weight-loss agents are not recommended as the ratio of adverse effects to advantages is high.6
While surgery (e.g., gastric bypass, adjustable gastric bands) is generally indicated if diet, exercise, and behavioral therapy are ineffective in patients who have a BMI greater than 40 or have serious complications, it is best avoided in the elderly.6 For specific details on the treatment of obesity, the reader is referred to References 5, 6, and 8.
Recommended Strategies to Prevent Obesity
Exercise, healthful eating, and behavior modification can improve health. The CDC indicates that in order to make healthy food choices, healthy options must be available and accessible; this means they must be available to families in low-income and minority neighborhoods who often have less access to healthier food and beverage choices than those in higher income areas.14
The CDC's Measures Project process, guided by expert opinion, included a systematic review of the published scientific literature, resulting in 24 recommended environmental and policy level strategies to prevent obesity.14 This report presents the first set of comprehensive recommendations published by the CDC (TABLE 3) to promote healthy eating and active living and reduce the prevalence of obesity in the U.S.14 (overview, evidence, and suggested measurement for each strategy are online; see Reference 14). Pharmacists may consider participating in community coalitions or partnerships to address obesity by outreaching to schools, business associations, senior centers, and health care facilities to educate the public about healthful measures; use of these measures, in conjunction with prescribed medication, is a step in the right direction to promote health and wellness through healthy weight maintenance.
REFERENCES
1. Overweight and Obesity. Centers for Disease Control and Prevention. www.cdc.gov/obesity/index.html
2. The fat of the land. Review & outlook. The Wall Street Journal. August 1-2, 2009. A10.
3. Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 3rd ed. Whitehouse Station, NJ: Merck & Co; 2000:47,99,603-605,851,1218.
4. Wertkin AD, Cizza G, Blackman MR. Complementary and alternative in aging. In: Hazzard WR, Blass JP, Halter JB, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York, NY: McGraw-Hill, Inc; 2003:231-242.
5. Kissinger JF, Youngkin EQ. Obesity. In: Youngkin EQ, Sawin KJ, Kissinger JF, et al, eds. Pharmacotherapeutics: A Primary Care Guide. Upper Saddle River, NJ: Pearson Prentice Hall; 2005:693-708.
6. Beers MH, Porter RS, Jones TV, et al. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2006:8, 56-61,112,499,1279.
7. Dorland's Pocket Medical Dictionary. 28th ed. Philadelphia, PA: Elsevier Saunders; 2009:595.
8. St. Peter JV, Khan Mehmood. Obesity. In: DiPiro JT, Talbert RL, Yee GC, et al., editors. Pharmacotherapy: A Pathophysiologic Approach, 6th ed. New York: McGraw-Hill; 2005:2659-2676.
9. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics. 5th ed. New York, NY: McGraw-Hill, Inc; 2004:3-15.
10. Phelan EA, Paniagua MA, Hazzard WR. Preventive gerontology: Strategies for optimizing health across the life span. In: Hazzard WR, Blass JP, Halter JB, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York, NY: McGraw-Hill, Inc; 2003:85-92.
11. Fraenkel L, Felson D. In: Hazzard WR, Blass JP, Halter JB, et al, eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York, NY: McGraw-Hill, Inc; 2003:961-972.
12. Subak LL, Wing R, West DS, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009;360(5):481-490.
13. Beers MH, Jones TV, Berkwits M, et al, eds. The Merck Manual of Health & Aging. Whitehouse Station, NJ: Merck Research Laboratories; 2004:40-41,210-213,382-384,
14. Recommended Community Strategies and Measurements to Prevent Obesity in the United States. MMWR. Centers for Disease Control and Prevention. Last reviewed 7/14/2009. www.cdc.gov/mmwr/preview/
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