- CONDITION CENTERS
From sedentary desk jobs to antipsychotics, the causes of weight gain are unique to each patient. Working together, pharmacists and patients can create a tailored weight loss plan that addresses individual goals and challenges.
Just 50 years ago, most people were thin. Because food was relatively costly, we ate what was in season, cooked at home, and available locally—often grown in our own yards. Fast food establishments and “food courts” only became national trends in the 1960s and 1970s. Today, much food is “processed,” meaning we’ve used technology to make it easier to prepare and ready to eat, often using added fats and sugars. And a significant amount of our food travels from distant places, so it is always in season.
We value and expect inexpensive food—large portions of readily available, wrapped-to-carry food at drive-through windows are the new normal. Americans, and in fact people around the world, are heavier than ever. Our growing girth is now contributing to increasing incidences of diabetes, heart disease, and cancer.
Obesity is an excess of total body fat 1 and usually expressed in terms of body mass index (BMI, expressed in kg/m2 ). A reliable indicator of body fat for most people, BMI underestimates body fat in some groups of people—the elderly, for example, or the very muscular. Cross-sectional studies report BMI increases with age, peaking at around 60 years and then declining. Researchers don’t know if BMI naturally decreases with age or if the downward trend reflects the fact that individuals with high BMIs tend to die prematurely.1 Increasingly, researchers suggest using waist circumference as an indicator of obesity because it correlates with visceral and total fat, possibly better than BMI does.2
People who are obese at age 40 live 6 to 7 years less than those who are not, and obesity at age 25 reduces life expectancy by 13 years.3 It is not just mortality that is a concern—morbidity is affected, too, with annual Medicare costs for obese individuals $600 higher than for nonobese others.4
When energy (caloric) intake exceeds energy expenditure, people gain weight. As people age, they tend to exercise less and resting metabolic rates decrease 2% to 3% every decade after age 20. With inexpensive food so available, portion sizes have grown. Add hormonal changes to overt inactivity and the weight gain can be sneaky and significant.3 After middle age, the challenge can be monumental—because of decreased activity, BMI increases an average of 1.3 kg/m2 between ages 50 and 60, and the time approaching retirement is when people have highest rates of weight gain.5
Obesity is associated with gait and functional impairment, especially as we age, and it increases risk for numerous chronic and life-threatening conditions. Hypertension, lipid aberrations, certain cancers, diabetes, musculoskeletal pain, urinary incontinence, and cardiac disease are closely linked to excess weight.1-3,6-9 Obesity has a few benefits: increased bone mineral density, decreased osteoporosis, and fewer hip fractures. 7 These benefits, however, do exceed obesity’s risks.
The stigma of obesity is particularly painful for younger people. In young adults, those considered obese may have few friends compared with others. They often suffer from low self-esteem, depression, and social isolation. Elder obesity is actually linked to increased socialization, however. Stigmatization tends to dissipate with age, possibly because people who gain weight as adults were not stigmatized as young adults, and obese elders tend to be more resilient and less impressionable.10
Weight Loss Benefits
The benefits of weight loss—a weight reduction of 5% that is maintained for at least 1 year11 —can be life-changing. Successful weight loss of even 10% to 15% of body weight can alleviate or eliminate comorbidities, increase energy, and improve social interaction.10,12 Modest weight loss also improves diabetes, hypertension, and cardiovascular disease control.13
Each weight loss program has to be tailored to the individual, and most dieters need to find ways to motivate themselves. They may need constant encouragement. If the dieter has lost weight successfully in the past, the program he or she used may work again. Again, with age, the individual’s needs may change. Older dieters will be influenced if they have experienced years of frustrated desire to lose weight, waning social support systems, and major life crises.14 These issues, compounded by decreasing basal metabolic rates and health conditions that make exercise difficult or even painful, can be almost insurmountable barriers.
Starting With Lifestyle Changes
Improving diet and increasing exercise are the first critical steps leading to weight loss. Creating an energy deficit by consuming fewer calories than expended is a simple theory, but challenging in practice. Modest changes are best; slashing caloric intake to less than 1000 calories a day, whether on a desperate whim or in a medically supervised setting, almost always succeeds initially, but fails over the long term and can lead to electrolyte imbalance.13 With increased age, older dieters need to select menus that are lower in fat and higher in carbohydrates and protein.15-19
Reduced calorie diets that are augmented with regular exercise, even of modest intensity, produce weight loss and weight maintenance superior to diet alone.19-21 Most Americans know the “30 minutes a day, 5 days a week” rule for exercise, but many find it difficult to follow. It is prudent to start any physical activity program slowly, increasing gradually as conditioning improves. Many enjoyable activities are excellent exercise, such as walking, gardening, shopping, and golfing. In addition, the older the obese individual is, the more important aerobic and strengthening exercise becomes to prevent functional decline.
Unfortunately, even supervised weight loss/exercise programs that are sciencebased often fail. Researchers have not clearly identified other factors that undermine weight loss attempts, but they do know that short sleep duration, low dietary calcium intake, and high disinhibited eating behavior (a tendency toward overeating and eating opportunistically) are significant barriers to weight loss.22
Can Pharmacotherapy Help?
Pharmacotherapy is an option only for younger adults or very robust elders. Drugs often used to help reduce weight— amphetamines, sibutramine (now withdrawn from the US market), and orlistat—have adverse event profiles and drug interactions that frequently prevent their use in elders.14
Diet and exercise frequently fail. For patients whose obesity is exceptional— BMI greater than or equal to 40 kg/m2 (or BMI between 35 and 39.9 kg/m2 in the presence of comorbidities)—bariatric surgery can be explored and employed if the patient is willing to undergo extensive assessment and comply with long-term treatment and follow-up. More effective than diet and exercise, bariatric surgery is used more often than ever before, but has certain risks.23
At the Pharmacy Counter
Patients who embark on weight loss journeys often visit the pharmacy seeking that “magic pill” (see the Counseling Focus in this issue) or some guidance from the pharmacist that will make the process easier. Pharmacists should screen for medication-related causes for weight gain. Among the most notorious of drugs causing weight gain are select beta-adrenergic blockers, the tricyclic antidepressants, almost all antipsychotics, estrogens and hormonal agents, many antidiabetic drugs, and drugs used to treat seizure disorders.
Patients may ask about safe and appropriate weight-loss supplements. Most (if not all) have not been proved helpful or been tested over the long term. Pharmacists can refer to the FDA’s guidance on dietary supplements (www.fda.gov/Food/GuidanceComplianceRegulatoryIformation/GuidanceDocuments/DietarySupplements/default.htm) for more information. Additionally, as patients lose weight, their prescribers may be unaware of that fact. Pharmacists should remind patients who take any medication that has a narrow therapeutic window or is dosed based on weight that they may need to see their prescribers and have the dose adjusted.
Carefully planned reducing programs can work, but only if the overweight person works the program. Adding aerobic and strength training exercise improves overall fitness, and may help prolong independence and improve quality of life even in very frail individuals. In any of the many conditions that are exacerbated by excess weight, reducing can also reduce the number of visits the trimmer, slimmer patient makes to the pharmacy. PT
Ms. Wick is a senior clinical research pharmacist at the National Cancer Insitute, National Institutes of Health, Bethesda, Maryland. The views expressed are those of the author and not those of any government agency.
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