Photo Credit: iStock.com/Jacob Wackerhausen

A recent study offers recommendations on how to balance weight loss goals and bone health concerns in weight management programs for older adults.

Designing weight loss programs for older adults remains difficult because weight loss in this population may lead to musculoskeletal tissue loss and a higher risk for osteoporotic fracture and disability.

In an article for Obesity, researchers investigated how to better design lifestyle-based weight loss programs for older adults in order to address muscle and bone health concerns.

The researchers analyzed more than 23 lifestyle-based weight loss trials and have some key recommendations for weight loss programs for older adults:

• Complete a baseline assessment of musculoskeletal health before starting a program.
• Aim for moderate caloric restriction (-500 Kcal/day) with 1.2g/kg of protein daily, 1,000-1,200 mg of calcium per day and 900-1,000 IU daily of vitamin D.
• Incorporate resistance training twice a week at minimum and at least 150 minutes of weight-bearing moderate aerobic training.
• Deliver the program via an interdisciplinary healthcare team.

These recommendations are ideals, and some participants may require workarounds. For example, if someone struggles to complete resistance training, wearing a weight vest on walks could be an alternative. If low bone density is present, it’s often treated alongside a weight loss program.

Weight loss programs for older adults also benefit from co-management by an interdisciplinary team that may include a geriatrician, an obesity medicine specialist, an endocrinologist, a registered dietitian, a bone metabolism specialist, a physical therapist and an exercise physiologist.

Interventions should also take into account a patient’s motivation and preferences, any comorbidities they have, and their current diet and physical activity levels. Programs for older adults may focus on motivators pertinent to this age group, such as improving physical function and quality of life.

Two of the researchers, Kacey Chae, MD, and Kristen M. Beavers, PhD, MPH, RD, spoke with Physician’s Weekly (PW) about practical ways clinicians can incorporate their findings into weight loss programs for older adults.

PW: What practical strategies do you recommend to help older adults achieve nutritional targets?

Dr. Beavers: There are two things to unpack here—how do we get older adults to meet key nutrient needs that are important for musculoskeletal health (ie, protein, calcium, vitamin D) while restricting total caloric intake? In practice, doing both simultaneously can be challenging but certainly possible with some planning.

First, to meet protein needs, patients can be counseled to include 30 grams of high-quality protein sources at each meal. Distributing intake throughout the day has been shown to enhance muscle synthesis, and targeting 90 g/day provides 1.2 g/kg/d for someone who is starting at 75 kg (or 165 lb). This might look like 3.5 oz of cooked chicken breast, 10 oz of Greek yogurt, and 4 oz of salmon. Protein supplements can also be effective, with one scoop of whey or soy protein powder containing 25 to 30 g, depending on the brand.

Calcium- and Vitamin D-rich (or fortified) foods can also be recommended throughout the day, such as dairy products, fortified cereals, milks, orange juice, and salmon. As with protein, supplements can be helpful here, too (either as multivitamins or isolated nutrients), as well as a 30-minute dose of sunshine two to three times a week on the face, arms, and legs, so your body can synthesize vitamin D.

The second piece is getting folks to be successful at restricting their calories, which works well when nutrition education and behavioral counseling strategies are combined—and even better when provided in a group setting. A registered dietitian could be consulted to help develop a comprehensive, personalized plan that aligns with these nutritional targets.

Many older adults may have limited access to training facilities or experience with resistance training. What practical strategies would you recommend for implementing resistance training in community or home-based settings?

Dr. Beavers: To make resistance training more accessible for older adults, bodyweight and chair-based exercises can be performed in the home (eg, squats to a chair, wall push-ups, seated leg lifts, and standing calf raises).

In addition, there are a variety of relatively inexpensive and portable resistance products, including resistance bands, weighted vests, and even common household items (eg,  water bottles or canned goods), which can serve as light weights for arm and shoulder exercises.

That said, two important things to remember about resistance exercise are: 1) it only works if you consistently do it, and 2) the resistance must be gradually increased over time to remain effective.

Structured exercise programs can help in both regards. For older adults, the YMCA’s Silver Sneakers Program is a fantastic community resource. This free, nationwide program for adults aged 65+ includes access to exercise equipment and in-person fitness classes at more than 15,000 locations across the country, as well as printed resources, online workout videos, and virtual sessions. Likewise, the National Institute on Aging developed a toolkit to help promote safe, effective exercise techniques for older adults.

Given practical constraints in many healthcare settings, who are the minimum essential team members for multidisciplinary management of weight loss in older adults? How might primary care physicians coordinate this care in settings with limited specialist access?

Dr. Chae: The four pillars of obesity care is a helpful framework that defines the essential elements of obesity care, which include nutrition therapy, physical activity, behavioral modification, and, if clinically indicated, medical interventions (eg, medication management, bariatric procedures, and complication management). It is also important to recognize that older adults represent a wide heterogeneity of health status and have varying needs to reach their weight loss goals for improved health.

Some older adults may need access to a structured intensive behavior therapy delivered by a trained primary care clinician. Others may require comprehensive multidisciplinary care to address physical function impairment, psychosocial barriers, and medical complexity. I envision primary care clinicians playing an important role in assessing the individual needs of the older adult patient and helping them access essential elements of the care plan.

While there are established counseling frameworks, such as the 5 A’s, to guide obesity care within primary care settings, I also recognize the challenges that primary care clinicians face. In the past several years, telehealth has opened tremendous opportunities to improve access to care. If the patient needs additional support beyond the primary care clinician’s capacity or scope of practice, telehealth visits or “E-consults” with an obesity medicine specialist, behavioral psychologist, dietician, physical therapist, or other healthcare professionals essential to the care plan are avenues to improve access.

Additionally, leveraging community partnerships, such as the YMCA or Take Off Pounds Sensibly (TOPS), can help support patient’s lifestyle behavior change between visits.

Your research indicates many older adults struggle with long-term adherence to lifestyle interventions. What strategies have you found most effective for maintaining adherence beyond the initial intervention period, and what should clinicians do when patients begin to regain weight?

Dr. Chae: It is helpful to set the stage for long-term weight maintenance during the initial conversation about weight loss with a patient. Framing lifestyle behavior change as a long-term change, rather than a quick fix, can inform the initial strategies to promote weight loss and ensure the plan is sustainable.

I also talk with patients about physiological changes that occur with weight loss that make weight maintenance extremely challenging. This helps the patient know that the challenge of weight maintenance is not due to their lack of willpower.

Approaches to maintain adherence are highly individualized, but social support, self-monitoring, and regular follow-up with a clinician who can guide weight management are some helpful strategies.

Social support from family and friends ensures the patient has a robust support system to continue engaging in lifestyle behavior change. Peer support from others who are also engaging in lifestyle behavior change can be valuable in troubleshooting common challenges and refining potential solutions.

Self-monitoring in the form of food tracking and/or self-weighing is a helpful behavioral tool that can bring awareness to certain lifestyle behavior patterns that need modifications. Lastly, Regular follow-up with a clinician (eg, primary care clinician, obesity medicine physician, endocrinologist, etc) provides accountability and continued monitoring of health status that can reinforce positive lifestyle behavior changes.

If there is weight regain, the most important step is to obtain a detailed history to understand major contributors, which will inform the management plan. Pertinent information includes the patient’s food intake, physical activity, medication history, significant medical events, stress, and sleep.

Polypharmacy is an issue for many older adults, so a new medication may have been started that is known to promote weight gain. The next step is to consider stopping the medication or switching to weight-neutral alternatives (if medically appropriate).

The patient may have worsening osteoarthritis, which limited their physical activity. Work collaboratively with a physical therapist to help the patient regain physical function.

To manage weight regain in the absence of medical factors, the patient may need to reintroduce some of the lifestyle behavior strategies that initially promoted weight loss (eg, food tracking, self-weighing).