Joint Position Statement on Obesity in Older Adults

Obesity has major implications in the older population because it can worsen age-related deterioration in health and cause frailty. However, management of older patients who are obese is difficult considering the risks associated with increased body mass index as well as the effects of weight loss, which is potentially harmful in older patients. The American Society for Nutrition (ASN), the North American Association for the Study of Obesity (NAASO), and the Obesity Society have issued a joint position statement that includes a review of concerns related to obesity in older persons and weight management guidelines for patients in this age group. The recommendations were published in the November 2005 issue of The American Journal of Clinical Nutrition.

When beginning weight-loss therapy for older patients, all appropriate information should first be collected (i.e., medical history, physical examination, laboratory tests, medication assessment, and evaluation of the patient's of inclination to lose weight). When deciding on the type of weight-loss therapy to use, programs that can reduce bone and muscle loss are recommended for older persons who have physical or metabolic complications. Physicians should assist their patients in making lifestyle and behavioral changes by setting goals, supervising progress, and motivating patients to adhere to a weight-loss program. Changing an older patient's diet or physical activity may be difficult because of many underlying factors (e.g., depression, disabilities, disease, dependency on others). All of these challenges should be addressed because they can make weight loss more difficult.

A diet consisting of a reduction of 500 to 750 kcal per day is recommended. However, diets that restrict energy intake to less than 800 kcal per day should be avoided because they may increase health complications. A diet should include multi-vitamins, mineral supplements, and 1.0 g of protein per kg of body weight to make sure daily requirements are met.

Before beginning an exercise regimen, exercise stress testing should be performed if necessary. The exercise regimen should be gradually incorporated into the patient's routine and tailored to each person, taking into consideration their current disabilities or problems. Routine physical exercise is important in preserving bone and muscle mass and improving physical abilities.

It is also important to evaluate the medications a patient is taking. Older patients are at higher risk of medication-related problems. Some medications can be the source of weight gain (e.g., steroids, antidepressants). Although there is little evidence for the use of obesity pharmacotherapy in older persons, orlistat (Xenical) may be the safest available agent for use in conjunction with lifestyle change, especially in patients with constipation.

Bariatric surgery should be used only in cases when a patient has a disability caused by obesity that can be improved with weight loss and when he or she meets the conditions required for surgery.

AAP Revised Recommendations for Examination of Infants for ROP

The American Academy of Pediatrics (AAP) has released a policy statement revising its 2001 statement on screening examination of premature infants for retinopathy of prematurity (ROP). The revised policy statement was published in the February 2006 issue of Pediatrics and is available at http://pediatrics.aappublications.org/cgi/content/full/117/2/572.

The statement focuses on the elements that help establish an efficient program for detecting and treating ROP. Because ROP is sequential and timely treatment has been proven to reduce the risk of vision loss, it is imperative that at-risk infants receive carefully timed retinal examinations and that all physicians who care for at-risk preterm infants should be aware of the importance of timing. Therefore, the AAP made the following recommendations:

• A retinal screening examination should be performed after pupillary dilation using binocular indirect ophthalmoscopy on all infants with a birth weight of less than 3 lb, 5 oz (1,500 g) or a gestational age of 32 weeks or less. Examination also should be performed on selected infants with a birth weight of 3 lb, 5 oz to 4 lb, 6 oz (1,500 to 2,000 g) or a gestational age of more than 32 weeks with an unstable clinical course.

• Knowledgeable and experienced ophthalmologists should perform retinal examinations on preterm infants and classify, diagram, and record findings using the standards from the International Committee for the Classification of Retinopathy of Prematurity.

• The initiation of acute-phase ROP screening should be based on the infant's age because the onset of serious ROP correlates more with postmenstrual age (i.e., gestational age at birth plus chronologic age) rather than postnatal age. Thus, the youngest infants at birth take the longest time to develop serious ROP.

• The ophthalmologist should recommend follow-up examination based on retinal findings categorized by the international classification.

• Physicians who are involved in ophthalmologic care of preterm infants should be aware that the findings calling for consideration of ablative treatment were recently revised using results from the Early Treatment for Retinopathy of Prematurity Randomized Trial Study.

• Acute retinal screening examination conclusions should be based on ophthalmoscopic findings and infant age.

• Parent and staff communication about ROP is important, and documentation of these conversations is recommended.

• Each newborn intensive care unit should define responsibility for examination of at-risk infants. Each unit should have specific criteria based on birth weight and gestational age, and the criteria should be established through discussion and agreement between the neonatal and ophthalmology departments.