Obesity among elderly poses rehab challenges

New study highlights problem

A new study shows a link between obesity and poor nutrition among the elderly, highlighting a problem that is common in rehabilitation facilities, as well as other health care settings.

Having surveyed more than 21,000 people, ages 65 and older, the Geisinger Medical Center’s Clinical Nutrition Research Center in Danville, PA, found that more than 70% were overweight for their height, with a body mass index (BMI) over 25. Thirty percent were obese, with BMIs of 30 or above, says Christopher Still, DO, director of the Center for Nutrition and Weight Management at the Geisinger Medical Center in Danville.

"In rehab, we see mainly geriatric patients, and a percentage of them are overweight or obese," notes Theresa James, MHS, supervisor of inpatient therapy at Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA.

"We usually find that they have other health factors that we have to take into consideration, such as high blood pressure, diabetes, and limitations on activities," James says.

"So in the clinic we’re seeing people who are not used to being active, and we’re trying to encourage them to be active," James adds. "That’s hard for them to adjust to, physically and emotionally."

The cohort studied included an elderly rural Pennsylvania population, but probably is representative of elderly people living in the United States, Still says.

Contrary to the popular image of the frail, malnourished elderly person, this was not the case. Only 2% of the people studied fell into that category, with BMIs of less than 18.5. Three times as many people as were underweight were found to be morbidly obese, with BMIs of greater than 40.

"The big problem in the elderly is obesity," Still says.

More striking was the discovery that even among those elderly people who ate more than enough calories and who took vitamin supplements, there was a lack of proper nutrition.

Investigators looked more closely at a representative sample of about 200 people. They conducted home visits, collected blood work to analyze for nutritional status, obtained medical histories (including a list of medications and supplements they used), and assessed them for depression and mental capacity.

They found that women who had the higher BMI numbers and waist circumferences also had the highest nutritional risk. They had an inadequate intake of fiber, folate, vitamin B6, vitamin B12, magnesium, iron, and zinc.

These are the same patients that rehab facilities might see following a stroke, orthopedic surgery, or another type of injury.

Focus on nutrition, not weight loss

One way to improve the outcomes for obese rehab patients is to include a dietitian or nutritionist on the rehab team.

Madonna Rehabilitation Hospital in Lincoln, NE, has two full-time and one part-time dietitian dedicated to rehab. A fourth dietitian works with the nursing home unit, says Sharon Balters, PhD, LMNT, manager of medical nutrition therapy and a registered dietitian.

"I agree that obesity is an epidemic, and it’s a risk factor in many health problems in America, including high blood pressure, osteoarthritis, and type II diabetes," Balters says.

However, when an obese patient is an inpatient in a rehab facility, that is not the right time to encourage the patient to begin losing weight, Balters adds.

"Our philosophy is that now is not the time to do that magic diet and lose weight while a patient is recuperating here in rehab," she says.

"The patient has just had knee or hip surgery, and while weight probably is cause or factor in their need for surgery, they’ve just had some blood loss and have gone some days without eating since their appetite is down, and so we’ve got to improve their nutrition," Balters says.

Using good nutrition to head off infection

Balters meets with patients to encourage them to eat enough nutritional foods, because if they were to deprive themselves of calories and nutrition, their surgery sites could become infected.

Sometimes physicians will forget that the healing process requires a higher caloric and nutritional intake, and they’ll instead talk with these patients about weight loss. That’s where a dietitian on the rehab staff can help by letting rehab physicians and therapists know how important it is to put the weight-loss issue on the back burner for now, Balters says.

"We will talk to patients about the future and will say that they’re welcome to come back as outpatients to talk about a healthy, low-calorie diet," she explains. "We say, It’d be nice, but not until you’re healed.’"

With cardiac rehab patients, a dietitian might advise rehab staff to keep the patient on a regular diet until the person’s appetite is improved, instead of switching immediately to low fat or low sodium.

"Heal first, and then get started on life changes and learning how to eat healthy and exercise," Balters says.

Another consideration is that rehab patients who are obese will need a higher calorie intake because of their excess weight, says Erin Krist, RD, LDN, dietitian with Cape Fear Valley Medical Center in Fayetteville, NC.

"When I do a follow-up, if they’re eating better I will recommend a lower-calorie diet and give them nutritional education," Krist says. "Once I know they are eating better and once they have adjusted to being here, I can talk to them more, but when they first were admitted they were so worn out and didn’t even have the energy to eat, which is another challenge."

There is no doubt, however, that morbidly obese patients can pose significant challenges to rehab staff, and there may be little a dietitian can do for the duration of these patients’ stay.

For example, Cape Fear once had a patient in her 40s who weighed more than 300 pounds. Admitted for a spinal cord injury, the woman was bedridden and was unmotivated to leave her room or transfer to a wheelchair, Krist recalls.

Education can reinforce weight loss

As difficult as it is to provide rehab therapy to such a patient, Krist initially could not put her on a low-fat diet because the woman was having eating problems and needed to maintain her usual caloric intake in order to regain her strength. However, Krist provides nutritional education to such patients before they are discharged, and patients’ efforts to lose weight can be reinforced by the rehab facility’s outpatient dietitian.

"Anytime I do a diet education, whether the patient is new or about to be discharged, I say, Don’t worry about these things while you’re here — these are for when you get home,’" Krist says. "I try to get feedback about what they typically like to eat at home and what their problem areas are."

Krist also will explain the different food groups and how some high-fat, low-nutrition foods are often substituted for more nutritionally rich foods.

"Everyone asks for recipes, and I go through the standard diet and then give them my name and number to call me later," Krist says. "I’ve had a few call-backs with minor questions."

The rehab team can be instrumental in nudging obese patients toward a healthier diet.

"Whether it’s the psychologist or the dietitian, we need to show them we understand that it’s difficult to lose weight," Balters says. "Sometimes, if patients really want to change, I may say that I’ll let them come back after the inpatient stay for one visit, but then we’ll have to charge them after that."

The team also could be a problem if therapists and nurses are not educated about the importance of a strong caloric and nutritional diet during the rehab experience, Balters says.

For example, Madonna Rehab had one patient who had lost a leg and was being fitted for a prosthesis. During his initial days as an inpatient, the man had lost weight, and it was important for the staff to encourage him to eat enough calories to heal his wound, Balters explains.

But then he began to gain weight steadily and was becoming overweight, as he had been before he lost his leg.

"People tend to go back to their usual weight, and normally that is good, but in his case, he needs strength in his arms to lift himself because he has an above-the-knee amputation," Balters says.

Holding on to extra pounds will make it that much more difficult for him to find a permanent prosthesis, and it will make ambulation painful. However, it’s not a good idea for the rehab team to discourage him from eating after so many weeks of telling him to eat more, Balters says.

Balters learned that one nursing shift had been vocal about how much food he was ordering, and she asked them to tone it down, telling them that this wasn’t the time to talk with him about his weight. She told them the patient was eating fine in terms of healing, and now they needed to watch out for the overeating, but to do so more tactfully.

"We’re trying to be positive with him when we see him drinking a diet pop instead of regular pop," Balters says. "The therapist may say, Isn’t that diet pop good? That’s the kind I like.’"

Or a nurse could compliment him on his having ordered only one or two desserts with a meal, instead of three or four, she adds.

Need More Information?

  • Sharon Balters, PhD, LMNT, Manager of Medical Nutrition Therapy, Registered Dietitian, Madonna Rehabilitation Hospital, 5401 South St., Lincoln, NE 68506. Telephone: (402) 489-7102, ext. 6396. E-mail: sbalters@madonna.org.
  • Theresa James, MHS, PT, Supervisor of Inpatient Therapy, Geisinger Wyoming Valley Medical Center, 1000 E. Mountain Drive, Wilkes-Barre, PA 18711. Telephone: (570) 826-7428.
  • Erin Krist, RD, LDN, Dietitian, Cape Fear Valley Medical Center, P.O. Box 2000, Fayetteville, NC 28302. Telephone: (910) 609-4560.
  • Christopher Still, DO, Director, Center for Nutrition and Weight Management, Geisinger Medical Center, 100 N. Academy Road, Danville, PA 17822-2111. Telephone: (570) 271-6439.