Drug-induced hyperphagia: what can we learn from psychiatric medications?

This brief review examines hyperphagia and associated weight gain as undesirable side effects of psychiatric medications; exploring the scope of the problem, proposed mechanisms, and potential interventions. Mechanisms of action appear to include drug-mediated effects on hypothalamic appetite pathways that have been implicated in other etiologies of obesity. There is great individual variation in response to these medications as well as variation in the degree of weight gain within drug classes. Gene polymorphisms may be a key factor in determining individual variations in response. Better understanding of the underlying mechanisms can guide useful interventions. Medication selection and dosing appear to be important strategies to minimize adverse weight gain.

School-based obesity prevention programs: an evidence-based review

OBJECTIVE

This review seeks to examine the effectiveness of school-based programs for reducing childhood overweight or obesity.

METHODS AND PROCEDURES

A systematic review of the research literature published since 1990 was conducted to identify experimental or quasi-experimental school-based curricular or environmental preventive interventions, with evaluation>or=6 months after baseline, which reported outcomes in terms of a measure of overweight.

RESULTS

Fourteen studies were identified, including one involving a nutrition-only program, two physical activity promotion interventions and eleven studies combining nutrition and physical activity components. Most studies (n=10) offered weak (grade 2) quality evidence. One study offered strong (grade 4) evidence reducing the odds ratio for overweight in girls only, while four grade 2 studies reported significant improvements in BMI or at-risk-for overweight or overweight prevalence in boys, girls, or both. Twelve studies reported significant improvement in at least one measure of dietary intake, physical activity, and/or sedentary behavior.

DISCUSSION

Our ability to draw strong conclusions as to the efficacy of school-based obesity prevention programs is limited by the small number of published studies and by methodological concerns. Qualitative analysis suggests programs grounded in social learning may be more appropriate for girls, while structural and environmental interventions enabling physical activity may be more effective for boys. High-quality evaluation protocols should be considered essential components of future programs.

Racial and ethnic differences in pediatric obesity-prevention counseling: national prevalence of clinician practices

OBJECTIVE

To assess the frequency of clinician-reported delivery of obesity-prevention counseling (OPC) at well-child visits; evaluating for racial/ethnic discrepancies.

METHODS AND PROCEDURES

Combined, weighted well-child visit data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 to 2004 were analyzed for patients aged 4-18 years. Obesity-prevention counseling was defined as the combined delivery of diet/nutrition and exercise counseling. Patients receiving over- or underweight related diagnoses were excluded. Counseling frequencies were calculated. Multivariate logistic regression models examined the relationship of OPC with race, ethnicity, region, provider, sex, age, and payor type.

RESULTS

Of 55,695,554 (weighted) visits, 24.4% included OPC (90.8% of these from NAMCS). 15.4% of Hispanic patients received OPC compared to 28.8% of non-Hispanics. Frequencies were similar between Whites and Blacks (25.0 and 27.1%). Patients with private insurance received more counseling (26.9%) than Medicaid (19.1%) or self-pay (15.1%). In logistic regression models, non-Hispanics were more likely to receive OPC (odds ratio (OR) = 1.94; confidence interval (CI) = 1.13-3.32), and patients in the West were less likely to receive OPC (OR = 0.39; CI = 0.18-0.85). Payor type was not predictive in regression analysis. Patients in hospital-based practices received less OPC (11.9% vs. 25.7% with OR = 0.40; CI =0.22-0.74).

DISCUSSION

Obesity prevention, like treatment, is a complex and multifactorial process. With the documented racial and ethnic disparities in rates of pediatric obesity, reasons for discrepancies in the provision of OPC must be further investigated as preventive strategies are formulated.

A dietary screening questionnaire identifies dietary patterns in older adults

Dietary patterns reflect habitual exposure of foods and nutrients and are a preferred means to assess diet and disease relations. Our objective was to design a screening tool to assess diet quality and dietary patterns among older adults and to relate the patterns to markers of general health and nutrition status. We used a population-specific data-based approach to design a diet screening instrument that was tested among subjects sampled from the Geisinger Rural Aging Study cohort (n=205). All participants attended a local clinic and had biochemical, anthropometric, and other health data collected. Dietary information was obtained via 24-h recall. We used principle components analysis to derive dietary patterns, which were then compared with nutritional outcomes using Pearson partial correlations, controlling for energy, age, BMI, and supplement use. Two dietary patterns were derived; 1 represented by more healthful foods and 1 by less optimal food choices. The healthy pattern was associated with more favorable biomarkers, more nutrient-dense diets, and lower waist circumference, whereas the converse was true for the second pattern. A screening tool can be used by older adults to identify dietary patterns that may relate to nutritional risk.

Inflammation as the key interface of the medical and nutrition universes: a provocative examination of the future of clinical nutrition and medicine

There has been tremendous interest in inflammation by researchers, the medical community, and the lay public. Modulation of injury response is felt to represent a tenuous balance of pro- and anti-inflammatory cytokines. Adverse outcomes may result from severe, sustained, or repeated bouts of inflammation. A critical observation is that nutrition support alone is inadequate to prevent muscle loss during active inflammation. It is necessary to take inflammation into consideration in conducting appropriate nutrition assessment, intervention, and monitoring. A host of medical conditions are actually inflammatory states that have important implications for nutrition care. Multifaceted interventions that may include anti-inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti-inflammatory agents, anticytokines, and probiotics, will be necessary to blunt undesirable aspects of inflammatory response to preserve body cell mass and vital organ functions. Nutrition practitioners can seize this opportunity to be a part of the future medical team that brings highly individualized patient care to the bedside.

Obesity among older persons: Screening for risk of adverse outcomes

A research overview is presented that highlights the growing prevalence of obesity among older persons and the associated risks for medical co-morbidity, healthcare resource use, functional decline and homebound status. Findings reveal that even for obese individuals poor diet quality and micronutrient deficiencies are relatively common concerns. Currently available nutrition risk screening instruments lack validity for overweight / obese older persons. Development and preliminary testing of a new Nutrition Health Outcomes Questionnaire (NHOQ) for this application are presented.

Weight, Dietary and Physical Activity Behaviors Two Years after Gastric Bypass

BACKGROUND

This cross-sectional survey was designed to determine the self-reported weight management, dietary and physical activity behaviors of Roux-en-Y gastric bypass (RYGBP) patients who were 1 to 4 years after the RYGBP operation, and to identify gaps in follow-up nutrition-related chronic disease prevention.

METHODS

Questionnaires including behavioral items from the 2003 and 2004 Behavioral Risk Factor Surveillance System (BRFSS) were mailed to all RYGBP patients in a clinically active outpatient database.

RESULTS

Of 212 patients, 140 (66%) returned completed questionnaires. Responders were 24.2 +/- 7.9 months postoperatively. They were older than nonresponders (45.2 +/- 9.9 vs 38.5 +/- 8.9 years, P<.001). Responders had an average weight loss of 55.8 +/- 15.2 kg, and most (81%) reported that they were still trying to lose weight. The most frequently reported dietary behavior for weight loss was decreasing calorie and fat intakes. However, in addition to avoiding sodas and sweet desserts, responders were also excluding nutrient-dense foods high in vitamins and minerals such as milk and dairy products, red meats, breads, cereals and nuts. Remarkably, only 25 (17.9%) engaged in regular exercise activities before surgery, while 116 (82.9%) indicated a moderate level of current physical activity averaging 54.7 +/- 38.5 minutes per episode. Multivariable linear regression analyses identified age, weight at age 21, pre-surgery BMI and time in regular physical activities as the four significant predictors of BMI after weight loss stabilization.

CONCLUSION

Postoperative RYGBP patients engage in various weight management behaviors, some of which could offer greater health benefits with follow-up intervention from dietitians and exercise specialists to prevent adverse outcomes such as weight regain and micronutrient deficiencies.

Obesity is a risk factor for reporting homebound status among community-dwelling older persons

OBJECTIVE

To test the a priori hypothesis that obesity is a predictor of risk for reporting homebound status.

RESEARCH METHODS AND PROCEDURES

A longitudinal cohort study was conducted with 21,645 community-dwelling men and women 65 to 97 years old. A nutrition risk screen was administered baseline between 1994 and 1999 and again 3 to 4 years later. Univariate analyses identified baseline variables associated with subsequent reporting of homebound status. Multivariable logistic regression models were created to identify baseline variables that were significant independent predictors of reporting homebound status.

RESULTS

At baseline, 24% of the cohort had BMI > or = 30. There were 12,834 (45% men) respondents at follow-up (68% response). Non-responders at follow-up differed little from responders except for greater baseline age (72.2 +/- 6.2 vs. 71.4 +/- 5.6 years, p < 0.001) and reporting of any functional limitations (9.2% vs. 4.9%, p < 0.001). At follow-up, those who reported homebound status (n = 169) were significantly (p < 0.001) older (80.3 +/- 7.3 vs. 75.1 +/- 5.5 years) and more likely to report functional limitations (83.4% vs. 10.8%). Univariate analyses identified 16 baseline variables that were eliminated stepwise until five significant independent predictors remained: age > or = 75 years (2.21, 1.55 to 3.15/odds ratio, 95% confidence interval), BMI > or = 35 (1.75, 1.04 to 2.96), poor appetite (2.50, 1.29 to 4.86), low income (1.59, 1.00 to 2.56), and any functional limitation (10.67, 7.36 to 15.46).

DISCUSSION

Obesity remained a significant independent predictor for reporting homebound status and should be considered in screening of older populations and in the planning, implementation, and evaluation of services for homebound older persons.

Obesity and functional decline: epidemiology and geriatric consequences

Obesity is growing in prevalence among older Americans and is accompanied by an unfortunate burden of chronic disease, functional decline, and poor quality of life. Elevated past or current body mass index (BMI) is strongly associated with increased self-reported functional limitations. Supportive findings have also related decreased physical performance test scores with elevated BMI. Body composition analyses have explored which body compartment is most strongly associated with obesity-related functional impairments. Studies have suggested possible contributions of decreased muscle mass and increased fat mass. Weight reduction intervention studies that have examined functional outcomes among older persons are limited.

Weight loss intervention for obese older women: improvements in performance and function

OBJECTIVES

To determine the feasibility of a 3-month weight loss program for obese older women with short-term laboratory, performance, functional, and life quality outcomes.

RESEARCH METHODS AND PROCEDURES

This was a pre- and postintervention design. Community-dwelling women (n = 26) > or =60 years old with BMI > or =30 were enrolled in a 3-month weight loss program promoting prudent diet, behavior modification, and physical activity. The primary emphasis of the program was on health, function, and quality of life. The approach was specifically tailored to older subjects through use of large-font instructional materials, supplementation of calcium and vitamin D, and moderate weight loss and physical activity goals. An initial assessment by a bariatric physician was followed by eight visits with a dietitian and a follow-up physician visit. Measurements included anthropometrics, body composition, laboratories, pedometer, physical performance, Short-Form 36 Health Status Survey (SF-36), Life Space Assessment, and dietary assessment.

RESULTS

Eighteen participants completed the program. There was a significant decrease in mean body weight (100 +/- 15 vs. 96 +/- 18 kg, p = 0.006), with a mean weight loss of 4.3 +/- 5.5 kg (range -15.5 to +7.20 kg). Significant improvements were observed for diastolic blood pressure, total cholesterol, triglycerides, physical performance, pedometer-measured step counts, and step climb and descent. Self-rated physical functioning (SF-36 subscore) and vitality (SF-36 subscore) were also significantly improved.

DISCUSSION

It is feasible for self-selected obese older women to achieve a moderate weight loss and increase in physical activity resulting in short-term improvements in laboratory, physical performance, self-reported function, vitality, and life quality outcomes.

Persistent oral health problems associated with comorbidity and impaired diet quality in older adults

Chewing, swallowing, and mouth pain (CSP) are identified as indicators of nutritional risk in older adults. Previous research has shown that oral health problems in community-living older rural adults were associated with increased hospitalization. The purpose of this study was to characterize older adults with self-reported persistent CSP problems at baseline and one-year follow-up. Participants were from the Geisinger Rural Aging Study, either with persistent oral problems (PCSP; n=22) or without problems (NCSP; n=125). Demographic, health, and anthropometric data were collected via home visit; diet information was assessed by five, 24-hour recalls collected over 10 months. PCSP subjects reported almost twice the number of medications (4.2 vs 2.6, respectively, P=.008) and diseases (7.0 vs 4.2, respectively, P=.001), with higher occurrence of type 2 diabetes mellitus, peptic ulcers/gastritis, and angina. PCSP participants had lower Healthy Eating Index scores (66.6 vs 70.6, respectively, P=.04), significantly lower intakes of vitamin A, and higher prevalence of inadequate intakes of vitamins B-6 and A. These results indicate that impaired intake of certain foods and nutrients is associated with persistent oral health problems. Oral status is an important component of overall health and should be monitored for intervention.

Hypertension-related dietary patterns of rural older adults

BACKGROUND

Prevalence of hypertension is greater in older adults, and increased intake of fruits, vegetables, and dairy-good sources of potassium, calcium, and magnesium-can reduce blood pressure. This study examined the hypertension-related dietary patterns of older adults.

METHODS

A cohort of 180 Pennsylvania adults (aged >/=65), 90 with hypertension, were randomly selected from the Geisinger Rural Aging Study (GRAS). Data were collected by trained interviewers at a home visit. Dietary assessment used five 24-h recalls. We compared the characteristics and dietary intake of people with hypertension to those without hypertension and compared their intakes to current recommendations.

RESULTS

Mean intakes of all participants were less than two thirds of the DRI for calcium and magnesium and fell far short of the 3,500 mg of potassium recommended for prevention and treatment of hypertension. Participants with hypertension consumed less sodium than controls. Both groups ate fewer fruits and vegetables than recommended but reached the dairy recommendation. Calcium intake was mainly from high-fat dairy products, beans were the top source of potassium and magnesium.

CONCLUSIONS

Older adults with hypertension should be guided to choose more low-fat dairy products and other low-fat calcium sources and to increase intakes of beans, dark green leafy vegetables, and other potassium and magnesium sources.

Dietary patterns of rural older adults are associated with weight and nutritional status

OBJECTIVES

To characterize dietary patterns of rural older adults and relate patterns to weight and nutritional status.

DESIGN

Cross-sectional.

SETTING

Rural Pennsylvania.

PARTICIPANTS

One hundred seventy-nine community-dwelling adults aged 66 to 87 years.

MEASUREMENTS

A home visit was conducted to collect demographic, health behavior, and anthropometric data and a blood sample. Five 24-hour dietary recall were administered. Cluster analysis classified participants into dietary patterns using food subgroup servings. Chi-square, analysis of covariance, and logistic regression were used to assess differences across clusters.

RESULTS

A low-nutrient-dense cluster (n=107), with higher intake of breads, sweet breads/desserts, dairy desserts, processed meats, eggs, and fats/oils, and a high-nutrient-dense cluster (n=72) with higher intake of cereals, dark green/yellow vegetables, other vegetables, citrus/melons/berries, fruit juices, other fruits, milks, poultry, fish, and beans, were identified. Those in the high-nutrient-dense cluster had lower energy intake; higher energy-adjusted intake of fiber, iron, zinc, folate, and vitamins B(6), B(12), and D; higher Healthy Eating Index scores; higher plasma vitamin B(12) levels; and a lower waist circumference. Those with a low-nutrient-dense dietary pattern were twice as likely to be obese, twice as likely to have low plasma vitamin B(12) levels, and three to 17 times more likely to have low nutrient intake.

CONCLUSION

This study provides support for recommending a high-nutrient-dense dietary pattern for older adults. Behavioral interventions encouraging diets characterized by high-nutrient-dense foods may improve weight and nutritional status of older adults.

Provision of high-protein supplement for patients recovering from hip fracture

OBJECTIVE

We compared clinical outcomes with a standard (Ensure) or a high-protein (Boost HP) liquid nutritional supplement for older adults recovering from hip fracture surgery in a rehabilitation hospital.

METHODS

This randomized, double-blind, parallel-group study compared the clinical effectiveness of a standard (Ensure) with a high-protein (Boost HP) liquid nutritional supplement among patients (n = 46) 60 y or older who recently underwent surgical repair of a hip fracture. Patients were encouraged to drink at least two 8-oz cans (17.8 g/d protein for Ensure versus 30 g/d protein for Boost HP) per day for 28 d. Study measurements included change in Functional Independence Measure between rehabilitation admission and discharge, length of rehabilitation stay, laboratory measures (i.e., serum albumin, prealbumin, and C-reactive protein), physical activity energy expenditure by 7-d triaxial accelerometry, and dietary intake by three random, telephonic, 24-h dietary recalls.

RESULTS

There were no significant group differences with respect to age, sex, acute hospital days, hip fracture assessment parameters, or surgical treatment. Consumption of supplement (260 oz/28 d of Ensure versus 239 oz/28 d of Boost HP) was comparable. There were no differences in complication or adverse event rates during the study. The Boost HP group consumed more protein than the Ensure group (63 versus 50 g, P < 0.048) and had a greater improvement in serum albumin over the 28-d supplementation period (+0.7 versus +0.2 g/dL, P < 0.019). The Boost HP group also consumed more fiber (12 versus 8 g), calcium (821 versus 639 mg), vitamin K (66 versus 45 microg), and phosphorus (1035 versus 833 mg) than did the Ensure group. Rehabilitation length of stay was shorter in the Boost HP than in the Ensure group, although this trend did not reach statistical significance (23 versus 28 d, P = 0.27). Outcome differences were not detected in the Functional Independence Measure.

CONCLUSIONS

Supplementation was well tolerated in this population and contributed significantly to total dietary intake. Consumption of a high-protein liquid nutritional supplement may offer some benefits by improving visceral protein status.

Nutritional risk assessment and obesity in rural older adults: a sex difference

BACKGROUND

Many older Americans are overweight or obese, but it is unclear whether obesity is associated with other nutritional risk indicators.

OBJECTIVE

This study investigated sex-associated differences in nutritional risk among community-dwelling, rural older adults and determined whether weight status [body mass index (BMI; in kg/m(2)) and waist circumference] was related to other measures of nutritional risk.

DESIGN

This cross-sectional study explored relations between weight status and nutritional risk, which was determined on the basis of the Level II Screen, overall diet quality, nutrient intakes, and plasma biomarkers.

RESULTS

Of the 179 subjects, 44% were overweight (BMI 25-29.9) and 35% were obese (BMI > 30). There were few differences in nutrient intakes between older men and women after we controlled for energy intake. In women, BMI was directly associated with multiple additional nutritional risk indicators, including the number of Level II items (r = 0.30), intakes of fat (r = 0.26) and saturated fat (r = 0.21), and homocysteine concentration (r = 0.25). Weight status in women was inversely associated with intakes of carbohydrates (r = -0.25), fiber (r = -0.35), folate (r = -0.24), magnesium (r = -0.29), iron (r = -0.22), and zinc (r = -0.23); Healthy Eating Index scores (r = -0.22); and plasma pyridoxal 5' phosphate (r = -0.30). Associations with waist circumference were similar. In men, weight status was associated only with plasma cobalamin (r = -0.33 for BMI) and pyridoxal 5' phosphate (r = -0.24 for waist circumference).

CONCLUSIONS

Overweight and obese older women, particularly those living alone, may be at greater nutritional risk than are men with a high BMI. Targeted nutritional intervention emphasizing nutrient-dense food choices to improve dietary patterns may be warranted.