Obesity in Nursing Homes: An Escalating Problem

High Medicaid Nursing Homes: Contextual Factors Associated with the Availability of Specialized Resources Required to Care for Obese Residents

Obesity is an increasingly important concern in the delivery of high-quality nursing home care. Obese nursing home residents require specialized equipment and resources. As high Medicaid nursing homes have limited financial ability, they may lack the necessary resources to address the needs of obese residents. Moreover, there are variations in the availability of obesity-related specialized resources across these facilities. This study aims to investigate the organizational and market factors associated with the availability of obesity-related specialized resources in high-Medicaid nursing homes. Survey and secondary data sources for the study period 2017-2018 were utilized. The survey data were merged with Brown University's Long Term Care Focus (LTCFocus), Nursing Home Compare, and Area Health Resource File datasets. The dependent variable was the composite score of obesity-related specialized resources, ranging from 0-19. An ordinary least square regression with propensity score weights (to adjust for potential survey non-response bias), along with appropriate organizational/market level control variables were used for our analysis. Our results suggest that payer-mix (>Medicare residents) and a higher proportion of obese residents were positively associated with the availability of obesity-related specialized resources. Policymakers should consider implementing incentives, such as increased Medicaid payments, to assist high Medicaid nursing homes in addressing the specific needs of obese residents.

Exercise Guidelines to Counteract Physical Deconditioning in Long-Term Care Facilities: What to Do and How to Do It?

With age, older adults experience a decrease in muscle function and changes in body composition, which raise the risk of functional incapacity and loss of autonomy. These declines are more pronounced in older adults living in long-term care (LTC) facilities than those living in the community (ie, sarcopenia prevalence: ∼41% vs ∼10%; obesity prevalence: 30% vs17%). The main cause of these declines is chronic diseases, which are a driver of higher rates of sedentary behavior (85% of time in LTC). Exercise, however, is recognized to help counteract age-related decline, yet it is not integrated into clinical practice.

Blood Pressure and Heart Rate Responses following Dietary Protein Intake in Older Men

Postprandial hypotension (PPH) occurs frequently in older people >65 years old. Protein-rich supplements, particularly whey protein (WP), are increasingly used by older people for various health benefits. We have reported that 70 g WP drinks cause significant, and in some cases marked, falls in blood pressure (BP) in older men. The effects of lower, more widely used, doses (~30 g) on systolic (SBP) and diastolic (DBP) blood pressure and heart rate (HR) are not known. In a randomized order, eight older men (age: 72 ± 1 years; body mass index (BMI): 25 ± 1 kg/m2) after overnight fast ingested a drink containing (i) a non-caloric control (~2 kcal), (ii) 30 g of whey protein (120 kcal; ‘WP30’), or (iii) 70 g of whey protein (280 kcal; ‘WP70’). The BP and HR were measured in this pilot study with an automated device before and at 3-min intervals for 180 min following drink ingestion. Drink condition effects were determined by repeated-measures ANOVA. The SBP decreased after both WP drinks compared to the control (p = 0.016), particularly between 120 and 180 min, with no difference in the effects of WP30 and WP70. The SBP decreased by ≥20 mmHg in more than 50% of people after both WP drinks (WP30: 63%; WP70: 75%) compared to 38% after the control. The maximum fall in the SBP occurred during the third hour, with the nadir occurring latest after WP70. The DBP decreased non-significantly by several mmHg more after the WP drinks than after the control. The maximum HR increases occurred during the third hour, with the greatest increase after WP70. The SBP decreased after both WP drinks compared to the control, with the effects most evident between 120 and 180 min. Accordingly, ingestion of even relatively modest protein loads in older men has the potential to cause PPH.

The impact of severe obesity on home health care agency admission: An organizational perspective

Home health care is a growing treatment option for older adults who wish to remain in their homes and communities. However, the growing number of older adults with severe obesity presents a challenge for home health professionals. This study utilizes survey data from 128 home health care agencies in Arkansas and Pennsylvania to explore home health care agencies' decision-making in admitting patients with severe obesity. The responding agencies indicated that concerns about adequate staffing levels were the primary barriers to entry for severe obesity patients. Existing research on the intersection of obesity and home health care is sparse, and this study adds an organizational perspective to the scant literature on the topic. Additional research on this topic is advised to accommodate the expected growth in home health care utilization and rising obesity rates among older adults.

Addressing Obesity to Promote Healthy Aging

The population worldwide is aging and prevalence of obesity in this population is increasing. The range of consequences that effect these at-risk patients include increased risk of falls, fractures, reduced quality of life, and cognitive decline. This article describes the epidemiology of obesity, risks and benefits of weight loss, and importance of treating obesity to help promote healthy aging. Health care professionals should encourage older adults with obesity to implement healthy lifestyle behaviors including exercise and diet routine. Treating obesity in older adults mitigates the significant public health crisis, and reduces health care utilization and risk of long-term adverse events.

Acute effects of whey protein on energy intake, appetite and gastric emptying in younger and older, obese men

BACKGROUND

Obesity is becoming more prevalent in older people. A management strategy in obese, young adults is to increase dietary protein relative to other macronutrients. It is not clear if this is effective in obese, older individuals. Obesity may be associated with diminished sensitivity to nutrients. We have reported that a 30-g whey protein drink slows gastric emptying more, and suppresses energy intake less, in older, than younger, non-obese men. The aim of this study was to determine the effect of a 30 g whey protein drink on energy intake, GE and glycaemia in obese, older and younger men.

METHODS

In randomized, double-blind order, 10 younger (age: 27 ± 2 years; BMI: 36 ± 2 kg/m²), and 10 older (72 ± 1 years; 33 ± 1 kg/m²), obese men were studied twice. After an overnight fast, subjects ingested a test drink containing 30 g whey protein (120 kcal) or control (2 kcal). Postprandial gastric emptying (antral area, 2D Ultrasound) and blood glucose concentrations were measured for 180 min. At t = 180 min subjects were given a buffet meal and ad libitum energy intake was assessed.

RESULTS

Older subjects ate non-significantly less (~20%) that the younger subjects (effect of age, P = 0.16). Whey protein had no effect on subsequent energy intake (kcal) compared to control in either the younger (decrease 3 ± 8%) or older (decrease 2 ± 8%) obese men (age effect P > 0.05, protein effect P = 0.46, age × protein interaction effect P = 0.84). Whey protein slowed gastric emptying, to a similar degree in both age groups (50% emptying time: control vs. protein young men: 255 ± 5 min vs. 40 ± 7 min; older men: 16 ± 5 min vs. 50 ± 8 min; protein effect P = 0.001, age effect P = 0.93, age × protein interaction effect P = 0.13).

CONCLUSIONS

Our data suggest that obesity may blunt/abolish the age-related effect of whey protein on suppression of energy intake.

Obesity among Nursing Home Residents: Association with Potentially Avoidable Hospitalizations

BACKGROUND/OBJECTIVES

Studies show that in nursing homes (NHs), the prevalence of moderate-to-severe obesity has doubled in the last decade and continues to increase. Obese residents are often complex and costly, and this increase in prevalence has come at a time when NHs struggle to decrease hospitalizations, particularly those that are potentially avoidable. This study examined the association between obesity and hospitalizations.

DESIGN

We linked 2011-2014 national data using Medicare NH assessments, hospital claims, and the NH Compare.

SETTING AND PARTICIPANTS

Individuals aged ≥65 years, newly admitted to NHs, who became long-term residents between July 1, 2011 and March 26, 2014. The analytical sample included 490,086 residents.

METHODS

NH-originating hospitalization was the outcome; a categorical variable defined as no hospitalization, potentially avoidable hospitalization (PAH), and other hospitalization (non-PAH). The main independent variable was body mass index (BMI) defined as normal weight (30 >BMI ≥18.5 kg/m2), mildly obese (35 >BMI ≥30 kg/m2), or moderately-to-severely obese (BMI ≥35 kg/m2). Covariates included individual and NH characteristics. Multinomial models with NH random effects and state dummies were estimated.

RESULTS

After adjusting for individual level covariates, the risk of non-PAH for the mildly and moderate/severely obese was not different from normal weight residents. But the risk of PAH remained significantly higher for the moderate/severely obese (relative risk ratio = 1.055; 95% confidence interval 1.018, 1.094). Several NH-level factors also influenced hospitalization risk.

CONCLUSIONS AND IMPLICATIONS

Obese residents are more likely to experience PAH but not non-PAH. Efforts to improve care for these residents may need to broadly consider the ability of NHs to commit additional resources to fully integrate care for this growing segment of the population.

Obesity and Nursing Home Care in the United States: A Systematic Review

BACKGROUND AND OBJECTIVES

Obesity is increasing among people residing in nursing homes, and resident obesity substantially affects services needed, equipment and facilities provided, and morbidity in this setting. The purpose of this article is to describe the scope and depth of evidence regarding the impact of obesity among nursing home residents in the United States.

RESEARCH DESIGN AND METHODS

A systematic literature review was performed in PubMed, EMBASE, CINAHL, and Web of Science databases as well as additional hand-searched documents. Included articles were published from 1997 to March 2017. The characteristics and content of the included articles were systematically reviewed and reported.

RESULTS

Twenty-eight studies met inclusion criteria for review. The median study size was 636 residents (interquartile range 40-11,248); 18 (64%) studies were retrospective and 10 (36%) were prospective in nature. Ten (36%) studies examined medical and functional morbidity, 10 (36%) examined health system effects, and 5 (18%) examined the risk of admission to nursing homes. Most studies found that obesity poses serious issues to resident health and the provision of health care, as well as broad health system and nursing challenges in the provision of high-quality nursing home care and services.

DISCUSSION AND IMPLICATIONS

Although obesity affects about one in four nursing home residents in the United States, relatively limited evidence exists on the complex challenges of obesity for their residents and their care. A continued focus on resident quality of life, health system improvement, and nursing best practices for properly caring for individuals with obesity is needed.

Comparison of hospitalised trends, treatment cost and health outcomes of fall-related hip fracture for people aged ≥ 65 years living in residential aged care and the community

This study compared hip fracture rates and health outcomes of older people living in residential aged care facilities (RACFs) to the community. The RACF resident age-standardised hospitalisation rate was five times higher than the community rate and declining. RACF residents experience overall worse health outcomes and survival post-hip fracture.

INTRODUCTION

To compare hospitalisation trends, characteristics and health outcomes following a fall-related hip fracture of older people living in residential aged care facilities (RACFs) to older people living in the community.

METHODS

A retrospective analysis of fall-related hip fracture hospitalisations of people aged ≥ 65 years during 1 July 2008 and 30 June 2013 in New South Wales (NSW), Australia's largest populated state. Linked hospitalisation, RACF and Aged Care Assessment Appraisal data collections were examined. Negative binomial regression examined the significance of hospitalisation temporal trends.

RESULTS

There were 28,897 hip fracture hospitalisations. One-third were of older people living in RACFs. The hospitalisation rate was 2180 per 100,000 (95%CI: 2097.0-2263.7) for RACF residents and 390 per 100,000 (95%CI 384.8-395.8) for older people living in the community. The hospitalisation rate for RACF residents was estimated to decline by 2.9% annually (95%CI: - 4.3 to - 1.5). Hospital treatment cost for hip fractures was AUD$958.5 million. Compared to older people living in the community, a higher proportion of RACF residents were aged ≥ 90 years (36.1% vs 17.2%), were female (75.3% vs 71.8%), had > 1 Charlson comorbidity (37.6% vs 35.6%) and 58.2% had dementia (vs 14.4%). RACF residents had fewer in-hospital rehabilitation episodes (18.7% vs 60.9%) and a higher proportion of unplanned readmissions (10.6% vs 9.1%) and in-hospital mortality (5.9% vs 3.3%) compared to older people living in the community.

CONCLUSIONS

RACF residents are a vulnerable cohort of older people who experience worse health outcomes and survival post-hip fracture than older people living in the community. Whether access to individualised hip fracture rehabilitation for RACF residents could improve their health outcomes should be examined.

The Increasing Prevalence of Obesity in Residents of U.S. Nursing Homes: 2005–2015

Background

Obesity prevalence has been increasing over decades among the U.S. population. This study analyzed trends in obesity prevalence among long-stay nursing home residents from 2005 to 2015.

Methods

Data came from the Minimum Data Sets (2005–2015). The study population was limited to long-stay residents (ie, those residing in a nursing home ≥100 days in a year). Residents were stratified into body mass index (BMI)-based groups: underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30); residents with obesity were further categorized as having Class I (30 ≤ BMI < 35), Class II (35 ≤ BMI < 40), or Class III (BMI ≥ 40) obesity. Minimum Data Sets assessments for 2015 were used to compare clinical and functional characteristics across these groups.

Results

Obesity prevalence increased from 22.4% in 2005 to 28.0% in 2015. The prevalence of Class III obesity increased from 4.0% to 6.2%. The prevalence of underweight, normal weight, and overweight decreased from 8.5% to 7.2%, from 40.3% to 37.1%, and from 28.9% to 27.8%, respectively. In 2015, compared with residents with normal weight, residents with obesity were younger, were less likely to be cognitively impaired, had high levels of mobility impairment, and were more likely to have important medical morbidities.

Conclusions and Relevance

There was a steady upward trend in obesity prevalence among nursing home residents for 2005–2015. Medical and functional characteristics of these residents may affect the type and level of care required, putting financial and staffing pressure on nursing homes.

Higher Level of Obesity Is Associated with Intensive Personal Care Assistance in the Nursing Home

OBJECTIVES

To examine whether higher obesity level was associated with extensive staffing assistance (from 2 or more persons) for completing activities of daily living (ADL) among older nursing home residents.

DESIGN

Retrospective cross-sectional study.

SETTING

US government-certified nursing homes.

PARTICIPANTS

Medicare beneficiaries residing in a nursing home on April 1, 2015. Exclusion criteria were age less than 65 years and body mass index (BMI) below 18.5 (underweight).

MEASURES

Residents were divided by obesity level according to established BMI cutoffs, as follows: nonobese (BMI = 18.5-29.9) or mild (BMI = 30.0-34.9), moderate (BMI = 35.0-39.9), or severe (BMI ≥40) obesity. Level of staffing assistance for completing each of 10 ADL (bed mobility, transfer, walking in room, walking in corridor, on- and off-unit locomotion, dressing, eating, toileting, and personal hygiene) was dichotomized as below 2 and 2 or more. Robust Poisson regression was used to test whether obesity conferred excess risk for needing 2 or more staff to complete each ADL. Adjusted models included individual-level covariates and nursing home fixed effects.

RESULTS

A total of 1,063,383 nursing home residents were identified, including 309,263 (29.0%) with obesity. Adjusted relative risks (95% confidence intervals) for 2-person assistance with bed mobility associated with mild, moderate, and severe obesity were 1.17 (1.15, 1.18), 1.28 (1.25, 1.31), and 1.40 (1.36, 1.43), respectively. Adjusted relative risks for 2-person assistance with transferring associated with mild, moderate, and severe obesity were 1.15 (1.13, 1.17), 1.24 (1.22, 1.27), and 1.36 (1.33, 1.39), respectively. Obesity was associated with 2-person assistance for all other ADL except for eating.

CONCLUSIONS

Higher obesity level was significantly associated with assistance from 2 or more staff for completing 9 of 10 ADL. Given increasing obesity rates in nursing homes, payment mechanisms that do not adjust for obesity or comprehensively account for excess ADL assistance may need revision to prevent adverse impacts on the long-term care system.

Obesity and intensive staffing needs of nursing home residents

The objective of this study is to examine how increasing body mass index (BMI) among nursing home residents affects the amount of staffing assistance needed for activities of daily living (ADL). We analyzed 1,627,141 US nursing home residents reported in the 2013 Minimum Data Set in seven BMI categories, from underweight (BMI < 18.5 kg/m²) to obesity Class IIIB (≥50 kg/m²). Logistic regression models estimated the odds of nursing home-reported need for extensive (≥2 staff member) assistance needed for ADLs. The adjusted odds increased from 1.07 (95% Confidence Interval (95%CI) 1.06-1.08) for Class I, 1.16 (95%CI 1.14-1.17) for Class II, 1.33 (95%CI 1.31-1.35) for Class IIIA, and 1.90 (95%CI 1.86-1.95) for Class IIIB obesity residents compared to residents of normal weight. As a nursing home resident's BMI increases, especially for BMI ≥40 kg/m², the need for extensive staffing assistance with ADLs also increases substantially.

Effect of Obesity on Postacute Outcomes of Skilled Nursing Facility Residents with Hip Fracture

OBJECTIVES

To examine the effect of obesity (body mass index (BMI)≥30.0 kg/m² ) on outcomes of older adults admitted to skilled nursing facilities (SNFs) for hip fracture postacute care (PAC).

DESIGN

Retrospective cohort study.

SETTING

U.S. Medicare- and Medicaid-certified SNFs from 2008 to 2015.

PARTICIPANTS

Medicare fee-for-service beneficiaries discharged to a SNF after hospitalization for hip fracture (N=586,683; n=82,768 (14.1%) meeting obesity criteria). Exclusion criteria were aged younger than 65, being underweight (BMI<18.5 kg/m² ), and SNF use in the year prior to index hospitalization.

MEASUREMENTS

Residents were divided into 4 BMI categories according to cutoffs that the World Health Organization has established: not obese (BMI 18.5-29.9 kg/m² ), mild obesity (BMI 30.0-34.9 kg/m² ), moderate obesity (BMI 35.0-39.9 kg/m² ), and severe obesity (BMI≥40.0 kg/m² ). Robust Poisson regression was used to compare differences in average nursing facility length of stay (LOS) and rates of 30-day hospital readmission, successful discharge to community, and becoming a long-stay resident (LOS>100) according to obesity level. Models were adjusted for individual-level covariates and facility fixed effects.

RESULTS

Residents with mild (adjusted relative risk (aRR)=1.16, 95% CI=1.12-1.19), moderate (aRR=1.27, 95% CI=1.20-1.35), and severe (aRR=1.67, 95% CI=1.54-1.82) obesity were more likely to be readmitted within 30 days than those who were not obese. The average difference in LOS between residents without obesity and those with mild obesity was 2.6 days (95% CI=2.2-2.9 days); moderate obesity, 4.2 days (95% CI=3.7-5.1 days); and severe obesity, 7.0 days (95% CI=5.9-8.2 days). Residents with obesity were less likely to be successfully discharged and more likely to become long-stay nursing home residents.

CONCLUSION

Obesity was associated with worse outcomes in postacute SNF residents with hip fracture. Efforts to provide targeted care to residents with obesity may be essential to improve outcomes. Obesity may be an overlooked risk adjuster in quality-of-care measures and in payment reforms related to PAC for individuals with hip fracture.

Are Obese Residents More Likely to Be Admitted to Nursing Homes That Have More Deficiencies in Care?

OBJECTIVES

To determine whether obese older adults who qualify for nursing home (NH) placement are as likely as nonobese adults to be admitted to NHs that provide adequate quality of care.

DESIGN

Retrospective study.

SETTING

NHs in New York State.

PARTICIPANTS

Individuals aged 65 and older newly admitted to a NH in New York State in 2006-07.

MEASUREMENTS

Total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses were used to assess the association between obesity (body mass index (BMI) 30.0-39.9 kg/m(2) ) and morbid obesity (BMI ≥ 40.0 kg/m(2) ) separately and admission to facilities with more deficiencies.

RESULTS

NHs that admitted a higher proportion of morbidly obese residents were more likely to have more deficiencies, whether total or healthcare related. These NHs also had greater odds of having severe deficiencies, or falling in the top quartile ranking of total deficiencies. After sequentially controlling for the choice of facilities within the inspection region, resident characteristics, and facility covariates, the association between morbid obesity and admission to higher-deficiency NHs persisted.

CONCLUSION

Residents with morbid obesity were more likely to be admitted to NHs of poorer quality based on deficiency citations. The factors driving these disparities and their impact on the care of obese NH residents require further elucidation.

Elevated Serum Osmolality and Total Water Deficit Indicate Impaired Hydration Status in Residents of Long-Term Care Facilities Regardless of Low or High Body Mass Index

BACKGROUND

Dehydration is typically associated with underweight and malnutrition in long-term care (LTC) settings. Evidence is lacking regarding the influence of the rising prevalence of overweight and obesity on risk factors, prevalence, and presentation of dehydration.

OBJECTIVE

The aim of this study was to objectively assess hydration status and the adequacy of total water intake, and determine relationships between hydration status, total water intake, and body mass index (BMI) in LTC residents.

DESIGN

A cross-sectional analysis of baseline data was performed.

PARTICIPANTS AND SETTING

Baseline data from 247 subjects recruited from eight community-based LTC facilities participating in two randomized trials comparing nutrient and cost-efficacy of between-meal snacks vs oral nutrition supplements (ONS).

MAIN OUTCOMES

Hydration status was assessed by serum osmolality concentration and total water intakes were quantified by weighed food, beverage, water, and ONS intake.

STATISTICAL ANALYSES

Simple and multiple linear regression methods were applied.

RESULTS

Forty-nine (38.3%) subjects were dehydrated (>300 mOsm/kg) and another 39 (30.5%) had impending dehydration (295 to 300 mOsm/kg). The variance in serum osmolality was significantly accounted for by blood urea nitrogen level, mental status score, and having diabetes (R(2)=0.46; P<0.001). Total water intake averaged 1,147.2±433.1 mL/day. Thus, 96% to 100% of subjects did not meet estimated requirements, with a deficit range of 700 to 1,800 mL/day. The variance in total water intake was significantly accounted for by type of liquid beverages (thin vs thick), type of ONS, total energy intake, total activities of daily living dependence, sex, and BMI (R(2)=0.56; P<0.001).

CONCLUSIONS

Dehydration and inadequate total water intake is prevalent in LTC residents across all BMI categories. Type of liquid beverages, type of ONS, and type of between-meal snacks are factors that could be targeted for nutrition interventions designed to prevent or reverse dehydration.

External Hand Forces Exerted by Long-Term Care Staff to Push Floor-Based Lifts: Effects of Flooring System and Resident Weight

OBJECTIVE

The aim of this study was to investigate the effects of flooring type and resident weight on external hand forces required to push floor-based lifts in long-term care (LTC).

BACKGROUND

Novel compliant flooring is designed to reduce fall-related injuries among LTC residents but may increase forces required for staff to perform pushing tasks. A motorized lift may offset the effect of flooring on push forces.

METHOD

Fourteen female LTC staff performed straight-line pushes with two floor-based lifts (conventional, motor driven) loaded with passengers of average and 90th-percentile resident weights over four flooring systems (concrete+vinyl, compliant+vinyl, concrete+carpet, compliant+carpet). Initial and sustained push forces were measured by a handlebar-mounted triaxial load cell and compared to participant-specific tolerance limits. Participants rated pushing difficulty.

RESULTS

Novel compliant flooring increased initial and sustained push forces and subjective ratings compared to concrete flooring. Compared to the conventional lift, the motor-driven lift substantially reduced initial and sustained push forces and perceived difficulty of pushing for all four floors and both resident weights. Participants exerted forces above published tolerance limits only when using the conventional lift on the carpet conditions (concrete+carpet, compliant+carpet). With the motor-driven lift only, resident weight did not affect push forces.

CONCLUSION

Novel compliant flooring increased linear push forces generated by LTC staff using floor-based lifts, but forces did not exceed tolerance limits when pushing over compliant+vinyl. The motor-driven lift substantially reduced push forces compared to the conventional lift.

APPLICATION

Results may help to address risk of work-related musculoskeletal injury, especially in locations with novel compliant flooring.

Challenges in the Management of Geriatric Obesity in High Risk Populations

The global prevalence of obesity in the older adult population is growing, an increasing concern in both the developed and developing countries of the world. The study of geriatric obesity and its management is a relatively new area of research, especially pertaining to those with elevated health risks. This review characterizes the state of science for this “fat and frail” population and identifies the many gaps in knowledge where future study is urgently needed. In community dwelling older adults, opportunities to improve both body weight and nutritional status are hampered by inadequate programs to identify and treat obesity, but where support programs exist, there are proven benefits. Nutritional status of the hospitalized older adult should be optimized to overcome the stressors of chronic disease, acute illness, and/or surgery. The least restrictive diets tailored to individual preferences while meeting each patient’s nutritional needs will facilitate the energy required for mobility, respiratory sufficiency, immunocompentence, and wound healing. Complications of care due to obesity in the nursing home setting, especially in those with advanced physical and mental disabilities, are becoming more ubiquitous; in almost all of these situations, weight stability is advocated, as some evidence links weight loss with increased mortality. High quality interdisciplinary studies in a variety of settings are needed to identify standards of care and effective treatments for the most vulnerable obese older adults.

Nursing Home Perspectives on the Admission of Morbidly Obese Patients From Hospitals to Nursing Homes

PURPOSE OF THE STUDY

Care challenges have been described for hospitalized morbidly obese (MO) patients. These challenges likely persist post discharge. As a result, nursing homes (NHs) may be reluctant to admit these patients, potentially leaving them "stranded in hospitals". This study identified issues NHs consider in admission decisions for MO patients transitioning from hospitals.

DESIGN AND METHOD

Approved surveys were mailed to nursing directors at federally-certified NHs in Arkansas (n = 234) and Pennsylvania (n = 710) to collect NH experience in the admission of patients weighing ≥ 325 pounds. Analyses included descriptive and inferential statistics to summarize and identify predictors of MO patient admission decisions.

RESULTS

In total, 360 surveys were returned (38.1% response rate). Although two-thirds of respondents reported patient size as an admission barrier, only 6% reported that MO patients were always refused admission. Adjusted analysis showed that NHs with adequate staff were significantly (p = .04) less likely to report obesity as an admission barrier whereas NHs reporting concerns about availability of bariatric equipment were significantly (p < .0001) more likely to report obesity as a barrier.

IMPLICATIONS

Lack of staff and bariatric equipment in NHs appears to negatively affect the transition of MO patients out of the hospital to NHs. Additional research, including examination of current regulations and reimbursement policies, should be undertaken to understand NH staffing and equipment acquisition decisions in light of the current obesity epidemic. Such research has implications for the optimal care of obese individuals during times of transition.

Varying Associations Between Body Mass Index and Physical and Cognitive Function in Three Samples of Older Adults Living in Different Settings

BACKGROUND

The study investigates variations in the associations between body mass index (BMI) and (a) physical and (b) cognitive function across three samples of older adults living in different settings, and moreover determines if the association between BMI and physical function is confounded by cognitive abilities.

METHODS

One hundred ninety-five patients of a geriatric day hospital, 322 persons receiving home care (HC), and 183 nursing home (NH) residents were examined regarding BMI, cognitive (Mini-Mental State Examination), and physical function (Barthel Index for activities of daily living). Differences in Mini-Mental State Examination and activities of daily living scores between BMI groups (<22, 22-<25, 25-<30, 30-<35, ≥35kg/m(2)) were tested by analysis of covariance considering relevant confounders.

RESULTS

Activities of daily living and Mini-Mental State Examination impairments increased from the geriatric day hospital over the HC to the NH sample, whereas prevalence rates of obesity and severe obesity (35%, 33%, 25%) decreased. In geriatric day hospital patients cognitive and physical function did not differ between BMI groups. In the HC and NH samples, cognitive abilities were highest in obese and severely obese subjects. Unadjusted mean activities of daily living scores differed between BMI groups in HC receivers (51.6±32.2, 61.8±26.1, 67.5±28.3, 72.0±23.4, 66.2±24.2, p = .002) and NH residents (35.6±28.6, 48.1±25.7, 39.9±28.7, 50.8±24.0, 57.1±28.2, p = .029). In both samples significance was lost after adjustment indicating cognitive function as dominant confounder.

CONCLUSIONS

In older adults the associations between BMI and physical and cognitive function were dependent on the health and care status corresponding to the setting. In the HC and the NH samples, cognitive status, as measured by the Mini-Mental State Examination, emerged as an important confounder within the association between BMI and physical function.

Effect of weight loss on mortality in overweight and obese nursing home residents during a 5-year follow-up

BACKGROUND/OBJECTIVES

The objective of this study was to ascertain the effect of weight loss over the course of 1 year on 5-year mortality in old nursing home (NH) residents in different classes of body mass index (BMI).

SUBJECTS/METHODS

A longitudinal study was conducted on 161 NH residents aged ⩾ 70 years at the Istituto di Riposo per Anziani, Padova, Italy. Data were collected using a comprehensive geriatric assessment at baseline and at a 1-year follow-up visit. Mortality was recorded over a 5-year follow-up. We divided our sample into four groups using as cutoffs a BMI of 25 and a weight gain or loss of 5% at 1 year (BMI ⩾ 25 and weight stable/gain, BMI ⩾ 25 and weight loss, BMI<25 and weight stable/gain and BMI <25 and weight loss).

RESULTS

People with a BMI ⩾ 25 and weight loss suffered the worst decline in activities of daily living, whereas those with a BMI <25 and weight loss had the most significant decline in nutritional status, which coincided with the worst decline in the Multidimensional Prognostic Index among the groups whose weight changed. Compared with those with a BMI ⩾ 25 and weight stable/gain (reference group), those with a BMI <25 were at the highest risk of dying (in association with weight loss: hazard ratio HR=3.60, P=0.005; in association with weight stable/gain: HR=2.45, P=0.01), and the mortality risk was also increased in people with a BMI ⩾ 25 and weight loss (HR=1.74, P=0.03).

CONCLUSIONS

In conclusion, weight loss increases the mortality risk in frail, disabled NH residents, even if they are overweight or obese.

Trends in fall-related hospitalisations in older people living in aged care facilities

The aim is to describe the trends in fall-related hospitalisations for older people living in aged care facilities. Over the 9-year period investigated, there were dramatic increases in fall-related hospitalisations. This worrying trend highlights that we may not be addressing falls in aged care facilities sufficiently.

INTRODUCTION

The purposes of this study are to describe the trends in fall-related hospitalisations in older people living in aged care facilities and to compare these trends across different demographic groups and injury types.

METHODS

This study was conducted in Australia's second most populous state, Victoria. Aged care facilities in Australia provide high- and low-level nursing care for people who can no longer live independently. Included in this study were hospital admitted episodes of care which met the following criteria: age 65+ years at admission, an admission source indicating a transfer from an aged care facility, an external cause indicating a fall, a care type of 'acute', a Victorian postcode of residence, and an admission date between July 1, 2003 and June 30, 2012 (inclusive). Rate denominator data were Victorian aged care bed years.

RESULTS

Over the last 9 years, 7098 episodes of care met the inclusion criteria. The age-standardised rate of hospitalisation increased by 11% (95% confidence interval [CI] 9%, 12%) per year. Serious injury increased at a slower pace than less serious injury. The slowest rate increase was for hip fracture (incidence rate ratio: 1.03 (95% CI 1.00, 1.06), the most common fracture type.

CONCLUSIONS

Rates of fall-related hospitalisations in older people living in aged care facilities increased at a dramatic pace in the period studied. The relative slower increase in hip fracture may point towards changing referral practices, possible success in osteoporosis management, body mass index increases in older people living in aged care facilities or a combination of these factors.

Effect of weight loss, exercise, or both on cognition and quality of life in obese older adults

BACKGROUND

Obesity impairs cognition and health-related quality of life (HRQOL) in older adults; however, the appropriate treatment of obese older adults remains controversial.

OBJECTIVE

The objective was to determine the independent and combined effects of weight loss and exercise on cognition, mood, and HRQOL in obese older adults.

DESIGN

One hundred seven frail, obese older adults were randomly assigned to a control, weight-management (diet), exercise, or weight-management-plus-exercise (diet-exercise) group for 1 y. In this secondary analysis, main outcomes were Modified Mini-Mental State Examination (3MS) and total Impact of Weight on Quality of Life-Lite (IWQOL) scores. Other outcomes included Word Fluency Test, Trail Making Test Parts A and B, and Geriatric Depression Scale (GDS) scores.

RESULTS

Scores on the 3MS improved more in the diet (mean ± SE: 1.7 ± 0.4), exercise (2.8 ± 0.4), and diet-exercise (2.9 ± 0.4) groups than in the control group (0.1 ± 0.4) (between-group P = 0.0001-0.04); scores in the diet-exercise group improved more than in the diet group but not more than in the exercise group. Scores on the Word Fluency Test improved more in the exercise (4.1 ± 0.8) and diet-exercise (4.2 ± 0.7) groups than in the control group (-0.8 ± 0.8; both P = 0.001). For the Trail Making Test Part A, scores in the diet-exercise group (-11.8 ± 1.9) improved more than in the control group (-0.8 ± 1.9) (P = 0.001); a similar finding was observed for the Trail Making Test Part B. Scores on the IWQOL improved more in the diet (7.6 ± 1.6), exercise (10.1 ± 1.6), and diet-exercise (14.0 ± 1.4) groups than in the control group (0.3 ± 1.6) (P = 0.0001-0.03); scores in the diet-exercise group improved more than in the diet group but not more than in the exercise group. In the diet-exercise group, peak oxygen consumption and strength changes were independent predictors of 3MS changes; weight and strength changes were independent predictors of IWQOL changes. GDS scores did not change.

CONCLUSIONS

Weight loss and exercise each improve cognition and HRQOL, but their combination may provide benefits similar to exercise alone. These findings could inform practice guidelines with regard to optimal treatment strategies for obese older adults. This trial was registered atclinicaltrials.govas NCT00146107.

Special Considerations for Older Adults With Diabetes Residing in Skilled Nursing Facilities

About 25% of all residents of skilled nursing facilities (SNFs) have diabetes, and that proportion is expected to increase. SNF residents with diabetes have special needs related to nutrition, hydration, physical activity, and medical therapy. Vigilant assessment and maintenance of safety is also crucial for such patients, including but not limited to issues such as hyper- and hypoglycemia, polypharmacy, falls, lower-extremity problems, and transitions of care. Interventions to provide stable glycemic control; ensure adequate nutrition, hydration, and physical activity; decrease polypharmacy; prevent falls; facilitate transitions of care; and improve the diabetes-related knowledge of SNF staff can help to meet these needs. Although this article focuses on SNFs, many of the topics covered also apply to elderly people with diabetes in other long-term care settings.

Changing Prevalence of Diabetes for Texas Nursing Home Residents, 1999-2009

This article examines change in the composition of the Texas nursing home population between 1990 and 2009 in relation to the changing prevalence of diabetes. Data from the federal Minimum Data Set for Texas for 1999 and 2009 were analyzed for change in proportion of age groups by the Two-Sample Proportion Test. Change by gender within age groups while controlling for race/ethnicity was analyzed by the Cochran–Mantel–Haenszel test. The percentage of nursing home residents aged 50 to 64 years increased from 8% in 1999 to 12% in 2009, and the change was statistically significant for each race/ethnic group and both genders. The percentage reporting diabetes increased among all groups with more pronounced change for minorities. These results point to a need for closer examination of the impacts of changing diabetes prevalence on nursing homes.

Obesity and pressure ulcers among nursing home residents

OBJECTIVES

To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year.

ANALYSES

The outcome variable was presence of pressure ulcers during the 1-year follow-up period. Residents were categorized as normal [18.5 ≤ body mass index (BMI)<30 kg/m2], mild obesity (30 ≤ BMI <35 kg/m2), and moderate or severe obesity (BMI ≥ 35 kg/m2). Pooled and stratified analyses were performed to examine the relationship between obesity and pressure ulcers, and how it varied by facility CNA level.

RESULTS

The prevalence of obesity increased from 16.9% to 25.8% among newly admitted NH residents over the last decade. Obesity was associated with higher risks of pressure ulcers among long-stay residents. The relationship between obesity and pressure ulcers persisted after accounting for individual health conditions at the baseline and facility-level variations. Further, the within-facility relationship between obesity and pressure ulcers varied by facility CNA levels. The odds of pressure ulcers were 18.9% higher for residents with moderate or severe obesity than for nonobese residents within NHs with low CNA levels. The percents for medium and high CNA level facilities were 14.0% and 12.8%, respectively.

CONCLUSION

To prepare for the growing obesity epidemic in NHs, policies should focus on strategies to improve care provided for obese residents.

Strategies to improve diet in older adults

It is estimated that by 2050 there will be 2 billion people aged 60 years and older in the world. The evidence base for the health benefits of good nutrition and physical activity, as well as weight loss among overweight and obese adults, is growing and a number of policies and guidelines are available to guide health professionals in serving older people at various stages of the lifecycle. There are many potential influences on dietary habits including individual factors, families and friends, community characteristics, the food and supplement industry, and public policy. This review focuses on the evidence base for factors influencing diet in older adults, food insecurity, Na, vitamin D, vitamin B12, protein, obesity and the benefits of energy restriction in overweight and obese older adults. Research is needed to continue to increase the evidence base for appropriate ways to improve diet and health in older people. Also, much of the available information is from the US, so there is a need to conduct research in other areas of the world.

Nutritional assessment and follow-up of residents with and without dementia in nursing homes in the Limousin region of France: a health network initiative

INTRODUCTION

Limousin in France has the second oldest regional population in Europe, with people over 65-years-old who have Alzheimer's disease accounting for more than 9%. In France as a whole, a large number of residents in nursing homes (NH) have dementia, leading to many nutritional problems. LINUT is a health network that assesses the nutritional status of elderly NH residents and provides support where necessary. Aims of the present study were to use this network to evaluate the nutritional status of NH residents with and without dementia and to review changes after 4 months of intervention.

METHODS

A cross-sectional survey was conducted by a doctor and a dietician at baseline (T0) and 4 months (T4) among residents at the 26 NH in Limousin that agreed to take part. The evaluation criteria included presence of dementia, depression and autonomy, weight, height, body mass index, Mini Nutritional Assessement (MNA™), and a 3-day survey of food intake.

RESULTS

The 346 residents assessed at T0 were aged 87.9±6.9 years, 83.4% were women, 66.8% had dementia, 53.3% were malnourished and 27.4% obese. Autonomy was not affected by obesity. Residents with dementia had a lower Activities of Daily Living score and a lower weight than non-demented individuals (2.2±1.2 vs. 2.7±1.7 p=0.03 and 60.1±16.3 vs. 64.7±20.0 kg p=0.03, respectively), were more often malnourished (56.1% vs. 46.4% p=0.004) and less often obese (22.0% vs. 39.1% p=0.004) but consumed more protein (62.6±17.8 vs. 58.2±16.9 g/d p=0.04, 1.1±0.4 vs. 1.0±0.4 g/kg/d p=0.005). Energy intake was at the lower limit of French recommendations (26.4±8.8 vs. >25.0 kcal/kg/d). Assessment of all residents at T4 showed improved MNA™ (+0.4 points/month p=0.02), protein intake (+3.3 g/d p=0.0007), and energy intake (+41.4 kcal/d p=0.01 and 0.1 kcal/kg/d p=0.03). Variations in prevalences of malnutrition and obesity were not statistically significant. MNA™ increased in the dementia group (+0.29±0.8 points/month p=0.003). All other changes were comparable, and nutritional status did not differ more between the two groups at T4 than at T0.

CONCLUSION

The prevalence of dementia was high in the population studied. Malnutrition was the main problem, particularly if residents had dementia. Protein intake was satisfactory, but energy intake often insufficient. The nutritional status of dementia patients improved after 4 months of follow-up, suggesting that effective action to support such services would be worthwhile.

Challenges to Hospital Discharge Planning for Older Adults

Hospital discharge planning for older adults is an essential component to successful transitional care and will become increasingly important as hospitals face financial penalties for avoidable readmissions. This study reports a cross-sectional descriptive web-based survey study about challenges to discharge planning experienced by hospitals in the Midwestern state of Missouri. Problems identified by respondents included difficulties finding placement for patients requiring ventilator care, hemodialysis, chemotherapy, radiation therapy, wound vacuums, or who have mental health care needs. In general, urban hospitals reported more problems with finding postacute discharge destinations for patients than did rural hospitals. It is essential that nursing homes, residential care facilities, and home health agencies be adequately reimbursed to manage complex patients. It may be equally important to identify ways to develop critical assessment and care management skills that are needed in postacute staff to increase the likelihood that patients will be accepted at the time of hospital discharge.

Weight loss, exercise, or both and physical function in obese older adults

BACKGROUND

Obesity exacerbates the age-related decline in physical function and causes frailty in older adults; however, the appropriate treatment for obese older adults is controversial.

METHODS

In this 1-year, randomized, controlled trial, we evaluated the independent and combined effects of weight loss and exercise in 107 adults who were 65 years of age or older and obese. Participants were randomly assigned to a control group, a weight-management (diet) group, an exercise group, or a weight-management-plus-exercise (diet-exercise) group. The primary outcome was the change in score on the modified Physical Performance Test. Secondary outcomes included other measures of frailty, body composition, bone mineral density, specific physical functions, and quality of life.

RESULTS

A total of 93 participants (87%) completed the study. In the intention-to-treat analysis, the score on the Physical Performance Test, in which higher scores indicate better physical status, increased more in the diet-exercise group than in the diet group or the exercise group (increases from baseline of 21% vs. 12% and 15%, respectively); the scores in all three of those groups increased more than the scores in the control group (in which the score increased by 1%) (P<0.001 for the between-group differences). Moreover, the peak oxygen consumption improved more in the diet-exercise group than in the diet group or the exercise group (increases of 17% vs. 10% and 8%, respectively; P<0.001); the score on the Functional Status Questionnaire, in which higher scores indicate better physical function, increased more in the diet-exercise group than in the diet group (increase of 10% vs. 4%, P<0.001). Body weight decreased by 10% in the diet group and by 9% in the diet-exercise group, but did not decrease in the exercise group or the control group (P<0.001). Lean body mass and bone mineral density at the hip decreased less in the diet-exercise group than in the diet group (reductions of 3% and 1%, respectively, in the diet-exercise group vs. reductions of 5% and 3%, respectively, in the diet group; P<0.05 for both comparisons). Strength, balance, and gait improved consistently in the diet-exercise group (P<0.05 for all comparisons). Adverse events included a small number of exercise-associated musculoskeletal injuries.

CONCLUSIONS

These findings suggest that a combination of weight loss and exercise provides greater improvement in physical function than either intervention alone. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00146107.).

Analysis of the food consumption of 87 elderly nursing home residents, depending on food texture

OBJECTIVES

Texture-modified food (chopped, mashed, or mixed) is often used for patients, and particularly for dependent elderly people facing swallowing disorders or dental problems. Food must be energy and protein enriched, because dilution is needed for preparation, and several meals like bread can be removed. The aim of the study was to assess the food consumption of residents in four French nursing homes depending on diet texture. DESIGN/PARTICIPANTS/MEASUREMENTS: The food consumption of 87 elderly people followed by a nutrition network, randomly taken and living in nursing homes in which texture-modified food enrichment was practiced was evaluated according to the type of texture used.

RESULTS

13.8% of residents had chopped texture and 29.9% mixed texture. There was no relationship between used food textures and nutritional status residents. Calorie consumption was below the recommended intakes for elderly nursing home residents in France, whatever the type of texture. The mixed texture had more protein than the normal one and was better balanced regarding fat intake. Protein consumption was at the lower limit of the recommended intakes. Residents in overweight were those whose food consumption relative to their weight was the lowest.

CONCLUSION

It seems important to check the mode of preparation of texture-modified food in nursing homes and to assess the real energy and protein consumptions of residents receiving this food.

Obesity paradox in elderly patients with cardiovascular diseases

Many elderly people are affected by cardiovascular diseases (CVD) and the majority of CVD patients are elderly people. For both patient populations, studies have shown that a high body mass index (BMI) is associated with lower mortality when compared to normal weight subjects, a fact commonly known as the "obesity paradox". Whether the correlation between obesity and better survival is based on methodological influences and other non-causal factors alone, or whether there is a causal link between obesity and a better survival in these subjects remains widely unexplored. The interrelation between aging, obesity, CVD, frailty and inflammation is a current issue of intensive research. For the elderly, parameters which include measures of body composition, fat and fat-free mass are of greater importance than BMI. Weight management in elderly people with cardiovascular diseases should aim at improvement and maintenance of physical function and quality of life rather than prevention of medical problems associated with obesity in younger and middle aged patients. Although many studies have shown that weight loss in elderly patients is associated with a poor prognosis, recent data demonstrate that intentional weight reduction in obese elderly people ameliorates the cardiovascular risk profile, reduces chronic inflammation and is correlated with an improved quality of life. An individual approach to weight management that includes the participation of the patient, co-morbidity, functional status, and social support should be aspired.

Exercise attenuates the weight-loss-induced reduction in muscle mass in frail obese older adults

PURPOSE

To evaluate the effect of adding exercise to a hypocaloric diet on changes in appendicular lean mass and strength in frail obese older adults undergoing voluntary weight loss.

METHODS

Thirty frail older (age, 70 +/- 5 yr) obese (body mass index, 37 +/- 5 kg.m) adults were randomly assigned to 6 months of diet/behavioral therapy (diet group, n = 15) or diet or behavioral therapy plus exercise that incorporated progressive resistance training (PRT; diet + exercise group; n = 15). Body composition was assessed using dual-energy x-ray absorptiometry, and muscle strength was assessed using one-repetition maximum. The volume of upper extremity (UE) and lower extremity (LE) exercise training was determined by multiplying the average number of repetitions performed by the average weight lifted during the first three exercise sessions and during the last three exercise sessions of the study.

RESULTS

The diet and the diet + exercise groups had similar (P > 0.05) decreases in weight (10.7 +/- 4.5 vs 9.7 +/- 4.0 kg) and fat mass (6.8 +/- 3.7 vs 7.7 +/- 2.9 kg). However, the diet + exercise group lost less fat-free mass (FFM; 1.8 +/- 1.5 vs 3.5 +/- 2.1 kg), LE lean mass (0.9 +/- 0.8 vs 2.0 +/- 0.9 kg), and UE lean mass (0.1 +/- 0.2 vs 0.2 +/- 0.2 kg) than the diet group (P < 0.05). The diet + exercise group had greater increases in percent of weight as FFM (FFM / weight x 100) than the diet group (7.9 +/- 3.3 vs 5.4 +/- 3.7%; P < 0.05). Despite lean mass losses, the diet + exercise group increased UE and LE strength in response to exercise (17-43%), whereas the diet group maintained strength. The volume of UE and LE exercises correlated with the amount of UE and LE lean mass (r = 0.64-0.84; P < 0.05).

CONCLUSION

Exercise added to diet reduces muscle mass loss during voluntary weight loss and increases muscle strength in frail obese older adults. Regular exercise that incorporates PRT should be used to attenuate muscle mass loss in frail obese older adults on weight-loss therapy.

Promoting cardiovascular health: special considerations for the elderly

Although clinicians and researchers understand the need to promote cardiovascular health in people of all ages, with population aging there are particular insights/issues that should be considered when counseling and caring for elderly patients. The focus here is to present current statistics relative to aging in the United States, discuss risk factors and lifestyle with a particular focus on those 65 years and older, and further discuss the need to continuously monitor activities of daily living and instrumental activities of daily living in elderly persons to ensure that whatever is done to promote cardiovascular health does not interfere with functional independence.

Body mass index and the risk of infections in institutionalised geriatric patients

The objective was to examine the effect of BMI on the incidence of various infectious diseases in institutionalised, geriatric subjects. In a retrospective cohort study we analysed medical records of 619 patients aged 75 years and older (mean age 87.6 (sd 6.4) years) who were treated in a geriatric hospital in Vienna, Austria. The total incidence rate of infection in this population was 0.80 per person-year. The most frequent infections were urinary tract infections (0.30 per person-year), followed by infections of the lower respiratory tract (0.19 per person-year), diarrhoea (0.12 per person-year) and other infections (0.20 per person-year). Incidence risk ratios were obtained by a multiplicative Poisson regression model. There was a J-shaped curve in the incidence of infections recorded by BMI with a nadir at 27-28 kg/m2. Compared with the reference group with a BMI of 24-27.9 kg/m2, subjects with a lower BMI had a higher incidence rate of infections. The incidence risk ratios, adjusted for sex, age and chronic diseases, were 1.62 (95 % CI 1.21, 2.17) for those with a BMI of < 20 kg/m2 and 1.84 (95 % CI 1.40, 2.42) for those with a BMI of 20-23.9 kg/m2. However, also patients with a BMI of 28 kg/m2 and above had a higher incidence rate of infections, with an incidence risk ratio of 1.54 (95 % CI 1.07, 2.22). These results show that both underweight and obesity are associated with a higher risk of infections in institutionalised geriatric patients.

Obesity and aging

In this article, the combined effects of aging and obesity on the respiratory system are examined. Following a concise epidemiologic overview of the prevalence of obesity among older adults, the occurrence of prospective, often variable, health consequences related to this trend are considered as well as the observed effects of the association of both aging and obesity on respiratory anatomy, physiology, and diseases. Last, findings of research related to weight loss on respiratory function in obese older adults are summarized.

Diet and exercise interventions reduce intrahepatic fat content and improve insulin sensitivity in obese older adults

Both obesity and aging increase intrahepatic fat (IHF) content, which leads to nonalcoholic fatty liver disease (NAFLD) and metabolic abnormalities such as insulin resistance. We evaluated the effects of diet and diet in conjunction with exercise on IHF content and associated metabolic abnormalities in obese older adults. Eighteen obese (BMI >or=30 kg/m(2)) older (>or=65 years old) adults completed a 6-month clinical trial. Participants were randomized to diet (D group; n = 9) or diet + exercise (D+E group; n = 9). Primary outcome was IHF quantified by magnetic resonance spectroscopy (MRS). Secondary outcomes included insulin sensitivity (assessed by oral glucose tolerance), body composition (assessed by dual-energy X-ray absorptiometry), physical function (VO(2 peak) and strength), glucose, lipids, and blood pressure (BP). Body weight (D: -9 +/- 1%, D+E: -10 +/- 2%, both P < 0.05) and fat mass (D: -13 +/- 3%, D+E -16 +/- 3%, both P < 0.05) decreased in both groups but there was no difference between groups. IHF decreased to a similar extent in both groups (D: -46 +/- 11%, D+E: -45 +/- 8%, both P < 0.05), which was accompanied by comparable improvements in insulin sensitivity (D: 66 +/- 25%, D+E: 68 +/- 28%, both P < 0.05). The relative decreases in IHF correlated directly with relative increases in insulin sensitivity index (ISI) (r = -0.52; P < 0.05). Improvements in VO(2 peak), strength, plasma triglyceride (TG), and low-density lipoprotein-cholesterol concentration, and diastolic BP occurred in the D+E group (all P < 0.05) but not in the D group. Diet with or without exercise results in significant decreases in IHF content accompanied by considerable improvements in insulin sensitivity in obese older adults. The addition of exercise to diet therapy improves physical function and other obesity- and aging-related metabolic abnormalities.

How to improve nutritional support in geriatric institutions

Nutritional problems are frequent in nursing homes including undernutrition, obesity, and diabetes mellitus, mainly related to disability and behavior troubles. Adequate nutritional care relies both on the quality of menus for regular and modified diet (texture-modified and enriched food) and on the staff knowledge of nutritional problems, particularly undernutrition. Self-assessment of professional practices for all staff categories that are involved in this area can be used to increase training of staff and quality of nutritional care.

An update on best practice guidelines for specialized facilities and resources necessary for weight loss surgical programs

The objective of this study is to update evidence-based best practice guidelines for specialized facilities and resources for weight loss surgery (WLS). We performed systematic search of English-language literature on WLS and facilities, equipment, and resources published between April 2004 and May 2007 in PubMed, MEDLINE, and the Cochrane Library. Keywords were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. Evidence-based best practice recommendations from the most recent literature on specialized facilities and resources for WLS were developed. We identified 1,647 papers in our literature search; the 46 most relevant were reviewed in detail. Regular updates of evidence-based recommendations for best practices in facilities and resources for WLS are required to address technology advances and growing recognition of the need for adequate equipment and specially built nursing units. Key factors in patient safety include availability of trained personnel and specialized equipment for the care of extremely obese WLS patients.