Addressing the Elephant in the Room ?. Obesity

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Addressing the Elephant in the Room?.Obesity
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I am only one.

• I am only one but still I am one.
• I cannot do everything but still I can do
  something
• And because I cannot do everything,
• I must not refuse to do something I can do

3
NHANES study

• Data from 4,111 children and young adults ages
  2-19
• Looked at total and specific IgE levels to
  inhalant allergies and foods
• Obesity defined as being in the 95 percentile for
  BMI for the childs age
• D. Zeldin MD. J of Allergy and Clinical
  Immunology, May 2012

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Childhood obesity and allergy

• Obese children and adolescents are at increased
  risk for some type of allergy especially to food
• IgE levels were higher in overweight and obese
  children
• Obese children were 26 more likely to have
  allergies than those of normal weight,
• Most increase in foods, obese 56 more likely to
  have food allergy

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Arkansas Stats

• 30.6 Arkansans obese
• 36 Arkansans overweight
• 16 youth (9-12 grades) overweight
• 14 obese
• 13 eat lt 5 fruits/vegetables per day
• 40 drink at least one non diet drink/day
• 33 watch at least 3 hours of TV daily

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Basic Metabolic IndexBMI

• Underweight lt18.5
• Normal lt24.9
• Overweight gt25 -29.9
• Obese gt30
• Extremely obese gt40

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A Modern day epidemic

• Current generation of children may have shorter
  life span than their parents
• 1/3 of children in the US are expected to have
  diabetes
• 1/4 Americans age 17-24 are unfit for military
  service..obesity
• White House Task Force on Childhood Obesity,
  Report to the President 2010

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Co-morbidities

• Cardiovascular
• Respiratory
• Metabolic syndrome
• Musculoskeletal
• Mental health
• Endocrine
• Sleep disorders
• Chronic pain
• Medications used to treat these disorders

• Heart attack
• Stroke
• Diabetes
• Hypothyroidism
• Rheumatoid arthritis
• Depression
• Sleep apnea
• Chronic fatigue
• Social outcast
• Cancer

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How did we get here?

• Years of overeating and under exercising
• Advertising to children and adults
• The Bigger Better Burger
• Larger cola drinks
• Sugary cereals
• Good news! Kids are watching less television
• Bad news!!! Gaming, Texting, Facebooking,
  Twittering, Linkedin,

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Road to illness

• Patient comes in for physical exam in their mid
  to late 30s or early 40s, asymptomatic at this
  point
• Family history positive for diabetes, heart
  disease, high cholesterol
• 20 pk/yr hx of smoking, FEV1 80, lung age 52
• FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116),
  metabolic profile and UA normal
• 132/84
• Overweight BMI 27
• Recommendation Advised to stop smoking and lose
  weight. Physical scheduled for 1 year

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Road to illness

• Skips a year or two or three, next physical exam
• Still asymptomatic
• Still smoking, lung age 65, smoking
  cessation discussed
• Weight has increased. BMI 29
• Blood pressure now 144/92
• Blood sugar is normal
• Total cholesterol now 230, TRI 180, LDL 130
• Plan Started on medication for mild hypertension
• Advised to lose weight watch your blood
  pressure, .
• Lets check you in 6 months

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Road to illness

• 6 months later,
• I have a swollen, hot, red big toe
• Dx Gout
• Indomethacin given, acute phase over, given
  Allopurinol for maintenance.
• Now on 2 medications

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Road to illness

• 6 months later in for his annual physical
• Fatigue, some insomnia, weight gain continues,
  not feeling up to par, increase stress in life
• BP now 160/100, Total cholesterol 250, LDL 160,
  fasting blood sugar 118
• Add second blood pressure medication, start
  cholesterol lowering medication
• You need to lose weight, increase your
  exercise
• Recheck schedule you for a recheck in 6 months

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6 months later

• Increase in urination, hungry all the time,
  urination 3-4 times a night,
• Increased snoring, frequent awakenings, sometimes
  short of breath
• Spouse calls and says dont dare tell him I
  called, he will kill me, if he knewbut he is
  really depressed, can you give him a medication
  for that?
• Now what has happened?

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Road to illness

• Hypertension is being treated with 2 medications
• Gout is controlled with Allopurinol
• Hypercholesterolemia is treated with a statin
• He is now obese with a BMI of 33
• Type 2 diabetes
• Sleep apnea, using C-pap
• On medication for depression
• Insomnia is controlled with Zolpidem hs
• Stress he is seeing a counselor for his
  depression and stress.

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Remember the first visit

• Patient comes in for physical exam in their mid
  to late 30s or early 40s
• Family history of diabetes, heart disease,
  elevated cholesterol
• 20 pk/yr hx of smoking, FEV1 80, lung age 60
• FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116),
  metabolic profile and UA normal
• 132/84
• Overweight BMI 27
• Rec Smoking cessation discussed, advised to lose
  weight. Physical scheduled for 1 year

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Road to illness

• What a difference I might have made in his or her
  life IF ONLY I had addressed the life style
  changes needed aggressively at that visit or at
  least a year later..
• I might have kept him from obesity and its
  associated illnesses.

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Chief complaints

• I am here for
• blood pressure
• my diabetes check up
• my annual physical
• my chronic fatigue
• my depression
• my headache
• you will have to ask my wife, she made this
  appointment, nothing is wrong with me.
• Rarely. very rarely do I hear I am here
  because I am overweight and I am ready to do
  something about it.

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Physicians addressing obesity

• Three studies over 13 years published looking at
  how and when physicians address obesity

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Are health care professionals advising obese
patients to lose weight (12,385 obese adults)

• JAMA 1999 Oct27282 (16) 1576-8
• Only 42 of obese patients reported that their
  health care professional advised them to lose
  weight (after NIH 1998 Guideline recommendation)
• Rec Barriers to obesity counseling need to be
  identified and addressed

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Are health care professionals advising obese
patients to lose weight (61,968)

• MedGenMed,2005 Oct127(4)10
• Only 40.3 of obese patients reported being
  advised to lose weight.
• Conclusion Barriers to obesity counseling need
  to be identified and addressed

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U.S. primary care physicians diet, physical
activity, and weight related care of adult
patients

• American J Pre Medicine 2011 Jul4133-42
• Fewer than 50 reported providing specific
  guidance on diet, physical activity or weight
  control
• ConclusionFurther research is needed to
  understand barriers to providing care and to
  improve physician engagement.

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Barriers reported by physicians

• Lack of time during an office visit
• Lack of confidence in addressing obesity
  
• Issues with patient non-compliance
• Lack of trained personnel
• Inadequate handouts and teaching materials
• Lack of knowledge for treating obesity

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Barriers reported by physicians

• Availability of affordable weight loss programs
• Intimate saboteurs, (grandparents, friends)
• Lack of Insurance coverage
• Lack of reimbursement for time and effort spent.
• Lack of counseling training of physician and
  staff

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Attitudes of physicians

• Overweight physicians are less likely to make the
  diagnoses of obesity
• Overweight physicians are
• less likely to discuss weight
• reduction or refer for diet
• instruction

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Barriers reported by patients

• My doctor did not mention my weight, I didnt
  think it was important. (39)
• Every time I see my doctor I get more medicine
  but have never been told to change my diet or
  exercise.
• I was told to lose weight but wasnt told how to
  do it.

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Barriers reported by patients

• Their weight or obesity not acknowledged or
  discussed y the provider
• No affordable diet/exercise plan given
• Little or no education about obesity given
• No time to cook or exercise
• I am too tired to exercise
• My arthritis, aches, pains keep me from
  exercising

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Survey results

• Only 39 of obese adults were ever told by a
  doctor or or other health care provider that
  they were obese
• 90 of those told to lose weight, only 1 in 3
  were given any guidance in how to do this

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USPS Task Force

• Screen using BMI (waist size in some)
• Intensive, multi-component with behavioral
  interventions for obese adults and children
• Improving knowledge of diet.
• diet or nutrition Addressing barriers to change
• Increasing physical activity
• Strategizing how to maintain lifestyle changes

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From Mayo Clinic.

• you need to work with a team of health
  professionals including a nutritionist,
  dietician, therapist or an obesity specialist.
• What planet are these folks living on????
• ..how many of our patients have access to these
  kinds of program.

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Obesity

• How many of you have a multiple behavioral
  intervention in your office?
• How many have a person in your office dedicated
  to the treatment of obesity?
• How many of you feel you personally address
  obesity adequately with your patients?

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Where are the programs that are ?

• Accessible?
• Affordable?
• Multiple trained personnel?
• Teaching materials?
• Financial aid avialable?
• Paid for by insurance?

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Yellow pages

• Weight control under physicians
• All refer to bariatric surgery
• Weight control (general)
• Hypnosis clinic
• Advanced Products
• Body Solution System
• Jenny Craig
• Life Style Weight Control Center
• Overeaters anonymous
• War on Weight

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What I cannot and can do

• I cannot treat and educate a patient with complex
  problems.hypertension, diabetes, pulmonary
  disease, AND BEING OVERWEIGHT in a 10-15 minute
  office visit
• I can acknowledge the weight problem
• I can provide information or guidance for
  direction
• I can schedule a separate office visit to discuss
  their overweight issues or direct them to a
  weight loss program

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Acknowledging the problem

• Obesity is the last disorder addressed in a
  patients visit, (if at all), maybe it should be
  moved up
• Stressing its importance earlier in the visit may
  make it more important to the patient
• If not brought, up patients assume being
  overweight or obese is not important.

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Addressing obesity

• Advise him/her of the life style changes needed
  to lose weight through printed materials,
  direction to internet information or local
  programs
• Assist towards a program that fits their
  affordability and access
• Arrange follow up by office visits, telephone or
  internet

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The 5 As of behavioral counseling

• Assess risk, current behavior, and willingness to
  change
• Advise change of specific behaviors
• Agree to, and set goals
• Assist in addressing barriers and securing
  support
• Arrange follow up

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Addressing obesity

• Acknowledge the problem with weight, show
  concern, listen to his/her feelings about their
  weight
• Ask how their weight is affecting his/her life
  physically mentally and socially
• Advise him/her of the relationship between their
  weight and present medical problem(s)and
  potential future problems
• Assess their interest in losing weight, discuss
  the benefits of sustained, long term weight loss

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Assist

• Providing or directing him/her to information
  about dieting, identifying high caloric foods
• Provide information about local programs
• Develop your own program in your office
• Suggest internet programs and aps

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Weight loss drugs OTC

• Over 400 otc
• From Abrexin to Zymelt
• Top 3
• Apidexim, Phenpfedrin, 7DFBX
• Lifetime guarantee, all over 97 effective, all
  60-90 MRSP but can be bought on line for 24 or
  less (If it is too good to be

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Weight loss drugs by Rx

• Currently FDA approved drugs are for short term
  use with diet and exercise
• Appetite suppressants
• Phentermine
• Phentermine Topamax (Qsymia)
• Fat absorption inhibitor
• Xenical approved for longer use, safety not
  established beyond 2 years

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Human chorionic gonadatropin

• Although approved by the FDA, off label use for
  diet. Lots of illegal knock-offs.
• Dec 2011 products are illegal, claims are false
  and misleading, hormone not regulated
• Made from urine of pregnant women
• Obtained through compounding pharmacies
• Significant side effects have been reported.

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The best investment you will ever make

• You will feel better
• You will look better
• You will have more energy
• You will decrease the chance of developing the
  ravages of being overweight
• You will enjoy a better quality of life
• Save money by reducing money spent on overeating

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Engaging patients

• How to tell a patient they are fat without using
  the words fat or obese.
• I am very concerned about your weight. Are you
  concerned?
• Acknowledges the fact
• Shows compassion
• Opens the door for discussion and sets in motion
  your plan for further action

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Educating patients

• French Fries 500 cal 63 carbs
• Coca Cola (12 oz) 110
• Coca Cola (Large) 310
• Big Breakfast 740
• Big Breakfast with hotcakes 1040
• Walnut/apple salad 210 cal

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Educating patients

• Walnut/apple salad 210 calories dressing
• Big Mac 540 calories 10 carbs
• French Fries 500 calories
• Coca Cola Large 310 cal
• Total 1350 calories
• Vs

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Restaurants are not the only problem
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USPS Task Force Screening obesity in children

• Screen children over 6 years of age with BMI
  index
• Overweight age- and gender-specific BMI at
  85th to 94th percentile
• Obesity age- and gender-specific BMI at 95th
  percentile

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ACH Obesity Clinic

• First visit is a 4 hour visit
• Major initial thrust is to identify each and
  every soda or pop or other liquid that
  contains sugar and avoid as best as possible,
  including Gatorade and sport drinks.
• Must keep it simple

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More common cause of childhood obesity

• Family dynamics, overweight parents
• Use of food to appease children
• Use of food for sleep
• Bullying
• Stresses of school, peers
• Depression and other psychosocial issues

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Pediatric Online sites for help

• Nutrition.gov Weight Management for Youth
• Fuel Up and Play
• Healthy Youth, Healthy TopicsChildhood
  Overweight
• Helping Kids Fight Obesity/Best Online Source
• My Plate for Children
• Helping Your Overweight Child

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Obesity Management

• Non-surgical
• Life style changes
• Life style changes with medication
• Surgical
• Bariatric surgery
• Lifestyle changes
• Goals
• 10 weight loss reduces cardiovascular disease
  risk
• Weight loss medications alone are ineffective

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Listing barriers to weight loss needing change

• Write barriers down, keep adding to the list as
  they appear
• Eating out frequently
• Snacking during the day or after dinner
• Bedtime snack
• Special occasions, I.e. anniversaries, birthdays
• Skipping meals
• Alcohol with meals

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Ask what did you eat/drink yesterday?

• Breakfast
• Mid morning snack
• Lunch
• Afternoon snack
• Before dinner snack
• Dinner
• After dinner

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24 hour recall (excuses,excuses)

• Looking for patterns of behavior
• Fruits and vegetables
• Restaurants eating out frequently
• Skipped meals, especially breakfast
• Snacks
• Sugar containing pops
• Exercise

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In office programMake up your own
diet/recommendationsKeep it simple

• Weigh and chart your weight weekly or daily
• Avoid eating out (one meal can erase several days
  of dieting)
• Omit all sodas/pop including diet drinks, fruit
  juices
• Severely reduce bread (use whole grain),
  crackers, pasta, potatoes, rice, corn, sugar
  containing deserts, beets, carrots, peas and
  beans/limit fruit,if not losing.cut back more
  on these foods
• No nuts, no cheese, no alcohol
• Exercise 30 minutes daily, as close to 7 days a
  week as you can

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Foods for your weight loss diet

• Limit your alcohol intake (2 drinks for men, 1
  for women)
• You may eat most any fish/seafood, lean cuts of
  beef, pork, poultry, or veal. broiled, baked,
  boiled, no frying
• Vegetables include asparagus, bell peppers,
  broccoli, cauliflower, cabbage, celery, collards,
  cucumbers, pickles, onions, kale, mushrooms,
  okra, radish, rhubarb, spinach, turnips, squash
• Water, coffee, tea for liquids, canola, olive,
  grapeseed oil for cooking
• Seasonings apple cider vinegar, any herbs,
  garlic, ginger, lemon, mustard, soy sauce,
  spices, white vinegar

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Tips for patients

• Keep a diet diary listing all that is consumed
  daily, food and liquids
• Learn and record calorie count
• Make a list of foods to omit, habits to be
  broken, substitutes to be used
• Aim to exercise 7 days a week (we eat 7 days a
  week.Daaa!
• Avoid eating out, if you do have to eat out, stay
  as close to your diet as you can

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Speaking of exercise

• We EAT 7 days a week, therefore
• We should exercise 7 days a week!
• But I dont have time..
• Make time!

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Exercise

• Aerobic exercise (minimum of 30 minutes a
  day.may be broken up
• Using pedometers.use all day
• 10,000 steps program
• Riding in a golf cart does not count
• Sit ups and push ups and pull ups
• Can you do this for 30 min??

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Portion control

• Discarding half the serving (save it for another
  meal)
• Use smaller, partitioned plate
• Split plate with friend or family member

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M.O.R.E.

• More fruits and vegetables
• Organize snacks
• Single servings (bought or made up)
• Ramp up the fiber
• Fruits, vegetables, beans, grains
• Exercise more
• 7 days per week

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Potholes

• Eating out
• Not drinking required amount of water
• Skipping meals (breakfast the most common)
• Skipping exercise sessions
• Giving in to peer or family pressure on special
  occasions.
• Eating more than allowed, losing portion control
• Snacking
• Alcohol
• Weekend activities

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Goal setting

• Process between patient and physician or coach
• Goal needs to be realistic for weight loss and
  time, 10 of your weight for starters.
• Goals can be changed
• Setting lifetime behavioral changes,
• The only way to keep the weight you lost OFF!

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APS

• Lose It
• Restaurant Nutrition
• My Net Diary
• Fitness Pal
• Daily Burn
• Fat Secret
• Meal Snap
• Tracknburn

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Important information

• Patients have to be reminded that once they reach
  maintenance
• They have succeeded because they abandoned old
  habits
• They have changed meal planning eliminating high
  caloric, dense foods
• They are exercising regularly and have to
  continue to exercise
• They must continue the maintenance phase by not
  veering far from the changed behaviors

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Rx weight loss drugs

• All except Xenical are controlled substances with
  addictive potential
• All are recommended for short term use
• Wt loss tends to level off at 6 months
• All have side effects

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Side effects of Rx loss drugs

• Appetite suppressants
• Rapid heart rate
• High blood pressure
• Sweating
• Constipation
• Insomnia
• Thirst
• Anxiety
• Headache
• Dry mouth

• Xenical
• Increase flatulence
• Oily stool
• Leakage (incontinence)
• Abdominal cramping
• Frequent BMs
• Fecal urgency
• Inability to control bowel movements
• Fat soluble vitamin deficiency
• Hepatotoxicity

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Assess willingness/interest

• Some overweight patients want help, need a push,
  and will be interested
• Some will want to go it alone
• Some are not the least bit interested at this
  time.dont give up, address it each time they
  are in the office.

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Coding for obesity counseling

• GO 447 15 minute face to face counseling for
  obesity (BMI 30 or greater)
• One face/face weekly for 1 month
• One face/face meeting every 2 weeks for months
  2-6
• One face/face meeting every month for months 7-12
• Patient must lose 6.6 pounds first 6 months
• Diagnosis codes use to support medical necessity
• V85.30 to V85.39 and V85.41 to V85.45
• Medical Economics, June 25, 2012

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Current diets

• Weight Watchers
• Atkins
• South Beach
• Ornish Diet
• Fat Burners
• Physicians Wt Loss
• Ideal Protein Diet
• Jenny Craig
• Diet Center

• Raw Food
• Volumetrics Diet
• Slim Fast Diet
• Vegan Diet
• Dash Diet
• TLC Diet
• Biggest Loser Diet
• Ideal Protein

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Maintenance is not the goal

• Changing and keeping new life style habits is the
  goal
• Patients must continue the maintenance phase by
  not veering far from their diet and exercise
  program.

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What I have learned

• Multiple, affordable, accessible and applicable
  weight loss programs need to be developed to be
  used in and outside the the medical community
• Physicians offices, institutions,
  communities..maybe even families need a full time
  staff member (or family member) on site and
  responsible for implementing and carrying out the
  program
• We must become proactive in addressing the
  marketing and delivery of high caloric foods that
  are fueling the problem
• We must increase physical activity at all age
  level

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Program director

• Someone who has had a weight loss problem and has
  lost and maintained their weight loss
• Nurse, nutritionist, dietician, physician
  assistant, coach . Anyone with a burning desire
  to help patients lead a healthier life style and
  lose weight.

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Physicians alone cannot solve this problem

• Patients and families
• Parents, grandparents
• The indulging divorced parent
• Industry/employers
• Teachers
• Schools
• Religious communities
• Local, regional, state wide communities

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In the meantime.

• Practice style changes
• Make it your habit to address each overweight
  patient
• Send them out with a diet or with information
• Become better role models for our patients by
  losing weight and exercising
• Join patients in weight loss and exercise
  programs
• Encourage your staff to do the same

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I am only one.

• I am only one but still I am one.
• I cannot do everything but still I can do
  something
• And because I cannot do everything,
• I must not refuse to do something I can do

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Thank you!
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