Integrating the Obese Patient into the Primary Care Setting

1
Integrating the Obese Patient into the Primary
Care Setting
Speaker notes included in notes section below
2
More than 60 of US Adults Are Overweight
Flegal, K et al. JAMA, 2002.
3
Obesity Is Caused by Long-Term Positive Energy
Balance

• Fat
• stores

Energy expenditure

Energy intake
4
Heritability of Body Weight
5
16 oz
32 oz
44 oz
52 oz
64 oz
1 oz 12 calories
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Couch Potatoes, Arise!
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Obesity and Coronary Heart Disease (CHD)
Coronary Heart Disease
Morbiditymortality
Morbiditymortality
Morbiditymortality
Hypertension
Diabetes
Dyslipidemia
80 are obese
50 70 are obese
40 are obese
OBESITY
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Abdominal Adiposity
Abdominal Obesity Visceral
Subcutaneous
Courtesy of Steven Smith, M.D.
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Visceral Obesity and Risk of Dyslipidemia
Despres JP, et al. Arteriosclerosis.
199010497-511.
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Characteristics of the Metabolic Syndrome
Wannabes
Full members

• Abdominal obesity
• Glucose intolerance
• High triglycerides
• Low HDL-cholesterol
• High blood pressure
• Insulin resistance

• Microalbuminuria
• Small dense LDL
• Inflammatory markers
• Thrombotic factors
• Endothelial dysfunction
• Hyperuricemia

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Medical Complications of Obesity
Idiopathic intracranial hypertension
Pulmonary disease abnormal function obstructive
sleep apnea hypoventilation syndrome
Stroke
Cataracts
Nonalcoholic fatty liver disease steatosis steatoh
epatitis cirrhosis
Coronary heart disease Diabetes
Dyslipidemia Hypertension
Severe pancreatitis
Gall bladder disease
Cancer breast, uterus, cervix colon, esophagus,
pancreas kidney, prostate
Gynecologic abnormalities abnormal
menses infertility polycystic ovarian syndrome
Osteoarthritis
Phlebitis venous stasis
Skin
Gout
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Relationship Between BMI and Risk of Type 2
Diabetes Mellitus
100
75
Age-Adjusted Relative Risk
50
25
0
23 - 23.9
24 - 24.9
25 - 26.9
27 - 28.9
33 - 34.9
29 - 30.9
31 - 32.9
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Body Mass Index (kg/m2)
Chan J et al. Diabetes Care 199417961. Colditz
G et al. Ann Intern Med 1995122481.
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Diabetes Prevention Program
Placebo
Metformin
Lifestyle
Cumulative Incidence of Diabetes ()
Year
Diabetes Prevention Program Research Group. N
Engl J Med. 2002346,393-403.
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Prevalence of Type 2 Diabetes Among Diabetic
Children in 4 Studies
Fagot-Campagna et al. J Pediatr 2000136664.
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How Are We Doing as a Medical Profession?
Obesity is under-diagnosed and under-treated
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Percent of Patients Receiving PCP Advice by
Obesity Classification
Simkin-Silverman LR et al. Prev Med 20054071-82.
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The Office Visit
The Evaluation Process Consists of 6 Action Steps

• Measure weight, height, waist circumference and
  record body mass index (BMI)
• Categorize obesity classification and risk
• Take a comprehensive history, physical exam,
  lab tests for medical condition
• Assess need for treatment
• Broach the subject
• Assess readiness for treatment

The Practical Guide, 2000.
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Broaching the Subject Words to Use

• Are you concerned about your weight?
• What is hard about managing your weight?
• How does being overweight affect you?
• What cant you do now that you would like to do
  if you weighed less?
• What kind of help do you need to manage your
  weight?

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Obesity Treatment Pyramid
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One Diet Does Not Fit All
Low Calorie Diet
Low Fat Diet
Low Carb Diet
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Comparison of Popular Diets
Mean Changes in Wt and Cardiac Risk at 12 Months
Dansinger, et al. JAMA 200529343-53.
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Meal Replacements Promote Long and Short term
Weight Loss
12001500 kcal/d diet prescription A
conventional foods B meal and snack replacement
for 1 meal, 1 snack
Fletchner-Mors et al. Obes Res 20008399.
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Examples of High vs Moderate Intensity Physical
Activities

• LOW/MODERATE (
• Walking
• (
• Playing with children
• Golfing (walking)
• Doubles tennis
• Mowing the lawn
• Gardening
• Walking the dog
• Playing catch
• General housework
• Weight Training

• HIGH ( 6 METs)
• Walking
• ( 5 mph-12min/mile)
• Singles tennis
• Vigorous downhill skiing
• Soccer
• Jumping rope
• Jogging/Running
• Bicycling (16-18mph)
• Touch football
• Shoveling snow by hand
• Circuit training
• Moving furniture

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Long vs Short Bouts

• Multiple short bouts are as effective as one long
  bout and perhaps may facilitate efforts to
  increase activity
• Helps address the barrier of perceived lack of
  time
• Multiple short bouts increase adoption of
  physical activity during first 6 months
• Long-term impact is less clear

Jakicic JM et al. JAMA 1999282(16)1554-60. Jacob
sen DJ et al. Int J Sports Med 200324459-64.
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Establish an Approach to the Obese Patient

• The patient who has a disease but is not the
  disease
• Medical and psychological benefits to the patient
• Personal challenge and economic opportunity for
  the patient
• Professional challenge and economic opportunity
  for the physician

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Assessing Readiness

• Why now?
• What changes will you have to make?
• What will change if you lose weight?
• What do others think about your weight?
• What else is going on in your life?

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Assessing Readiness

• We are not good at predicting outcomes.
• Patients ultimately make the decision.
• Providers assess costs/benefits in a variety of
  contexts.

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5 Steps to Behavior Change

• 1. Have patient identify specific goals
• Activity (ie, one specific goal for exercise)
• Intake (ie, one specific goal for diet)
• 2. Identify when, where, and how behaviors will
  be performed
• 3. Have patient keep record of behavior change
  (i.e., diet and activity diaries)
• 4. Follow-up progress at next treatment visit
• 5. Congratulate patient on successes do not
  criticize shortcomings

Wadden Foster. Medical Clinics of North
America, 2000.
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Obesity is a Medical Disease to be Treated by
ProfessionalsUsing Medical Tools

• Shared Decision Making Model
• Match the tools with the task, the treatment with
  the patient
• Medical
• Psychological
• Diet
• Cognitive-Behavioral
• Physical Activity
• Surgical

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The Office Environment
Example of Waiting Room
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The Office Environment
Equipment

• Large adult thigh and blood pressure cuffs, large
  tape measure
• Large exam tables and gowns
• Scales that weigh up to 500 lbs or more
• Exam tables
• Sturdy, wide and bolted to the floor to prevent
  tipping

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Staff

• The cornerstone of effective obesity treatment
  is grounded in skillful and empathetic
  physician-patient communication
• - The Therapeutic Bond
• Empathetic, compassionate, supportive,
  trustworthy, nonjudgmental, caring
• Optimistic hope is an important medicine
• Healthy role models, helpful, kind

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Referrals

• Nutritionist
• Behavior therapist
• Psychiatrist
• Bariatric surgeon

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Conclusions

• Obese patients can be easily integrated into any
  primary care setting
• With the increase in obesity as well as co-morbid
  conditions, obese patients need access to quality
  care
• Small differences in approach and attitude
  related to weight and weight loss can have a huge
  impact