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Tools for obesity prevention and intervention in a clinical setting

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Title: Tools for obesity prevention and intervention in a clinical setting


1
Tools for obesity prevention and intervention in
a clinical setting
  • Stan Reedy MD, MPH
  • Medical Director, Washtenaw County Public Health
  • Eden Wells MD, MPH
  • Preventive Medicine Resident, UM School of Public
    Health

2
Objectives
  • Define overweight and obesity
  • Discuss the importance of Primary Care Providers
    in preventing obesity
  • Discuss obesity in children and adolescents
  • Provide resources for clinicians
  • Open discussion on weight management in the
    clinical setting

3
What is Obesity?
  • Definitions
  • Obesity having a very high amount of body fat in
    relation to lean body mass, or Body Mass Index
    (BMI) of 30 or higher
  • Body Mass Index (BMI) a measure of an adults
    weight in relation to his or her height,
    specifically the adults weight in kilograms
    divided by the square of his or her height in
    meters

(CDC, 2002)
4
Body Mass Index (BMI)
  • Healthy Weight BMI18.9-24.9kg/m2
  • Overweight BMI25-29.9kg/m2
  • Obese BMIgt30kg/m2
  • Extreme/morbid BMIgt40kg/m2

BMI differs for children and adolescents
5
2010 National health objectives for Primary Care
Providers
  • Increase the proportion of physician office
    visits made by patients with a diagnosis of
    cardiovascular disease, diabetes, or
    hyperlipidemia that include ordering or providing
    counseling or education related to diet and
    nutrition from 42 to 75.

(U.S. Department of Health and Human Services,
2000)
6
The importance of Primary Care Providers in
preventing obesity
  • PCPs are well positioned within the health care
    systems to provide preventive services
  • Screening and assessment
  • Counseling on safe weight management
  • Education on benefits of physical activity and
    dietary management
  • Pharmacotherapy and surgery
  • Referral to professional dietician
  • Encourage breastfeeding

(American Family Physician, 2001)
7
1) Screening and Assessment
  • Assess degree of overweight based on BMI
  • Assess presence of abdominal obesity based on
    waist circumference
  • Assess presence of underlying diseases and
    conditions
  • Assess presence of cardiovascular disease (CVD)
    risk factors
  • Assess other risk factors
  • Physical inactivity
  • Elevated serum triglyceride levels

(American Family Physician, 2001)
8
Assess degree of overweight
(AFP, 2001)
9
Assess presence of associated diseases and
conditions
  • Coronary heart disease
  • Other atherosclerotic diseases
  • Type 2 diabetes
  • Sleep apnea
  • Gynecologic abnormalities
  • Osteoarthritis
  • Stress incontinence
  • Gallstones and their complications

(American Family Physician, 2001)
10
Assess presence of CVD risk factors
  • Cigarette smoking
  • Hypertension
  • High low-density lipoprotein cholesterol
  • Low high-density lipoprotein cholesterol
  • Impaired fasting glucose
  • Family history of premature coronary heart
    disease
  • Age (men45 years women55 years or
    postmenopausal

(American Family Physician, 2001)
11
Obesity and overweight assessment
(American Family Physician, 2001)
12
(AMA, 2003)
13
2) Counseling on safe weight management
  • Patients with BMI 25.0 to 29.9 kg/m2 or a high
    waist circumference, and 2 or more risk factors
  • Patients with BMI of 30 or more kg/m2
  • Overweight persons without risk factors should be
    encouraged to avoid further weight gain

(American Family Physician, 2001)
14
Patient readiness for change-why is it important?
  • Important for success
  • Prevents frustration when attempts fail
  • Future success not hampered
  • False Hope Syndrome prevented self blame and
    search for diets etc
  • Patient centered collaborative approach more
    likely to succeed

(AMA, 2003)
15
Targeted questions for assessing patient readiness
  • 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 would you like to get out of this visit
    regarding your weight?

(AMA, 2003)
16
Stages of change model
  • Pre-contemplation
  • Patient Unaware of problem, no interest in
    change
  • Provider Provide information about health risks
    and benefits of weight loss
  • Contemplation
  • Patient Aware of problem, beginning to think of
    changing
  • Provider Help resolve ambivalence discuss
    barriers

(AMA, 2003)
17
Stages of change model
  • Preparation
  • Patient Realizes benefits of making changes and
    thinking about how to change
  • Provider Teach behavior modification provide
    education
  • Action
  • Patient Actively taking steps toward change
  • Provider Provide support and guidance, with a
    focus on the long term
  • Maintenance
  • Patient Initial treatment goals reached
  • Provider Relapse control

(AMA, 2003)
18
What weight management goals to establish?
  • Prevention of further weight gain low risk
    persons who are prepared to make minor changes
    only-less threatening, and more achievable
  • Weight reduction of 5-10 moderate risk and
    committed to make behavior changes, translates to
    1-2lbs/wk over 6mths, significantly reduces
    obesity associated risk factors
  • Maintenance of weight loss Continued lifestyle
    modifications for maintenance of goal weight

(AMA, 2003)
19
3) Education on benefits of physical activity and
dietary management
  • Physical Activity
  • Match the activity to your patients abilities
  • Help your patients achieve realistic goals
  • Divide physical activity into short bouts as
    needed
  • Match the activity to your patients interest
  • Address your patients barriers to physical
    activity

(AMA, 2003)
20
Physical activity
  • Tailor the prescription to your patients health
    status
  • Stress the importance of social support
  • If increasing activity is a challenge, first try
    to decrease sedentary habits
  • Aim to make physical activity a part of the daily
    routine

(AMA, 2003)
21
Physical activity recommendations
  • Moderate intensity allows individuals to
    maintain same pace for 30minutes or more and to
    recover to baseline within 30 minutes
  • Brisk walk at 15-20 minutes/mile
  • Bicycling at 10 miles/hr
  • Dancing
  • Gardening
  • Golfing without cart
  • Hiking
  • Raking
  • Mowing with push mower
  • Washing or waxing a car
  • Swimming or water aerobics

22
Barriers to physical activity
  • Lack of access to exercise facilities
  • Long work commutes
  • Burden of excess weight
  • Comorbid health conditions
  • Low self-confidence
  • Self-esteem and body image concerns
  • Poor conditioning

(AMA, 2003)
23
Dietary management
  • Establish regular meal times
  • Read food labels when purchasing food items
  • Make small substitutions in your diet to cut
    calories
  • Identify guilty pleasures such as ice cream,
    cookies, or potato chips
  • Pre-portion your servings to control the amount

(AMA, 2003)
24
Dietary management
  • Control calories when dining out
  • Share an entrée with a friend at sit-down
    restaurants
  • Pre-plan meals and snacks, and make certain to
    have the food on hand
  • Avoid places and situations that trigger eating
  • Try substituting other activities for eating

(AMA, 2003)
25
Recommendations for a well balanced diet
  • 5-9 servings fruits and vegetables
  • Fish twice a week
  • 25-30gms fiber/day
  • 2 servings low fat dairy/day
  • 64oz water
  • Limit salt to 2400mg/day
  • Soy skinless chicken and turkey as protein
    sources
  • Whole grains instead of refined carbohydrates

(AMA, 2003)
26
4) Pharmacotherapy and surgery
(AMA, 2003)
27
Pharmacotherapy
  • Obese patients with a BMI 30 or
  • Overweight patients with a BMI of 27 and
    concomitant obesity related risk factors or
    diseases such as
  • Hypertension
  • Diabetes
  • Dyslipidemia

(AMA, 2003)
28
When should pharmacotherapy be used?
  • When patients are unable to achieve weight loss
    despite their best use of lifestyle approaches to
    diet, physical activity, and behavioral changes
  • When patients weight plateaus before their goal
    weight is attained

(AMA, 2003)
29
Who should be considered for pharmacotherapy?
  • Pharmacotherapy should be considered only if the
    patient
  • will be taking the medication in conjunction with
    an overall weight management program, including a
    reduced-calorie diet and increased physical
    activity
  • has realistic expectations of medication therapy
  • does not have other medical conditions or take
    other medications that are a contraindication for
    obesity drugs

(AMA, 2003)
30
Classes of pharmacotherapy
  • Sympathomimetic medications approved for
    long-term use
  • Gastrointestinal (GI) lipase inhibitors
  • Sympathomimetic medications approved for
    short-term use

(AMA, 2003)
31
Surgery
  • Surgical intervention is an option for carefully
    selected patients
  • With clinically severe obesity (a BMI 40 or a
    BMI 35 with comorbid conditions)
  • who are at high risk for obesity associated
    morbidity or mortality
  • when less invasive methods of weight loss have
    failed

(AMA, 2003)
32
Who should be considered for surgery?
  • Surgery should be considered only if the patient
    has
  • realistic expectations about what the surgical
    procedure entails
  • ability/desire to follow the surgically-imposed
    dietary changes
  • a good social support system
  • no active substance abuse or clinically
    significant and unstable psychopathology
  • demonstrated adherence to medical recommendations

(AMA, 2003)
33
5) Referral to professional dietician
  • Become knowledgeable about community resources
    and referral services (e.g. registered
    dieticians)
  • Establish an on-going dialogue with the RDs to
    whom you refer patients
  • Diabetic patients have RD expenses covered with
    Medicare and Medicaid in some states
  • Find an RD near you
  • www.eatright.org

(AMA, 2003)
34
Local professionals
  • UM CVC Preventive Cardiology
  • Nutrition Services
  • Exercise Consultation
  • UMHS M-Fit
  • Weight Management
  • Fitness consultations
  • St. Jospeh Mercy Hospital
  • Healthy Solutions Weight Management Programs
  • Saint Joseph Mercy Nutricare
  • Chelsea Community Hospital
  • Dietary and Nutrition Services
  • LiveWell Community Health Program

35
6) Encourage breastfeeding
  • Breastfeeding is linked to decreased risk of
    obesity, possibly due to physiologic factors in
    human milk, feeding and parenting patterns
    associated with nursing.
  • Breastfed infants are leaner at 1 year compared
    to formula-fed counterparts. Early growth pattern
    may influence later growth.

(AAP, 2003 Dept. of HHS, 2000)
36
Obesity in children and adolescents
  • 20 of 4-year-olds who are obese will be obese as
    adults
  • 80 of obese adolescents will be obese adults
  • Odds are 31 of a child being obese if one parent
    is obese
  • Increases to 101 if both parents are obese
  • Similar genetic and environmental influences
    implicated

(AMA, 2003)
37
BMI for children and adolescents
  • Children's body fatness changes over the years as
    they grow
  • Girls and boys differ in their body fatness as
    they mature
  • BMI for children, also referred to as
    BMI-for-age, is gender and age specific
  • BMI-for-age is plotted on gender specific growth
    charts.

(CDC, 2003)
38
BMI-for-age
39
BMI-for-age
  • Underweight
  • At risk of overweight
  • Overweight
  • BMI-for-age lt 5th percentile
  • BMI-for-age 85th percentile to lt 95th percentile
  • BMI-for-age gt 95th percentile

(CDC, 2003)
40
Assessment of overweight children and adolescents
(Barlow and Dietz, 1998)
41
Therapy for overweight children and adolescents
  • Intervention should begin early
  • The family must be ready for change
  • Clinicians should educate families about medical
    complications of obesity
  • Clinicians should involve the family and all
    caregivers in the treatment program
  • Teach families to monitor eating and activity

(Barlow and Dietz, 1998)
42
Therapy for overweight children and adolescents
  • Treatment programs should institute permanent
    changes, not short-term changes
  • The treatment program should help the family make
    small, gradual changes
  • Clinicians should encourage and empathize, not
    criticize
  • A variety of experienced professionals can
    accomplish many aspects of a weight management
    program (Referrals!)

(Barlow and Dietz, 1998)
43
Obesity prevention in children
  • Using BMI measures to track children and
    adolescents at risk
  • Counsel parents to promote healthy eating and
    physical activity
  • Counsel parents to limit TV and video viewing to
    a maximum of 2 hours
  • Monitor blood pressure, lipids, and glucose in
    those at risk

(AMA, 2003)
44
Conclusions
  • Primary Care Providers have an important role in
    the diagnosis and management of obesity.
  • The Primary Care Provider should feel comfortable
    discussing weight issues with their
    patients/clients.
  • Early intervention in overweight/obese children
    and adolescents, including diagnosis, education,
    counseling, and treatment, is necessary.

45
Resources for physicians and patients
  • http//www.ama-assn.org/ama/pub/category/10931.htm
    l
  • Assessment of health risks
  • Assessment of patient readiness
  • Treatment options
  • Office Environment
  • Patient handouts
  • http//www.nhlbi.nih.gov/guidelines/obesity/practg
    de.htm

46
Clinical Tools
  • Determining BMI
  • BMI chart
  • Measuring waist circumference
  • Waist circumference and BMI and associated
    disease risk
  • Obesity related risk factors and conditions
  • Algorithm for assessment and management of
    overweight and obesity
  • Patient readiness checklist
  • Stages of change model chart
  • Guide to selecting treatment chart
  • Guide to weight loss medications

47
Other resources
  • www.aafp.org/prebuilt/obesitymonograph.pdf
  • www.acpm.org/polstmt_weight.pdf
  • www.nhlbi.nih.gov/guidelines/cholesterol
  • www.naaso.org/information/practicalguide.asp
  • www.naaso.org/information/practicalguide.asp
  • www.ahcpr.gov/clinic/ppipix.htm
  • www.obesityhelp.com
  • www.chid.nih.gov
  • www.iotf.org
  • www.obesitycme.org
  • www.medical-supplies-equipment.net

48
Sources
  • AAFP Lyznicki JM, Young DC, Riggs JA, and Davis
    RM. 2001. Obesity Assessment and Management in
    Primary Care. American Family Physician.
    63(11)2185-2196.
  • AMA (Roadmaps for clinical practice) American
    Medical Association. 2003. Assessment and
    Management of Adult Obesity A Primer for
    Physicians.
  • Barlow SE and Dietz WH. 1998. Obesity Evaluation
    and Treatment Expert Committee Recommendations.
    Pediatrics. 102(3)1-11.
  • Center for Disease Control. 2003. Overweight and
    Obesity. http//www.cdc.gov/nccdphp/dnpa/obesity/i
    ndex.htm

49
Acknowledgements
  • Talat Danish, MD
  • Sharon P. Sheldon, MPH
  • Jenna M. Bacolor, MPH, MSW
  • Will Story, MPH
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