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Obesity Diagnosis and Action Plan Implementation


Must fail lifestyle intervention for weight loss ... MD not familiar with weight loss meds, UNC and community resources for lifestyle ... – PowerPoint PPT presentation

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Title: Obesity Diagnosis and Action Plan Implementation

Obesity Diagnosis and Action Plan Implementation
  • September 17, 2008
  • Dr. David Andrew Nicholas Rometo

  • Background
  • Obesity
  • Comorbidities
  • Treatments
  • Barriers to care
  • PDSA cycle 1
  • Plan creation of trial Green Sheet
  • Do Pilot run
  • Study the results and feedback
  • Act Brainstorming

Background Obesity
  • Worldwide epidemic
  • 61 of US adults have BMI 25 (1999)
  • 2nd leading cause of preventable death in
    developing countries
  • 300,000 deaths/yr in US associated with obesity
  • Cost of obesity 117 billion in US (2000).
    Directly 5.7 of U.S. health expenditures.
  • Ethnic and gender based disparities
  • Hispanic and black, women men
  • Low SES

  • Heart disease
  • MI, CHF, sudden cardiac death, angina, arrhythmia
  • HTN is 2x as common
  • High triglycerides, low HDL
  • Diabetes type 2
  • 11 to 18 lb weight gain doubles risk of DM
  • 80 of those with DM2 are overweight/obese
  • Stroke
  • Arthritis weight loss improves symptoms
  • OSA and asthma
  • Reproductive complications
  • Fetal and maternal death, eclampsia, gestational
    DM, spina bifida
  • Irregular cycles and infertility
  • Depression
  • Certain types of cancer
  • Endometrial, colon, gall bladder, prostate,
    kidney, breast CA
  • 20 lb wt gain after age 18 doubles risk of
    postmenopausal breast CA.

  • Imbalance in calorie consumption and physical
  • Some medicines and medical conditions may
    contribute to weight gain and difficulty with
    weight loss, but to not cause normal weight
    people to become obese.
  • Combination of genetic, metabolic, behavioral,
    environmental, and socioeconomic influences.

  • Goal
  • 5-15 weight loss, ½ to 2 lbs per week.
  • easier management of comorbidities
  • Improved quality of life, decrease morbidity,
  • Decreased costs of care
  • Physical Activity
  • Recommended 30-60 min/day, 5-7 days/week.
  • 40 of US adults get no leisure time physical
  • Diet
  • Various diets Mediterranean, low carb, low fat,
    etc. Shai et al, NEJM July 2008
  • Weight loss meds
  • Sibutramine- appetite suppressant (HTN)
  • Orlistat- intestinal lipase antagonist, fat
    malabsorption (steatorrhea)

Bariatric Surgery
  • Procedures
  • Roux-en-Y gastric bypass
  • Laparoscopic adjustable gastric banding
  • Biliopancreatic diversion
  • Laparoscopic sleeve gastrectomy
  • Buchwald et al meta-analysis
  • 1990-2003, 22,000 pts
  • DM resolved/improved in 86, lipids in 70, HTN
    in 78, OSA in 84
  • Operative mortality 0.1-1.1

Bariatric Surgery
  • Available at 3 local centers UNC, Durham
    Regional, and ECU
  • Generally for patients with BMI 40, or 35 with
    comorbidities, aged 18-60, well-informed,
  • Must fail lifestyle intervention for weight loss
  • Medicaid requires 6 months of monthly
    PCP/Nutrition visits focused specifically on
    weight loss
  • At UNC, cannot accept Medicare (not a center of
    excellence). Must weight
  • There are 150 -250 application fees to get into
    these programs AFTER initial interview/info

  • U.S. Preventive Services Task Force
  • Screen all adult patients for obesity with BMI.
  • Offer intensive counseling and behavioral
    interventions to promote sustained weight loss
  • There is fair to good evidence that
    high-intensity counselingabout diet, exercise,
    or bothtogether with behavioral interventions
    aimed at skill development, motivation, and
    support strategies produces modest, sustained
    weight loss (typically 3-5 kg for 1 year of more)
    in adults who are obese (BMI 30).
  • improved glucose metabolism, lipid levels, and
    blood pressure, from modest weight loss
  • Defined high-intensity intervention as more than
    1 person-to-person (individual or group) session
    per month for at least the first 3 months of the

How are we doing?
  • Galuska et al, JAMA 1999. National survey showed
    42 obese patients reported their PCP advised
    weight loss in last 12 months.
  • More likely to receive advice were female, middle
    aged, had higher levels of education, lived in
    the northeast, reported poorer perceived health,
    were more obese, and had diabetes mellitus. If
    advised, they were more likely to report trying
    to lose weight.
  • Bardia et al, Mayo Clinic Proceedings 2007. In
    Mayo Clinic, PCPs diagnosed 20 of obese patients
    with obesity, and had obesity management plan for
  • Most likely diagnosed were BMI 35, OSA, DM.
    Less likely were elderly and men.

Our clinic
  • Review of 9390 patients seen by Internal Medicine
    at ACC in last 2 years.
  • 2680 (28.5) have BMI
  • 2880 (30.8) have BMI 25-30, overweight
  • 1830 (19.5) have BMI 30-35, Class I obesity
  • 1000 (10.6) have BMI 35-40, Class II
  • 1000 (10.6) have BMI 40, Class III, extreme,
    severe, morbid
  • Thats 40.7 of our patients are obese! 2 in 5!
  • If you see 5 patients in a half day of resident
    clinic, 2 are obese!
  • Are we following USPSTF guidelines? I didnt
    look. Dont think I need to. I think the answer
    is no. I may need to look to have some before
    data to compare final intervention to.

Barriers to Care the MD
  • MD not aware of medical consequences of obesity
  • MD not aware patient is obese
  • MD forgets to mention it, deal with it
  • MD does not want to embarrass the patient by
    addressing the issue
  • MD does not have time to address the issue, more
    important things during visit to discuss
  • MD feels patient is too old/too sick to diet or
  • MD feels patient does not have access to
    appropriate resources for adequate results
  • MD not familiar with weight loss meds, UNC and
    community resources for lifestyle interventions,
    or appropriate steps to referral for bariatric
  • MD feels any intervention is futile
  • MD blames patient for their obesity, does not
    feel it is a doctors job to address the issue

Barriers to Care the Patient
  • Does not know he/she is obese
  • Does not understand how obesity is affecting/will
    affect his/her health
  • Has friends and family with same body-type, diet,
    activity level
  • Frustration from prior attempts
  • Lack of motivation
  • Lack of knowledge
  • Lack of family or community support
  • Fear of embarrassment
  • Cost concerns

Barriers to Care the System
  • Lack of High Intensity program offered by UNC
  • Lack of adequate visit time with MD
  • Inaccurate weight measurement?
  • Errors in BMI on WebCIS, Kg vs lbs
  • Lack of reimbursement for MD visit
  • Lack of reimbursement for dietician visit

PDSA cycle 1
  • The problem many obese patients, few being
    identified and offered High-intensity Lifestyle
    Intervention (HLI) (not meeting USPSTF
    recommendations), patients stay obese, develop
    comorbidities, have high cost management,
    increased morbidity and mortality
  • The goal educate all obese patients and offer
    them HLI, reach 5-15 weight loss goals, achieve
    improved outcomes

Plan How do we do it?
  • The Enhanced Care solution the database
  • Amy Bouthillette has DM patients and others she
    has seen for nutrition visits in a database.
  • DM patients are in a database which generates the
    yellow sheet
  • To improve care of our non-diabetic patients,
    creation of a sheet to attach to check-in
    paperwork of all patients to address disease
    management issues without the hassle of WebCIS
  • First, well need a database of all ACC IM
  • For now, obesity will be the first issue
    addressed on the new sheet

Current Nutrition Database
Do The Green Sheet
  • In cycle 1, a sheet was created to address a few
    MD related issues and obtain feedback, assess
    compliance, and MD preference.
  • 3 sections
  • Comorbid factors
  • Action plan
  • Nutrition referral
  • The sheet was primarily designed to assess what
    actions residents would take when prompted to
    act, and to see if prompting would result in
    Nutrition referral.

Pilot day 9/3/08
(No Transcript)
Data not on Sheets
  • Blank sheet returned
  • All had DM
  • Obesity was not addressed in clinic note
  • Sheet not returned
  • Unknown DM status (no fasting glucose or OGTT in
    past 3 years)
  • Obesity was addressed in clinic note

  • Residents oriented during pre-clinic conference,
    on-call residents needed to be oriented after
    930 when they arrived.
  • What are the available weight loss meds?
  • Can patients without diabetes see the
  • Reasons obesity not addressed today Too many
    other issues, Difficulty complying with many
    other meds, etc already

  • Residents are willing to fill out Green Sheet
  • Referral to nutrition at later date is preferred
  • 15 obese patient visits / day in resident clinic
  • Residents are not prescribing weight loss meds
  • Addressing obesity not a priority at some clinic
  • Obese patients with risk factors do not have
    appropriate DM screening
  • USPSTF only recs screening for adults with BP
  • ADA adults 45yo q3yr, and overweight w/ RF at
    any age q1-3yr

Act Suggested Interventions
  • More condensed Green Sheet vs yellow sheet for
    all. Flag patients obesity, identify
    comorbidities, prompt referral to Nutrition.
  • Offer HLI as 6 month program, including group
  • Health care maintenance for obese patients? DM,
    lipid, OSA screening
  • After 6 mo of HLI /- meds, prompt referral to
    appropriate bariatric program
  • Track weight since entry into database
  • Can measure weight loss vs. frequency of
    nutrition visits or specific intervention (low
    carb vs low fat)
  • Dr. Thomas collecting this data from Nutrition
    database now

Other Interventions
  • Educate House staff and attendings at the
    BEGINNING of every ACT!!!
  • New vs. calibrated scales
  • Standardize weighing technique
  • Eliminate Kg vs. lbs mistakes
  • Focus on those eligible for bariatric surgery
  • Anything else?...

Act the Next Step
  • Create database of all IM patients
  • Create patient specific printed sheet that
    addresses disease management, including diabetes
    screening and nutrition referral for obese
  • Create High-intensity Lifestyle Intervention that
    meets USPSTF guidelines provided by Enhance Care

A note on Prediabetes
  • American College of Endocrinology (ACE) and
    American Association of Clinical Endocrinologists
    (AACE) 2008 consensus conference
  • Lifestyle modifications for prediabetes
  • Use same BP and lipid goals as diabetes
  • Annual OGTT, urine microalbumin
  • Biannual FPG, Hgb A1C, lipids

UKPDS 10 year follow-up
  • Conventional therapy (dietary restriction) vs.
    sulfonylurea/insulin or metformin (for overweight
    patients) in new dx DM2
  • Sulfonylurea/insulin RRR microvascular disease
    24, MI 15, all cause mortality 13
  • Metformin RRR MI 33, ACM 27

  • Bardia et al. Diagnosis of obesity bt primary
    care physicians and impact on obesity management.
    Mayo Clin Proc. August 2007 82(8)927-932.
  • Dansinger et al. Meta-analysis the effect of
    dietary counseling for weight loss. Ann Intern
    Med. 2007 14741-50.
  • Screening for obesity in adults recommendations
    and rationale. USPSTF. Ann Intern Med. 2003
  • The Surgeon Generals call to action to prevent
    and decrease overweight and obesity.
  • Zare, MM. Surgery for severe obesity patient
    selection, surgical options, and aftercare.
    Hospital Physician, September 2008 44(9)8-16.
  • Shai et al. Weight loss with a low-carbohydrate,
    Mediterranean, or low-fat diet. N Eng J Med 2008
  • Guidelines stress lifestyle changes for
    prediabetes, by Heidi Splete. Internal Medicine
    News, August 15, 2008.
  • Holman et al. 10-year follow-up of intensive
    glucose control in type 2 diabetes. N Engl J Med,
    September 10, 2008359.
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