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Managing Obesity in Primary Care Settings

Managing Obesity in Primary Care Settings. Doina Kulick, M.D. F.A.C.P. Director of the Wellness and Weight Management Program- UNSOM, Reno Campus. UNIVERSITY OF NEVADA SCHOOL of MEDICINE. Learning Objectives

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Managing Obesity in Primary Care Settings

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  1. Managing Obesity in Primary Care Settings Doina Kulick, M.D. F.A.C.P. Director of the Wellness and Weight Management Program- UNSOM, Reno Campus UNIVERSITY OF NEVADA SCHOOL of MEDICINE

  2. Learning Objectives Review the U.S. Preventive Services Task Force recommendations on obesity screening and treatment Learn about the status of addressing obesity by the primary care physicians Updates on insurance coverage of obesity treatment in primary care Learn about the 5As approach to the obesity management in primary care settings

  3. “Obesity is a complex, multifactorial, chronic disease that develops from the interaction of the genotype and the environment and consists in excessive accumulation of fat tissue.” Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,The NIH, National Heart, Lung and Blood Institute , 98-4083, Sept. 1998 278.00 - Obesity, unspecified 278.01 - Morbid obesity 278.02 - Overweight 277.70 - Metabolic syndrome

  4. The Prevalence of Overweight and Obese Adults in U.S • The most recent NHANES data show that: • 34.2% of Americans are overweight • 33.8% are obese • J Am Med Assoc 2010;303:235-241

  5. County Level Estimates of Obesity-2008 County-level Estimates of Obesity among Adults aged ≥ 20 years: United States 2008 Age-adjusted percent

  6. Etiology of Obesity • Genetic • Physiological • Psychological • Social/Environmental

  7. Portion distortion COFFEE 40 Years Ago Coffee(with whole milk and sugar) Today Mocha Coffee(with steamed whole milk and mocha syrup) 45 calories 8 ounces 350 calories 16 ounces Calorie Difference: 305 calories

  8. MUFFIN 40 Years Ago Today 210 calories 1.5 ounces 500 calories 4 ounces Calorie Difference: 290 calories

  9. Portion Distortion CHEESEBURGER Today 40 Years Ago 333 calories 590 calories Calorie Difference: 257 calories

  10. Portion Distortion SODA 40 Years Ago Today 85 Calories 6.5 ounces 250 Calories 20 ounces Calorie Difference: 165 Calories

  11. EATING ALL THESE FOUR ITEMS: 40 years agoToday 1690 calories ▼▼ ▼ ▼ 673 calories

  12. Average Annual U.S. Medicare Charges per Person According to BMI These are average annual U.S. Medicare charges per person in 2002 dollars for inpatient and outpatient care from 1984-2002 by baseline Daviglus. JAMA, 2004, 292(22):2743-2749.

  13. Obesity A Leading U.S. Healthcare Cost Driver • Obesity is growing faster than any previous public health issue America has faced. If current trends continue, 103 million American adults will be considered obese by 2018. • Obesity-related direct expenditures are expected to account for more than 21 percent of the nation’s direct health care spending in 2018. • • If obesity levels were held at their current rates, the U.S. could save an estimated $820 per adult in health care costs by 2018 — a saving of almost $200 billion dollars • Source: The Future Costs of Obesity: National and State Estimates of the Impact of Obesity on Direct Health Care Expenses. A collaborative report from United Health Foundation, the American Public Health Association and Partnership for Prevention. Based onresearch by Kenneth E. Thorpe, Ph.D. of Emory University November 2009

  14. Screening for Obesity in Adults Recommendations and Rationale http://www.ahrq.gov/clinic/uspstf/uspsobes.htm U.S. Preventive Services Task Force (USPSTF) December, 2003 (updated guidelines pending) The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive* counseling and behavioral interventions to promote sustained weight loss for obese adults. Rating of Recommendation: B *A high-intensity intervention is more than 1 person-to-person (individual or group) session per month for at least the first 3 months of the intervention.

  15. The USPSTF concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. Rating of Recommendation: I The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults. Rating of Recommendation: I

  16. Despite a 69% increase in the prevalence of overweight and obesity between 1994 and 2008 there was no changein the odds of being diagnosed overweight by a physician Overweight and obese individuals were 40 and 42% less likely in 2008 compared with 1994 to self-diagnose as overweight. Yates EA, Macpherson AK, Kuk JL. Obesity (Silver Spring). 2011 Aug 25

  17. Physicians diagnose only 1 in 5 obese patients as having the disease - 9827 patients seen at Mayo Clinic for an annual exam between November 2004 and October 2005 - 2543 were obese (based upon a calculated BMI ≥30), but only 505 (19.9%) had a diagnosis of obesity documented somewhere in their chart (based on an extensive chart review, not ICD-9 coding alone). Bardia A, at all. Mayo Clin Proc 2007; 82:927–932.

  18. Barriers to addressing obesity by primary care physicians (PCPs): • Lack of physician training • Lack confidence in patients’ ability to change • their eating and exercise behavior • Inadequate reimbursement • Lack of time: PCPs have an average of 4 minutes to address each clinical item during a visit* • Ma J, Xiao L, Stafford RS. Adult obesity and office-based quality of care in the United States. Obesity (Silver Spring). 2009;17(5):1077-1085. • * Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med. 2008;23(12):2058-2065

  19. CMS Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N) http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253& -Intensive behavioral therapy for obesity (defined as BMI ≥ 30 kg/m2) is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B, and is recommended with a grade of A or B by the U.S. Preventive Services Task Force . AHRQ Publication No. 11-05159-EF-1, October 2011

  20. CMS Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N) • Intensive behavioral therapy for obesity consists of the following: • Screening for obesity in adults using measurement of BMI; • Dietary (nutritional) assessment; and • Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

  21. CMS will cover counseling provided by a qualified primary care physician or other primary care practitioner and in a primary care setting as follow: • One face-to-face visit every week for the first month; • One face-to-face visit every other week for months 2-6; • One face-to-face visit every month for months 7-12, if the beneficiary lost 3kg in the first six months. • For beneficiaries who do not achieve a weight loss of at least 3kg during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six month period.

  22. CMS recommends that the intensive behavioral intervention for obesity should be consistent with the 5-As framework method: • 1. Assess/Ask • 2. Agree • 3. Advise • 4. Assist • 5. Arrange • Rao G. Am Fam Physician. 2010;81(12)1449-1455.

  23. 1998 NIH Guide to Selecting Obesity Treatment NHLBI and NIDDKD. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: evidence report. Obes Res. 1998;6(suppl 2):51S–210S.

  24. The 5As Framework Approach to Managing Obesity in Primary Care Settings

  25. Assess/Ask: • Assess and chart the patient’s body mass index (BMI) • Assess the presence metabolic syndrome, and other obesity related medical conditions! • Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods. • We cannot treat the disease if it is not diagnosed: a diagnosis of obesity in the PCP office is the strongest predictor that an obesity management plan would be formulated(Bardia A, at all. Mayo Clin Proc 2007; 82:927–932).

  26. Assess the patients readiness to change and ask permission to talk about weight and agree that the patient is interested in losing weight! • While physicians agree that the word “obesity” should be used, research shows that: • Patients dislike terms such as: • fatness • obesity • large size • Patients prefer terms such as: • unhealthy body weight or unhealthy BMI • BMI or weight problem • Ward SH. J Gen Intern Med. 2009;24(5):579-584

  27. The conversation about obesity can begin like this: “Mr. Jones, could we talk about your weight for a few minutes?” Most patients will respond, “Yes, Doctor, I know I need to lose weight. I’ve been trying, but it’s not working.” If the patient does not wish to discuss his or her weight, the PCP should continue to evaluate and treat other risk factors for cardiovascular disease . The conversation about weight management can be re-initiated at a later time.

  28. BMI (Kg/ m2)= weight in kilograms divided by the square of height in meters - Underweight <18.5 - Normal weight 18.5-24.9 - Overweight 25-29.9 - Obese I 30-34.9 - Obese II 35-39.9 - Obese III >40 Body Mass Index Adult Categories

  29. Metabolic Syndrome = any 3 of following 5 risk factors Risk Factor Abdominal Obesity Fasting Glucose Triglycerides Reduced HDL Cholesterol Blood Pressure Defining Level Waist Circumference ≥40 in (102 cm) in men ≥35 in (88 cm) in women ≥100 mg/dLor Rx for DM 150 mg/dLorRx. for  TG <40 mg/dL in men <50 mg/dL in women or Rx. for low HDL 130 or 85 mm Hg or Rx. for HTN ______________________________________________________ Circulation,Oct.18,2005

  30. Metabolic Syndrome: Impact on Mortality Without metabolic syndrome With metabolic syndrome * * Mortality Rate (%) *P < 0.001. Isomaa B et al. Diabetes Care. 2001;24:683-689.

  31. Idiopathic intracranial hypertension Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Stroke Cataracts Nonalcoholic fatty liver disease NASH Cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Gall bladder disease Pancreatitis Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Osteoarthritis Skin Gout Medical Complications of Obesity www.obesityonline.com GERD Phlebitis venous stasis

  32. Advise: • Give clear, specific, and personalized behavior change advice regarding diet and physical activity, including information about personal health harms and benefits. • “In order to loose weight you should eat about 1600 calories/day” • “Weight loss will improve your diabetes and will reduce stress on your joints, making it easier for you to do the activities that you enjoy."

  33. Daily Calorie Intake Recommendations for Weight Loss Adapted from the American Gastroenterology Association Technical Review on Obesity, Gastroenterology 123(3):882-932, 2002, and from CLINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF OVERWEIGHT AND OBESITY IN ADULTS,NIH PUBLICATION NO. 98-4083 SEPTEMBER 1998 NATIONAL INSTITUTES OF HEALTH

  34. Advise – cont. No adult who has been studied in a metabolic chamber has needed fewer than 1000 kcal/day for weight maintenance. Thus, even subjects who claim to be "metabolically resistant" to weight loss should lose weight if they comply with a diet of 800 to 1200 kcal/day. If subjects claim to eat less than 1200 kcal/day and yet do not lose weight one can conclude they are recording intake erroneously and suggest that they reduce by half what they claim to eat. Advise your patients to keep a daily food diary!! –one of the simplest and most effective tool to help people with their weight loss

  35. Physical Activity: • Has health benefits independent of weight loss • It is the intervention most likely to promote long-term maintenance of weight loss • Start slowly and increase gradually • Can be single session or intermittent • Start with walking 30 minutes 3 days/week • Goal: 60-90 min of low/mod activity every day • Encourage increased “lifestyle” activities • Aids: Pedometer – goal 10,000 steps/day

  36. 3. Agree: • Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior • Weight loss goals! • Short-term goal: 1 to 2 lb per week, • 5 to 10 % body weight loss in 6 months • Interim goal: Maintenance. • Long-term goal: Additional weight loss, and long-term weight maintenance. • “

  37. Most often, obese patients have unrealistic weight loss goals: Foster et al. J Consult Clin Psychol 1997;65:79.

  38. Benefits of weight loss (5-10% of body weight) Mortality 20–25% fall in total mortality 30–40% fall in DM related deaths 40–50% fall in ob. related cancers deaths Blood pressure Fall of 10 mm Hg systolic pressure Fall of 20 mm Hg diastolic pressure Diabetes 30–50% fall in fasting glucose Lipids 10% decrease in total cholesterol 15% decrease in LDL 30% decrease in triglycerides 8% increase in HDL Jung R. Obesity as a disease. Br Med Bull 1997;53:307-21.

  39. 4. Assist: Using behavior change techniques, aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

  40. OBESITY Components of Behavioral Therapy for Obesity SelfMonitoring ProblemSolving CognitiveRestructuring ContingencyManagement SocialSupport StimulusControl StressManagement Wadden and Foster. Med Clin North Am 2000:84:441.

  41. Self-Monitoring • Keep records of: • Amount and types of foods eaten • Frequency, intensity, and type of physical activity • Time, place, and feelings

  42. Self Monitoring: Food Diary

  43. Stress Management • Defuse situations that lead to overeating • Coping strategies • Meditation • Relaxation techniques

  44. Stimulus Control • Behavior change techniques: • Learn to shop for healthy foods. • Keep high-calorie foods out of the home. • Limit the times and places of eating.

  45. Cognitive Restructuring • Rational thoughts designed to replace negative thoughts: Instead of. . . • “I blew my diet this morning by eating that doughnut.” Use. . . • “Well, I ate the doughnut, but I can still eat in a healthy manner the rest of the day.”

  46. Social Support • Maintain motivation and positive reinforcement: • Family • Friends • Colleagues

  47. Cardinal Behaviors of Successful Long-term Weight Management - National Weight Control Registry Data • Self-monitoring: • Diet: record food intake daily, limit certain foods or food quantity • Weight: check body weight >1 x/wk • Low-calorie, low-fat diet: • Total energy intake: 1300-1400 kcal/d • Energy intake from fat: 20%-25% • Eat breakfast daily • Regular physical activity: 2500-3000 kcal/wk (eg, walk 4 miles/d) Klem et al. Am J Clin Nutr 1997;66:239. McGuire et al.Int J Obes Relat Metab Disord 1998;22:572.

  48. Responding to Nonadherence • Do not take patient’s behavior personally • Assume lack of planning, not motivation, is the problem • Do not criticize patient ( safeguard their self-esteem) • Identify obstacles • Determine how obstacles can be handled in the future • Acknowledge the difficulty of behavior change and provide encouragement • Develop a new plan and shorten interval required for success

  49. Supplemented with adjunctive medical treatments when appropriate. • Obesity Drugs: • Orlistat • Sympathomimetic drugs (Phentermine)

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