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

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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)
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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)
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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)
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Assess degree of overweight
(AFP, 2001)
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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)
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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)
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Obesity and overweight assessment
(American Family Physician, 2001)
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(AMA, 2003)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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

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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)
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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)
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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)
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4) Pharmacotherapy and surgery
(AMA, 2003)
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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)
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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)
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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)
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Classes of pharmacotherapy

• Sympathomimetic medications approved for
  long-term use
• Gastrointestinal (GI) lipase inhibitors
• Sympathomimetic medications approved for
  short-term use

(AMA, 2003)
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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)
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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)
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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)
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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

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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)
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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)
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BMI-for-age
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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)
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Assessment of overweight children and adolescents
(Barlow and Dietz, 1998)
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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)
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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)
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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.

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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

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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

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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

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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

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Acknowledgements

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