Obesity Diagnosis and Action Plan Implementation

1
Obesity Diagnosis and Action Plan Implementation

• September 17, 2008
• Dr. David Andrew Nicholas Rometo

2
Outline

• 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

3
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

4
Co-morbidities

• 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.

5
Causes

• Imbalance in calorie consumption and physical
  activity
• 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.

6
Treatments

• Goal
• 5-15 weight loss, ½ to 2 lbs per week.
• easier management of comorbidities
• Improved quality of life, decrease morbidity,
  mortality
• Decreased costs of care
• Physical Activity
• Recommended 30-60 min/day, 5-7 days/week.
• 40 of US adults get no leisure time physical
  activity
• 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)

7
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

8
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,
  motivated
• 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
  meeting.

9
Recommendations

• 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
  intervention.

10
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
  22.
• Most likely diagnosed were BMI 35, OSA, DM.
  Less likely were elderly and men.

11
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.

12
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
  exercise
• 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
  surgery
• MD feels any intervention is futile
• MD blames patient for their obesity, does not
  feel it is a doctors job to address the issue

13
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

14
Barriers to Care the System

• Lack of High Intensity program offered by UNC
  dietician
• 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

15
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

16
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
  patients
• For now, obesity will be the first issue
  addressed on the new sheet

17
Current Nutrition Database
18
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.

19
Pilot day 9/3/08
20
Study
21
(No Transcript)
22
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

23
Issues

• 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
  nutritionist?
• Reasons obesity not addressed today Too many
  other issues, Difficulty complying with many
  other meds, etc already

24
Interpretation

• 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
  visits
• Obese patients with risk factors do not have
  appropriate DM screening
• USPSTF only recs screening for adults with BP
  135/80
• ADA adults 45yo q3yr, and overweight w/ RF at
  any age q1-3yr

25
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
  meetings
• 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

26
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?...

27
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
  patients
• Create High-intensity Lifestyle Intervention that
  meets USPSTF guidelines provided by Enhance Care
  Nutrition

28
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

29
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

30
Resources

• 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
  139(11)930-932.
• The Surgeon Generals call to action to prevent
  and decrease overweight and obesity.
  http//www.surgeongeneral.gov/topics/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
  359229-41.
• 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.