Integrating the Obese Patient into the Primary Care Setting

Speaker notes included in notes section below

More than 60% of US Adults Are Overweight

0

10

20

30

40

50

60

70

1960-1962 1971-1974 1976-1980 1988-1994/91 1999-2000

NHANES I, II, III & 1999-2000

Pre

va

len

ce

(%

)

Flegal, K et al. JAMA, 2002.

Obesity (BMI ≥ 30)

Overweight (BMI 25 - 29.9)

Obesity Is Caused by Long-Term Positive Energy Balance

Fatstores

Energyintake

Energyexpenditure

Heritability of Body Weight

16 oz 32 oz 44 oz 52 oz 64 oz

1 oz ≈ 12 calories

Coronary Heart Disease

Morbiditymortality

Morbiditymortality

Morbiditymortality

Hypertension Diabetes Dyslipidemia

40% are obese 80% are obese 50% – 70% are obese

OBESITY

Obesity and Coronary Heart Disease (CHD)

Abdominal Obesity Visceral Subcutaneous

Abdominal Adiposity

Courtesy of Steven Smith, M.D.

Visceral Obesity and Risk of Dyslipidemia

Obese: level of deep abdominal fat

Variable% Body Fat

Deep Abdominal Fat Area (cm2)

TG (mmol/L)

CHOL (mmol/L)

LDL CHOL (mmol/L)

HDL CHOL (mmol/L)

Fasting insulin (pmol/L)

Glucose area ([mmol/L/180 min]x10-3)

Insulin area ([pmol/L/180 min]x10-3

Nonobese (n=25))28.0 ± 5.6

50.3 ± 16.8

0.79 ± 0.35

4.59 ± 0.88

3.00 ± 0.87

1.36 ± 0.24

39.0 ± 12.4

10.7 ± 0.19

46.6 ± 19.4

Low (n=10)47.0 ± 6.4

107.0 ± 33.4

1.47 ± 0.79

5.18 ± 0.93

3.56 ± 0.92

1.25 ± 0.18

91.5 ± 59.9

1.14 ± 0.22

82.1 ± 48.3

High (n=10)49.8 ± 3.2

186.7 ± 36.8

2.57 ± 2.41

5.65 ± 1.23

3.81 ± 1.10

0.96 ± 0.12

150.3 ± 57.3

1.40 ± 0.19

121.0 ± 39.5

Despres JP, et al. Arteriosclerosis. 1990;10:497-511.

Characteristics of the Metabolic Syndrome

• Abdominal obesity• Glucose intolerance• High triglycerides• Low HDL-cholesterol• High blood pressure• Insulin resistance

• Microalbuminuria• Small dense LDL• Inflammatory markers• Thrombotic factors• Endothelial

dysfunction• Hyperuricemia

Full members Wannabes

Pulmonary diseaseabnormal functionobstructive sleep apneahypoventilation syndrome

Nonalcoholic fatty liver diseasesteatosissteatohepatitiscirrhosis

Coronary heart disease Diabetes Dyslipidemia Hypertension

Gynecologic abnormalitiesabnormal mensesinfertilitypolycystic ovarian syndrome

Osteoarthritis

Skin

Gall bladder disease

Cancerbreast, uterus, cervixcolon, esophagus, pancreaskidney, prostate

Phlebitisvenous stasis

Gout

Medical Complications of ObesityIdiopathic intracranial hypertension

Stroke

Cataracts

Severe pancreatitisSevere pancreatitis

Relationship Between BMI and Risk of Type 2 Diabetes Mellitus

Chan J et al. Diabetes Care 1994;17:961.Colditz G et al. Ann Intern Med 1995;122:481.

Age

-Adj

uste

d R

elat

ive

Ris

k

Body Mass Index (kg/m2)

< 23 24 - 24.9

25 - 26.9

27 -28.9

33 -34.9

0

25

50

75

100

1.02.9 4.3 5.0

8.1 15.8

27.6

40.3

54.0

93.2

< 22 23 - 23.9

29 -30.9

31 -32.9

35 +

1.0 1.52.2

4.46.7

11.6

21.3

42.1

1.0

Men

Women

Diabetes Prevention Program Research Group. N Engl J Med. 2002;346,393-403.

Diabetes Prevention Program

40

30

20

10

00 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Placebo

Metformin

Lifestyle

Cum

ulat

ive

Inci

denc

eof

Dia

bete

s (%

)

Year

Prevalence

Caucasian/African-American (N = 1057) 17%

Caucasian/Hispanic(N = 560) 18%

Hispanic (N = 31) 45%

African-American(N = 97) 47%

Prevalence of Type 2 Diabetes Among Diabetic Children in 4 Studies

Fagot-Campagna et al. J Pediatr 2000;136:664.

How Are We Doing as a Medical Profession?

Obesity is under-diagnosed and under-treated

Percent of Patients Receiving PCP Advice by Obesity Classification

Simkin-Silverman LR et al. Prev Med 2005;40:71-82.

The Office Visit

1. Measure weight, height, waist circumference and record body mass index (BMI)

2. Categorize obesity classification and risk

3. Take a comprehensive history, physical exam, & lab tests for medical condition

4. Assess need for treatment

5. Broach the subject

6. Assess readiness for treatment

The Practical Guide, 2000.

The Evaluation Process Consists of 6 Action Steps

Broaching the Subject: Words to Use

• “Are you concerned about your weight?”

• “What is hard about managing your weight?”

• “How does being overweight affect you?”

• “What can’t you do now that you would like to do if you weighed less?”

• “What kind of help do you need to manage your weight?”

Obesity Treatment Pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI 40

35

30

25

One “Diet” Does Not Fit All

Comparison of Popular Diets

Dansinger, et al. JAMA 2005;293:43-53.

Mean Changes in Wt and Cardiac Risk at 12 Months

-3.3

-2.2

-10.8

-2.1-2.5

-3.0

-3.2 -2.9

-10.1

-3.0 -3.3

-8.2

-12

-10

-8

-6

-4

-2

0

Weight, kgWaist circumference,

cmTotal cholesterol,

mg/dl

Mea

n C

han

ge

Atkins Zone Weight Watchers Ornish

Meal Replacements Promote Long and Short term Weight Loss

*1200–1500 kcal/d diet prescriptionA: conventional foodsB: meal and snack replacement for 1 meal, 1 snack

Fletchner-Mors et al. Obes Res 2000;8:399.

Examples of High vs Moderate Intensity Physical Activities

LOW/MODERATE (< 6 METs)• Walking

– (< 4 mph-15min/mile)

• Playing with children• Golfing (walking)• Doubles tennis• Mowing the lawn• Gardening • Walking the dog• Playing catch• General housework• Weight Training

HIGH (> 6 METs)• Walking

– (> 5 mph-12min/mile)

• Singles tennis• Vigorous downhill skiing• Soccer• Jumping rope• Jogging/Running• Bicycling (16-18mph)• Touch football• Shoveling snow by hand• Circuit training• Moving furniture

Long vs Short Bouts

• Multiple short bouts are as effective as one long bout and perhaps may facilitate efforts to increase activity

• Helps address the barrier of perceived lack of time

• Multiple short bouts increase adoption of physical activity during first 6 months

• Long-term impact is less clear

Jakicic JM et al. JAMA 1999;282(16):1554-60.Jacobsen DJ et al. Int J Sports Med 2003;24:459-64.

Establish an Approach to the Obese Patient

• The patient who has a disease but is not the disease

• Medical and psychological benefits to the patient

• Personal challenge and economic opportunity for the patient

• Professional challenge and economic opportunity for the physician

Assessing Readiness

• Why now?• What changes will you have to make?• What will change if you lose weight?• What do others think about your weight?• What else is going on in your life?

Assessing Readiness

• We are not good at predicting outcomes.• Patients ultimately make the decision.• Providers assess costs/benefits in a variety of

contexts.

5 Steps to Behavior Change1. Have patient identify specific goals

– Activity (ie, one specific goal for exercise)

– Intake (ie, one specific goal for diet)

2. Identify when, where, and how behaviors will be performed

3. Have patient keep record of behavior change (i.e., diet and activity diaries)

4. Follow-up progress at next treatment visit

5. Congratulate patient on successes; do not criticize shortcomings

Wadden & Foster. Medical Clinics of North America, 2000.

Obesity is a Medical Disease to be Treated by Professionals

Using Medical Tools• Shared Decision Making Model

• Match the tools with the task, the treatment with the patient– Medical– Psychological– Diet– Cognitive-Behavioral– Physical Activity– Surgical

The Office EnvironmentExample of Waiting Room

The Office Environment

• Large adult thigh and blood pressure cuffs, large tape measure

• Large exam tables and gowns

• Scales that weigh up to 500 lbs or more

• Exam tables– Sturdy, wide and bolted to the

floor to prevent tipping

Equipment

Staff

• “The cornerstone of effective obesity treatment is grounded in skillful and empathetic physician-patient communication”- The Therapeutic Bond

• Empathetic, compassionate, supportive, trustworthy, nonjudgmental, caring

• Optimistic – hope is an important medicine

• Healthy role models, helpful, kind

Referrals

• Nutritionist

• Behavior therapist

• Psychiatrist

• Bariatric surgeon

Conclusions

• Obese patients can be easily integrated into any primary care setting

• With the increase in obesity as well as co-morbid conditions, obese patients need access to quality care

• Small differences in approach and attitude related to weight and weight loss can have a huge impact