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Addressing the Elephant in the Room ?. Obesity. I am only one…. I am only one; but still I am one. I am only one; but still I am one. I cannot do everything.

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Presentation on theme: "Addressing the Elephant in the Room ?. Obesity. I am only one…. I am only one; but still I am one. I am only one; but still I am one. I cannot do everything."— Presentation transcript:

1 Addressing the Elephant in the Room ?. Obesity

2 I am only one…. I am only one; but still I am one. I am only one; but still I am one. I cannot do everything but still I can do something… I cannot do everything but still I can do something… And because I cannot do everything, And because I cannot do everything, I must not refuse to do something I can do I must not refuse to do something I can do

3 NHANES study Data from 4,111 children and young adults ages 2-19 Data from 4,111 children and young adults ages 2-19 Looked at total and specific IgE levels to inhalant allergies and foods Looked at total and specific IgE levels to inhalant allergies and foods Obesity defined as being in the 95 percentile for BMI for the child’s age Obesity defined as being in the 95 percentile for BMI for the child’s age D. Zeldin MD. J of Allergy and Clinical Immunology, May 2012 D. Zeldin MD. J of Allergy and Clinical Immunology, May 2012

4 Childhood obesity and allergy Obese children and adolescents are at increased risk for some type of allergy especially to food Obese children and adolescents are at increased risk for some type of allergy especially to food IgE levels were higher in overweight and obese children IgE levels were higher in overweight and obese children Obese children were 26% more likely to have allergies than those of normal weight, Obese children were 26% more likely to have allergies than those of normal weight, Most increase in foods, obese 56% more likely to have food allergy Most increase in foods, obese 56% more likely to have food allergy

5 Arkansas Stats 30.6% Arkansans obese 30.6% Arkansans obese 36% Arkansans overweight 36% Arkansans overweight 16% youth (9-12 grades) overweight 16% youth (9-12 grades) overweight 14% obese 14% obese 13% eat < 5 fruits/vegetables per day 13% eat < 5 fruits/vegetables per day 40% drink at least one non diet drink/day 40% drink at least one non diet drink/day 33% watch at least 3 hours of TV daily 33% watch at least 3 hours of TV daily

6 Basic Metabolic Index BMI Underweight <18.5 Underweight <18.5 Normal <24.9 Normal <24.9 Overweight > Overweight > Obese >30 Obese >30 Extremely obese >40 Extremely obese >40

7 A Modern day epidemic Current generation of children may have shorter life span than their parents Current generation of children may have shorter life span than their parents 1/3 of children in the US are expected to have diabetes 1/3 of children in the US are expected to have diabetes 1/4 Americans age are unfit for military service…..obesity 1/4 Americans age are unfit for military service…..obesity White House Task Force on Childhood Obesity, Report to the President 2010 White House Task Force on Childhood Obesity, Report to the President 2010

8 Co-morbidities Cardiovascular Cardiovascular Respiratory Respiratory Metabolic syndrome Metabolic syndrome Musculoskeletal Musculoskeletal Mental health Mental health Endocrine Endocrine Sleep disorders Sleep disorders Chronic pain Chronic pain Medications used to treat these disorders Medications used to treat these disorders Heart attack Stroke Diabetes Hypothyroidism Rheumatoid arthritis Depression Sleep apnea Chronic fatigue Social outcast Cancer

9 How did we get here? Years of overeating and under exercising Years of overeating and under exercising Advertising to children and adults Advertising to children and adults The Bigger Better Burger The Bigger Better Burger Larger cola drinks Larger cola drinks Sugary cereals Sugary cereals Good news! Kids are watching less television Good news! Kids are watching less television Bad news!!! Gaming, Texting, Facebooking, Twittering, Linkedin, Bad news!!! Gaming, Texting, Facebooking, Twittering, Linkedin,

10 Road to illness Patient comes in for physical exam in their mid to late 30s or early 40s, asymptomatic at this point Patient comes in for physical exam in their mid to late 30s or early 40s, asymptomatic at this point Family history positive for diabetes, heart disease, high cholesterol Family history positive for diabetes, heart disease, high cholesterol 20 pk/yr hx of smoking, FEV1 80%, lung age pk/yr hx of smoking, FEV1 80%, lung age 52 FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile and UA normal FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile and UA normal 132/84 132/84 Overweight… BMI 27 Overweight… BMI 27 Recommendation: Advised to stop smoking and lose weight. Physical scheduled for 1 year Recommendation: Advised to stop smoking and lose weight. Physical scheduled for 1 year

11 Road to illness Skips a year or two or three, next physical exam Still asymptomatic Still smoking, lung age 65, smoking cessation discussed Still smoking, lung age 65, smoking cessation discussed Weight has increased. BMI 29 Weight has increased. BMI 29 Blood pressure now 144/92 Blood pressure now 144/92 Blood sugar is normal Blood sugar is normal Total cholesterol now 230, TRI 180, LDL 130 Total cholesterol now 230, TRI 180, LDL 130 Plan: Started on medication for mild hypertension “Advised to lose weight” “watch your blood pressure,”. “Advised to lose weight” “watch your blood pressure,”. “Lets check you in 6 months” “Lets check you in 6 months”

12 Road to illness 6 months later, 6 months later, “I have a swollen, hot, red big toe” “I have a swollen, hot, red big toe” Dx: Gout Dx: Gout Indomethacin given, acute phase over, given Allopurinol for maintenance. Indomethacin given, acute phase over, given Allopurinol for maintenance. Now on 2 medications Now on 2 medications

13 Road to illness 6 months later in for his annual physical 6 months later in for his annual physical Fatigue, some insomnia, weight gain continues, not feeling up to par, increase stress in life Fatigue, some insomnia, weight gain continues, not feeling up to par, increase stress in life BP now 160/100, Total cholesterol 250, LDL 160, fasting blood sugar 118 BP now 160/100, Total cholesterol 250, LDL 160, fasting blood sugar 118 Add second blood pressure medication, start cholesterol lowering medication Add second blood pressure medication, start cholesterol lowering medication “You need to lose weight, increase your exercise” “You need to lose weight, increase your exercise” Recheck schedule you for a recheck in 6 months Recheck schedule you for a recheck in 6 months

14 6 months later Increase in urination, “hungry all the time,” urination 3-4 times a night, Increase in urination, “hungry all the time,” urination 3-4 times a night, Increased snoring, frequent awakenings, sometimes short of breath Increased snoring, frequent awakenings, sometimes short of breath Spouse calls and says “don’t dare tell him I called, he will kill me, if he knew…but he is really depressed, can you give him a medication for that? Spouse calls and says “don’t dare tell him I called, he will kill me, if he knew…but he is really depressed, can you give him a medication for that? Now what has happened? Now what has happened?

15 Road to illness Hypertension is being treated with 2 medications Hypertension is being treated with 2 medications Gout is controlled with Allopurinol Gout is controlled with Allopurinol Hypercholesterolemia is treated with a statin Hypercholesterolemia is treated with a statin He is now obese with a BMI of 33 He is now obese with a BMI of 33 Type 2 diabetes Type 2 diabetes Sleep apnea, using C-pap Sleep apnea, using C-pap On medication for depression On medication for depression Insomnia is controlled with Zolpidem hs Insomnia is controlled with Zolpidem hs Stress he is seeing a counselor for his depression and stress. Stress he is seeing a counselor for his depression and stress.

16 Remember the first visit Patient comes in for physical exam in their mid to late 30s or early 40s Patient comes in for physical exam in their mid to late 30s or early 40s Family history of diabetes, heart disease, elevated cholesterol Family history of diabetes, heart disease, elevated cholesterol 20 pk/yr hx of smoking, FEV1 80%, lung age pk/yr hx of smoking, FEV1 80%, lung age 60 FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile and UA normal FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile and UA normal 132/84 132/84 Overweight… BMI 27 Overweight… BMI 27 Rec: Smoking cessation discussed, advised to lose weight. Physical scheduled for 1 year Rec: Smoking cessation discussed, advised to lose weight. Physical scheduled for 1 year

17 Road to illness What a difference I might have made in his or her life IF ONLY I had addressed the life style changes needed aggressively at that visit or at least a year later….. What a difference I might have made in his or her life IF ONLY I had addressed the life style changes needed aggressively at that visit or at least a year later….. I might have kept him from obesity and its associated illnesses. I might have kept him from obesity and its associated illnesses.

18 “Chief complaints” “I am here for… “I am here for… “blood pressure” “blood pressure” “my diabetes check up” “my diabetes check up” “my annual physical” “my annual physical” “my chronic fatigue “my chronic fatigue “my depression” “my depression” “my headache” “my headache” “you will have to ask my wife, she made this appointment, nothing is wrong with me. “you will have to ask my wife, she made this appointment, nothing is wrong with me. Rarely. very rarely do I hear “I am here because I am overweight and I am ready to do something about it. Rarely. very rarely do I hear “I am here because I am overweight and I am ready to do something about it.

19 Physicians addressing obesity Three studies over 13 years published looking at how and when physicians address obesity Three studies over 13 years published looking at how and when physicians address obesity

20 Are health care professionals advising obese patients to lose weight (12,385 obese adults) JAMA 1999 Oct27;282 (16) JAMA 1999 Oct27;282 (16) Only 42% of obese patients reported that their health care professional advised them to lose weight (after NIH 1998 Guideline recommendation) Only 42% of obese patients reported that their health care professional advised them to lose weight (after NIH 1998 Guideline recommendation) Rec: Barriers to obesity counseling need to be identified and addressed Rec: Barriers to obesity counseling need to be identified and addressed

21 Are health care professionals advising obese patients to lose weight (61,968) MedGenMed,2005 Oct12;7(4):10 MedGenMed,2005 Oct12;7(4):10 Only 40.3% of obese patients reported being advised to lose weight. Only 40.3% of obese patients reported being advised to lose weight. Conclusion: Barriers to obesity counseling need to be identified and addressed Conclusion: Barriers to obesity counseling need to be identified and addressed

22 U.S. primary care physician’s diet, physical activity, and weight related care of adult patients American J Pre Medicine 2011 Jul;41:33-42 American J Pre Medicine 2011 Jul;41:33-42 Fewer than 50% reported providing specific guidance on diet, physical activity or weight control Fewer than 50% reported providing specific guidance on diet, physical activity or weight control Conclusion:Further research is needed to understand barriers to providing care and to improve physician engagement. Conclusion:Further research is needed to understand barriers to providing care and to improve physician engagement.

23 Barriers reported by physicians Lack of time during an office visit Lack of time during an office visit Lack of confidence in addressing obesity Lack of confidence in addressing obesity Issues with patient non-compliance Issues with patient non-compliance Lack of trained personnel Lack of trained personnel Inadequate handouts and teaching materials Inadequate handouts and teaching materials Lack of knowledge for treating obesity Lack of knowledge for treating obesity

24 Barriers reported by physicians Availability of affordable weight loss programs Availability of affordable weight loss programs Intimate saboteurs, (grandparents, friends) Intimate saboteurs, (grandparents, friends) Lack of Insurance coverage Lack of Insurance coverage Lack of reimbursement for time and effort spent. Lack of reimbursement for time and effort spent. Lack of counseling training of physician and staff Lack of counseling training of physician and staff

25 Attitudes of physicians Overweight physicians are less likely to make the diagnoses of obesity Overweight physicians are less likely to make the diagnoses of obesity Overweight physicians are Overweight physicians are less likely to discuss weight less likely to discuss weight reduction or refer for diet reduction or refer for diet instruction instruction

26 Barriers reported by patients “My doctor did not mention my weight, I didn’t think it was important.” (39%) “My doctor did not mention my weight, I didn’t think it was important.” (39%) “Every time I see my doctor I get more medicine but have never been told to change my diet or exercise.” “Every time I see my doctor I get more medicine but have never been told to change my diet or exercise.” “I was told to lose weight but wasn’t told how to do it.” “I was told to lose weight but wasn’t told how to do it.”

27 Barriers reported by patients Their weight or obesity not acknowledged or discussed y the provider Their weight or obesity not acknowledged or discussed y the provider No affordable diet/exercise plan given No affordable diet/exercise plan given Little or no education about obesity given Little or no education about obesity given “No time to cook or exercise” “No time to cook or exercise” “I am too tired to exercise” “I am too tired to exercise” “My arthritis, aches, pains keep me from exercising” “My arthritis, aches, pains keep me from exercising”

28 Survey results Only 39 % of obese adults were ever told by a doctor or or other health care provider that they were obese Only 39 % of obese adults were ever told by a doctor or or other health care provider that they were obese 90% of those told to lose weight, only 1 in 3 were given any guidance in how to do this 90% of those told to lose weight, only 1 in 3 were given any guidance in how to do this

29 USPS Task Force Screen using BMI (waist size in some) Screen using BMI (waist size in some) Intensive, multi-component with behavioral interventions for obese adults and children Intensive, multi-component with behavioral interventions for obese adults and children Improving knowledge of diet. diet or nutrition Addressing barriers to change Increasing physical activity Increasing physical activity Strategizing how to maintain lifestyle changes Strategizing how to maintain lifestyle changes

30 From Mayo Clinic…. “you need to work with a team of health professionals including a nutritionist, dietician, therapist or an obesity specialist.” “you need to work with a team of health professionals including a nutritionist, dietician, therapist or an obesity specialist.” What planet are these folks living on???? What planet are these folks living on???? …..how many of our patients have access to these kinds of program. …..how many of our patients have access to these kinds of program.

31 Obesity How many of you have a multiple behavioral intervention in your office? How many of you have a multiple behavioral intervention in your office? How many have a person in your office dedicated to the treatment of obesity? How many have a person in your office dedicated to the treatment of obesity? How many of you feel you personally address obesity adequately with your patients? How many of you feel you personally address obesity adequately with your patients?

32 Where are the programs that are ? Accessible? Accessible? Affordable? Affordable? Multiple trained personnel? Multiple trained personnel? Teaching materials? Teaching materials? Financial aid avialable? Financial aid avialable? Paid for by insurance? Paid for by insurance?

33 Yellow pages Weight control under physicians Weight control under physicians All refer to bariatric surgery All refer to bariatric surgery Weight control (general) Weight control (general) Hypnosis clinic Hypnosis clinic Advanced Products Advanced Products Body Solution System Body Solution System Jenny Craig Jenny Craig Life Style Weight Control Center Life Style Weight Control Center Overeaters anonymous Overeaters anonymous War on Weight War on Weight

34 What I cannot and can do I cannot treat and educate a patient with complex problems….hypertension, diabetes, pulmonary disease, AND BEING OVERWEIGHT in a minute office visit I cannot treat and educate a patient with complex problems….hypertension, diabetes, pulmonary disease, AND BEING OVERWEIGHT in a minute office visit I can acknowledge the weight problem I can acknowledge the weight problem I can provide information or guidance for direction I can provide information or guidance for direction I can schedule a separate office visit to discuss their overweight issues or direct them to a weight loss program I can schedule a separate office visit to discuss their overweight issues or direct them to a weight loss program

35 Acknowledging the problem Obesity is the last disorder addressed in a patients visit, (if at all), maybe it should be moved up Obesity is the last disorder addressed in a patients visit, (if at all), maybe it should be moved up Stressing its importance earlier in the visit may make it more important to the patient Stressing its importance earlier in the visit may make it more important to the patient If not brought, up patients assume being overweight or obese is not important. If not brought, up patients assume being overweight or obese is not important.

36 Addressing obesity Advise him/her of the life style changes needed to lose weight through printed materials, direction to internet information or local programs Advise him/her of the life style changes needed to lose weight through printed materials, direction to internet information or local programs Assist towards a program that fits their affordability and access Assist towards a program that fits their affordability and access Arrange follow up by office visits, telephone or internet Arrange follow up by office visits, telephone or internet

37 The 5 A’s of behavioral counseling Assess risk, current behavior, and willingness to change Assess risk, current behavior, and willingness to change Advise change of specific behaviors Advise change of specific behaviors Agree to, and set goals Agree to, and set goals Assist in addressing barriers and securing support Assist in addressing barriers and securing support Arrange follow up Arrange follow up

38 Addressing obesity Acknowledge the problem with weight, show concern, listen to his/her feelings about their weight Acknowledge the problem with weight, show concern, listen to his/her feelings about their weight Ask how their weight is affecting his/her life physically mentally and socially Ask how their weight is affecting his/her life physically mentally and socially Advise him/her of the relationship between their weight and present medical problem(s)and potential future problems Advise him/her of the relationship between their weight and present medical problem(s)and potential future problems Assess their interest in losing weight, discuss the benefits of sustained, long term weight loss Assess their interest in losing weight, discuss the benefits of sustained, long term weight loss

39 Assist Providing or directing him/her to information about dieting, identifying high caloric foods Providing or directing him/her to information about dieting, identifying high caloric foods Provide information about local programs Provide information about local programs Develop your own program in your office Develop your own program in your office Suggest internet programs and “aps” Suggest internet programs and “aps”

40 Weight loss “drugs” OTC Over 400 otc Over 400 otc From Abrexin to Zymelt From Abrexin to Zymelt Top 3 Top 3 Apidexim, Phenpfedrin, 7DFBX Apidexim, Phenpfedrin, 7DFBX “Lifetime guarantee, all over 97% effective, all 60-90$ MRSP but can be bought on line for $24 or less” (If it is too good to be…… “Lifetime guarantee, all over 97% effective, all 60-90$ MRSP but can be bought on line for $24 or less” (If it is too good to be……

41 Weight loss drugs by Rx Currently FDA approved drugs are for short term use with diet and exercise Currently FDA approved drugs are for short term use with diet and exercise Appetite suppressants Appetite suppressants Phentermine Phentermine Phentermine + Topamax (Qsymia) Phentermine + Topamax (Qsymia) Fat absorption inhibitor Fat absorption inhibitor Xenical approved for longer use, safety not established beyond 2 years Xenical approved for longer use, safety not established beyond 2 years

42 Human chorionic gonadatropin Although approved by the FDA, off label use for diet. Lots of illegal knock-offs. Although approved by the FDA, off label use for diet. Lots of illegal knock-offs. Dec 2011 “products are illegal, claims are false and misleading, hormone not regulated Dec 2011 “products are illegal, claims are false and misleading, hormone not regulated Made from urine of pregnant women Made from urine of pregnant women Obtained through compounding pharmacies Obtained through compounding pharmacies Significant side effects have been reported. Significant side effects have been reported.

43 “The best investment you will ever make” You will feel better You will feel better You will look better You will look better You will have more energy You will have more energy You will decrease the chance of developing the ravages of being overweight You will decrease the chance of developing the ravages of being overweight You will enjoy a better quality of life You will enjoy a better quality of life Save money by reducing money spent on overeating Save money by reducing money spent on overeating

44 Engaging patients How to tell a patient they are fat without using the words fat or obese…. How to tell a patient they are fat without using the words fat or obese…. “I am very concerned about your weight. Are you concerned?” “I am very concerned about your weight. Are you concerned?” Acknowledges the fact Acknowledges the fact Shows compassion Shows compassion Opens the door for discussion and sets in motion your plan for further action Opens the door for discussion and sets in motion your plan for further action

45 Educating patients French Fries 500 cal 63 carbs French Fries 500 cal 63 carbs Coca Cola (12 oz) 110 Coca Cola (12 oz) 110 Coca Cola (Large) 310 Coca Cola (Large) 310 Big Breakfast 740 Big Breakfast 740 Big Breakfast with hotcakes 1040 Big Breakfast with hotcakes 1040 Walnut/apple salad 210 cal Walnut/apple salad 210 cal

46 Educating patients Walnut/apple salad 210 calories + dressing Walnut/apple salad 210 calories + dressing Big Mac 540 calories 10 carbs Big Mac 540 calories 10 carbs French Fries 500 calories French Fries 500 calories Coca Cola Large 310 cal Coca Cola Large 310 cal Total 1350 calories Total 1350 calories Vs Vs

47 Restaurants are not the only problem

48 USPS Task Force Screening obesity in children Screen children over 6 years of age with BMI index Screen children over 6 years of age with BMI index Overweight = age- and gender-specific BMI at ≥85th to 94th percentile Overweight = age- and gender-specific BMI at ≥85th to 94th percentile Obesity = age- and gender-specific BMI at ≥95th percentile Obesity = age- and gender-specific BMI at ≥95th percentile

49 ACH Obesity Clinic First visit is a 4 hour visit First visit is a 4 hour visit Major initial thrust is to identify each and every “soda” or “pop” or other liquid that contains sugar and avoid as best as possible, including Gatorade and sport drinks. Major initial thrust is to identify each and every “soda” or “pop” or other liquid that contains sugar and avoid as best as possible, including Gatorade and sport drinks. Must keep it simple Must keep it simple

50 More common cause of childhood obesity Family dynamics, overweight parents Family dynamics, overweight parents Use of food to appease children Use of food to appease children Use of food for sleep Use of food for sleep Bullying Bullying Stresses of school, peers Stresses of school, peers Depression and other psychosocial issues Depression and other psychosocial issues

51 Pediatric Online sites for help Nutrition.gov Weight Management for Youth Nutrition.gov Weight Management for Youth Fuel Up and Play Fuel Up and Play Healthy Youth, Healthy Topics:Childhood Overweight Healthy Youth, Healthy Topics:Childhood Overweight Helping Kids Fight Obesity/Best Online Source Helping Kids Fight Obesity/Best Online Source My Plate for Children My Plate for Children Helping Your Overweight Child Helping Your Overweight Child

52 Obesity Management Non-surgical Non-surgical Life style changes Life style changes Life style changes with medication Life style changes with medication Surgical Surgical Bariatric surgery Bariatric surgery Lifestyle changes Lifestyle changes Goals Goals 10% weight loss reduces cardiovascular disease risk 10% weight loss reduces cardiovascular disease risk Weight loss medications alone are ineffective Weight loss medications alone are ineffective

53 Listing barriers to weight loss needing change Write barriers down, keep adding to the list as they appear Write barriers down, keep adding to the list as they appear Eating out frequently Eating out frequently Snacking during the day or after dinner Snacking during the day or after dinner Bedtime snack Bedtime snack Special occasions, I.e. anniversaries, birthdays Special occasions, I.e. anniversaries, birthdays Skipping meals Skipping meals Alcohol with meals Alcohol with meals

54 Ask “what did you eat/drink yesterday?” Breakfast Breakfast Mid morning snack Mid morning snack Lunch Lunch Afternoon snack Afternoon snack Before dinner snack Before dinner snack Dinner Dinner After dinner After dinner

55 24 hour recall (excuses,excuses) Looking for patterns of behavior Fruits and vegetables Fruits and vegetables Restaurants eating out frequently Restaurants eating out frequently Skipped meals, especially breakfast Skipped meals, especially breakfast Snacks Snacks Sugar containing pops Sugar containing pops Exercise Exercise

56 In office program Make up your own diet/recommendations Keep it simple Weigh and chart your weight weekly or daily Weigh and chart your weight weekly or daily Avoid eating out (one meal can erase several days of dieting) Avoid eating out (one meal can erase several days of dieting) Omit all “sodas/pop” including diet drinks, fruit juices Omit all “sodas/pop” including diet drinks, fruit juices Severely reduce bread (use whole grain), crackers, pasta, potatoes, rice, corn, sugar containing deserts, beets, carrots, peas and beans/limit fruit,…if not losing….cut back more on these foods Severely reduce bread (use whole grain), crackers, pasta, potatoes, rice, corn, sugar containing deserts, beets, carrots, peas and beans/limit fruit,…if not losing….cut back more on these foods No nuts, no cheese, no alcohol No nuts, no cheese, no alcohol Exercise 30 minutes daily, as close to 7 days a week as you can Exercise 30 minutes daily, as close to 7 days a week as you can

57 Foods for your weight loss diet Limit your alcohol intake (2 drinks for men, 1 for women) Limit your alcohol intake (2 drinks for men, 1 for women) You may eat most any fish/seafood, lean cuts of beef, pork, poultry, or veal…. broiled, baked, boiled, no frying You may eat most any fish/seafood, lean cuts of beef, pork, poultry, or veal…. broiled, baked, boiled, no frying Vegetables include asparagus, bell peppers, broccoli, cauliflower, cabbage, celery, collards, cucumbers, pickles, onions, kale, mushrooms, okra, radish, rhubarb, spinach, turnips, squash Vegetables include asparagus, bell peppers, broccoli, cauliflower, cabbage, celery, collards, cucumbers, pickles, onions, kale, mushrooms, okra, radish, rhubarb, spinach, turnips, squash Water, coffee, tea for liquids, canola, olive, grapeseed oil for cooking Water, coffee, tea for liquids, canola, olive, grapeseed oil for cooking Seasonings: apple cider vinegar, any herbs, garlic, ginger, lemon, mustard, soy sauce, spices, white vinegar Seasonings: apple cider vinegar, any herbs, garlic, ginger, lemon, mustard, soy sauce, spices, white vinegar

58 Tips for patients Keep a diet diary listing all that is consumed daily, food and liquids Keep a diet diary listing all that is consumed daily, food and liquids Learn and record calorie count Learn and record calorie count Make a list of foods to omit, habits to be broken, substitutes to be used Make a list of foods to omit, habits to be broken, substitutes to be used Aim to exercise 7 days a week (we eat 7 days a week….Daaa! Aim to exercise 7 days a week (we eat 7 days a week….Daaa! Avoid eating out, if you do have to eat out, stay as close to your diet as you can Avoid eating out, if you do have to eat out, stay as close to your diet as you can

59 Speaking of exercise… We EAT 7 days a week, therefore We EAT 7 days a week, therefore We should exercise 7 days a week! We should exercise 7 days a week! “But I don’t have time…..” “But I don’t have time…..” Make time! Make time!

60 Exercise Aerobic exercise (minimum of 30 minutes a day….may be broken up Aerobic exercise (minimum of 30 minutes a day….may be broken up Using pedometers….use all day Using pedometers….use all day 10,000 steps program 10,000 steps program Riding in a golf cart does not count Riding in a golf cart does not count Sit ups and push ups and pull ups Sit ups and push ups and pull ups Can you do this for 30 min?? Can you do this for 30 min??

61 Portion control Discarding half the serving (save it for another meal) Discarding half the serving (save it for another meal) Use smaller, partitioned plate Use smaller, partitioned plate Split plate with friend or family member Split plate with friend or family member

62 M.O.R.E. More fruits and vegetables More fruits and vegetables Organize snacks Organize snacks Single servings (bought or made up) Single servings (bought or made up) Ramp up the fiber Ramp up the fiber Fruits, vegetables, beans, grains Fruits, vegetables, beans, grains Exercise more Exercise more 7 days per week 7 days per week

63 Potholes Eating out Eating out Not drinking required amount of water Not drinking required amount of water Skipping meals (breakfast the most common) Skipping meals (breakfast the most common) Skipping exercise sessions Skipping exercise sessions Giving in to peer or family pressure on special occasions. Giving in to peer or family pressure on special occasions. Eating more than allowed, losing portion control Eating more than allowed, losing portion control Snacking Snacking Alcohol Alcohol Weekend activities Weekend activities

64 Goal setting Process between patient and physician or coach Process between patient and physician or coach Goal needs to be realistic for weight loss and time, 10 % of your weight for starters. Goal needs to be realistic for weight loss and time, 10 % of your weight for starters. Goals can be changed Goals can be changed Setting lifetime behavioral changes, Setting lifetime behavioral changes, The only way to keep the weight you lost OFF! The only way to keep the weight you lost OFF!

65 APS Lose It Lose It Restaurant Nutrition Restaurant Nutrition My Net Diary My Net Diary Fitness Pal Fitness Pal Daily Burn Daily Burn Fat Secret Fat Secret Meal Snap Meal Snap Tracknburn Tracknburn

66 Important information Patients have to be reminded that once they reach maintenance Patients have to be reminded that once they reach maintenance They have succeeded because they abandoned old habits They have succeeded because they abandoned old habits They have changed meal planning eliminating high caloric, dense foods They have changed meal planning eliminating high caloric, dense foods They are exercising regularly and have to continue to exercise They are exercising regularly and have to continue to exercise They must continue the maintenance phase by not veering far from the changed behaviors They must continue the maintenance phase by not veering far from the changed behaviors

67 Rx weight loss drugs All except Xenical are controlled substances with addictive potential All except Xenical are controlled substances with addictive potential All are recommended for short term use All are recommended for short term use Wt loss tends to level off at 6 months Wt loss tends to level off at 6 months All have side effects All have side effects

68 Side effects of Rx loss drugs Appetite suppressants Appetite suppressants Rapid heart rate Rapid heart rate High blood pressure High blood pressure Sweating Sweating Constipation Constipation Insomnia Insomnia Thirst Thirst Anxiety Anxiety Headache Headache Dry mouth Dry mouth Xenical Increase flatulence Oily stool Leakage (incontinence) Abdominal cramping Frequent BMs Fecal urgency Inability to control bowel movements Fat soluble vitamin deficiency Hepatotoxicity

69 Assess willingness/interest Some overweight patients want help, need a push, and will be interested Some overweight patients want help, need a push, and will be interested Some will want to “go it alone” Some will want to “go it alone” Some are not the least bit interested at this time….don’t give up, address it each time they are in the office. Some are not the least bit interested at this time….don’t give up, address it each time they are in the office.

70 Coding for obesity counseling GO minute face to face counseling for obesity (BMI 30 or greater) GO minute face to face counseling for obesity (BMI 30 or greater) One face/face weekly for 1 month One face/face weekly for 1 month One face/face meeting every 2 weeks for months 2-6 One face/face meeting every 2 weeks for months 2-6 One face/face meeting every month for months 7-12 One face/face meeting every month for months 7-12 Patient must lose 6.6 pounds first 6 months Patient must lose 6.6 pounds first 6 months Diagnosis codes use to support medical necessity Diagnosis codes use to support medical necessity V85.30 to V85.39 and V85.41 to V85.45 V85.30 to V85.39 and V85.41 to V85.45 Medical Economics, June 25, 2012 Medical Economics, June 25, 2012

71 Current diets Weight Watchers Weight Watchers Atkins Atkins South Beach South Beach Ornish Diet Ornish Diet Fat Burners Fat Burners Physicians Wt Loss Physicians Wt Loss Ideal Protein Diet Ideal Protein Diet Jenny Craig Jenny Craig Diet Center Diet Center Raw Food Volumetrics Diet Slim Fast Diet Vegan Diet Dash Diet TLC Diet Biggest Loser Diet Ideal Protein

72

73 Maintenance is not the goal Changing and keeping new life style habits is the goal Changing and keeping new life style habits is the goal Patients must continue the maintenance phase by not veering far from their diet and exercise program. Patients must continue the maintenance phase by not veering far from their diet and exercise program.

74 What I have learned Multiple, affordable, accessible and applicable weight loss programs need to be developed to be used in and outside the the medical community Multiple, affordable, accessible and applicable weight loss programs need to be developed to be used in and outside the the medical community Physicians offices, institutions, communities..maybe even families need a full time staff member (or family member) on site and responsible for implementing and carrying out the program Physicians offices, institutions, communities..maybe even families need a full time staff member (or family member) on site and responsible for implementing and carrying out the program We must become proactive in addressing the marketing and delivery of high caloric foods that are fueling the problem We must become proactive in addressing the marketing and delivery of high caloric foods that are fueling the problem We must increase physical activity at all age level We must increase physical activity at all age level

75 Program director Someone who has had a weight loss problem and has lost and maintained their weight loss Someone who has had a weight loss problem and has lost and maintained their weight loss Nurse, nutritionist, dietician, physician assistant, coach …. Anyone with a burning desire to help patients lead a healthier life style and lose weight. Nurse, nutritionist, dietician, physician assistant, coach …. Anyone with a burning desire to help patients lead a healthier life style and lose weight.

76 Physicians alone cannot solve this problem Patients and families Patients and families Parents, grandparents Parents, grandparents The indulging divorced parent The indulging divorced parent Industry/employers Industry/employers Teachers Teachers Schools Schools Religious communities Religious communities Local, regional, state wide communities Local, regional, state wide communities

77 In the meantime…. “Practice style” changes “Practice style” changes Make it your habit to address each overweight patient Make it your habit to address each overweight patient Send them out with a diet or with information Send them out with a diet or with information Become better role models for our patients by losing weight and exercising Become better role models for our patients by losing weight and exercising Join patients in weight loss and exercise programs Join patients in weight loss and exercise programs Encourage your staff to do the same Encourage your staff to do the same

78 I am only one…. I am only one; but still I am one. I am only one; but still I am one. I cannot do everything but still I can do something… I cannot do everything but still I can do something… And because I cannot do everything, And because I cannot do everything, I must not refuse to do something I can do I must not refuse to do something I can do

79 Thank you!

80


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