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Addressing the Addressing the Elephant in the Elephant in the
RoomRoom?.?.
ObesityObesity
I am only one….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 I cannot do everything but still I can do
something… 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
NHANES studyNHANES study
Data from 4,111 children and young adults Data from 4,111 children and young adults ages 2-19ages 2-19
Looked at total and specific IgE levels to Looked at total and specific IgE levels to inhalant allergies and foodsinhalant allergies and foods
Obesity defined as being in the 95 Obesity defined as being in the 95 percentile for BMI for the child’s agepercentile for BMI for the child’s age
D. Zeldin MD. J of Allergy and Clinical Immunology, May D. Zeldin MD. J of Allergy and Clinical Immunology, May 20122012
Childhood obesity and allergyChildhood obesity and allergy
Obese children and adolescents are at Obese children and adolescents are at increased risk for some type of allergy increased risk for some type of allergy especially to foodespecially to food
IgE levels were higher in overweight and IgE levels were higher in overweight and obese childrenobese children
Obese children were 26% more likely to Obese children were 26% more likely to have allergies than those of normal weight, have allergies than those of normal weight,
Most increase in foods, obese 56% more Most increase in foods, obese 56% more likely to have food allergylikely to have food allergy
Arkansas StatsArkansas Stats
30.6% Arkansans obese30.6% Arkansans obese 36% Arkansans overweight36% Arkansans overweight 16% youth (9-12 grades) overweight16% youth (9-12 grades) overweight 14% obese14% obese 13% eat < 5 fruits/vegetables per day13% eat < 5 fruits/vegetables per day 40% drink at least one non diet drink/day40% drink at least one non diet drink/day 33% watch at least 3 hours of TV daily33% watch at least 3 hours of TV daily
Basic Metabolic IndexBasic Metabolic IndexBMIBMI
Underweight <18.5Underweight <18.5 Normal Normal <24.9 <24.9
OverweightOverweight >25 -29.9 >25 -29.9
ObeseObese >30 >30Extremely obese >40Extremely obese >40
A Modern day epidemicA Modern day epidemic
Current generation of children may have shorter Current generation of children may have shorter life span than their parentslife span than their parents
1/3 of children in the US are expected to have 1/3 of children in the US are expected to have diabetesdiabetes
1/4 Americans age 17-24 are unfit for military 1/4 Americans age 17-24 are unfit for military service…..obesityservice…..obesity
White House Task Force on Childhood Obesity, Report to the President 2010White House Task Force on Childhood Obesity, Report to the President 2010
Co-morbiditiesCo-morbidities
CardiovascularCardiovascular RespiratoryRespiratory Metabolic syndromeMetabolic syndrome MusculoskeletalMusculoskeletal Mental healthMental health Endocrine Endocrine Sleep disorders Sleep disorders Chronic pain Chronic pain Medications used to treat Medications used to treat
these disordersthese disorders
Heart attackHeart attack StrokeStroke DiabetesDiabetes HypothyroidismHypothyroidism Rheumatoid arthritisRheumatoid arthritis DepressionDepression Sleep apneaSleep apnea Chronic fatigueChronic fatigue Social outcastSocial outcast
CancerCancer
How did we get here?How did we get here?
Years of overeating and under exercisingYears of overeating and under exercising Advertising to children and adultsAdvertising to children and adults
The Bigger Better BurgerThe Bigger Better Burger Larger cola drinksLarger cola drinks Sugary cerealsSugary cereals
Good news! Kids are watching less televisionGood news! Kids are watching less television Bad news!!! Gaming, Texting, Facebooking, Bad news!!! Gaming, Texting, Facebooking,
Twittering, Linkedin, Twittering, Linkedin,
Road to illnessRoad to illness
Patient comes in for physical exam in their mid to late 30s or early Patient comes in for physical exam in their mid to late 30s or early 40s, asymptomatic at this point40s, asymptomatic at this point
Family history positive for diabetes, heart disease, high cholesterolFamily history positive for diabetes, heart disease, high cholesterol 20 pk/yr hx of smoking, FEV1 80%, lung age 5220 pk/yr hx of smoking, FEV1 80%, lung age 52 FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile
and UA normaland UA normal 132/84132/84 Overweight… BMI 27Overweight… BMI 27 Recommendation: Advised to stop smoking and lose weight. Recommendation: Advised to stop smoking and lose weight.
Physical scheduled for 1 yearPhysical scheduled for 1 year
Road to illnessRoad to illness
Skips a year or two or three, next physical examSkips a year or two or three, next physical exam
Still asymptomaticStill asymptomatic
Still smoking, lung age 65, smoking cessation discussedStill smoking, lung age 65, smoking cessation discussed
Weight has increased. BMI 29Weight has increased. BMI 29
Blood pressure now 144/92Blood pressure now 144/92
Blood sugar is normalBlood sugar is normal
Total cholesterol now 230, TRI 180, LDL 130Total cholesterol now 230, TRI 180, LDL 130
Plan: Started on medication for mild hypertensionPlan: 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”
Road to illnessRoad 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, Indomethacin given, acute phase over,
given Allopurinol for maintenance.given Allopurinol for maintenance. Now on 2 medicationsNow on 2 medications
Road to illnessRoad to illness
6 months later in for his annual physical6 months later in for his annual physical Fatigue, some insomnia, weight gain continues, not Fatigue, some insomnia, weight gain continues, not
feeling up to par, increase stress in lifefeeling up to par, increase stress in life BP now 160/100, Total cholesterol 250, LDL 160, fasting BP now 160/100, Total cholesterol 250, LDL 160, fasting
blood sugar 118blood sugar 118 Add second blood pressure medication, start cholesterol Add second blood pressure medication, start cholesterol
lowering medicationlowering 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 monthsRecheck schedule you for a recheck in 6 months
6 months later6 months later Increase in urination, “hungry all the time,” urination 3-4 Increase in urination, “hungry all the time,” urination 3-4
times a night, times a night, Increased snoring, frequent awakenings, sometimes Increased snoring, frequent awakenings, sometimes
short of breathshort of breath Spouse calls and says “don’t dare tell him I called, he will 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 kill me, if he knew…but he is really depressed, can you give him a medication for that?give him a medication for that?
Now what has happened?Now what has happened?
Road to illnessRoad to illness Hypertension is being treated with 2 medicationsHypertension is being treated with 2 medications Gout is controlled with AllopurinolGout is controlled with Allopurinol Hypercholesterolemia is treated with a statinHypercholesterolemia is treated with a statin He is now obese with a BMI of 33He is now obese with a BMI of 33 Type 2 diabetesType 2 diabetes Sleep apnea, using C-papSleep apnea, using C-pap On medication for depressionOn medication for depression Insomnia is controlled with Zolpidem hsInsomnia is controlled with Zolpidem hs Stress he is seeing a counselor for his depression and Stress he is seeing a counselor for his depression and
stress. stress.
Remember the first visitRemember the first visit Patient comes in for physical exam in their mid to late 30s or early 40sPatient comes in for physical exam in their mid to late 30s or early 40s Family history of diabetes, heart disease, elevated cholesterolFamily history of diabetes, heart disease, elevated cholesterol 20 pk/yr hx of smoking, FEV1 80%, lung age 6020 pk/yr hx of smoking, FEV1 80%, lung age 60 FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile and UA FBS, lipids (Tcl 206, Tri 144, HDL 38, LDL 116), metabolic profile and UA
normalnormal 132/84132/84 Overweight… BMI 27Overweight… BMI 27 Rec: Smoking cessation discussed, advised to lose weight. Physical Rec: Smoking cessation discussed, advised to lose weight. Physical
scheduled for 1 yearscheduled for 1 year
Road to illnessRoad to illness
What a difference I might have made in his What a difference I might have made in his or her life IF ONLY I had addressed the or her life IF ONLY I had addressed the life style changes needed aggressively at life style changes needed aggressively at that visit or at least a year later…..that visit or at least a year later…..
I might have kept him from obesity and its I might have kept him from obesity and its associated illnesses. associated illnesses.
““Chief complaints”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 fatiguemy chronic fatigue ““my depression”my depression” ““my headache”my headache” ““you will have to ask my wife, she made this appointment, you will have to ask my wife, she made this appointment,
nothing is wrong with me. nothing is wrong with me. Rarely. very rarely do I hear “I am here because I Rarely. very rarely do I hear “I am here because I
am overweight and I am ready to do something am overweight and I am ready to do something about it.about it.
Physicians addressing Physicians addressing obesityobesity
Three studies over 13 years published Three studies over 13 years published looking at how and when physicians looking at how and when physicians address obesityaddress obesity
Are health care professionals advising Are health care professionals advising obese patients to lose weight (12,385 obese patients to lose weight (12,385
obese adults)obese adults) JAMA 1999 Oct27;282 (16) 1576-8JAMA 1999 Oct27;282 (16) 1576-8 Only 42% of obese patients reported that Only 42% of obese patients reported that
their health care professional advised their health care professional advised them to lose weight (after NIH 1998 them to lose weight (after NIH 1998 Guideline recommendation)Guideline recommendation)
Rec: Barriers to obesity counseling need Rec: Barriers to obesity counseling need to be identified and addressedto be identified and addressed
Are health care professionals advising Are health care professionals advising obese patients to lose weight (61,968)obese patients to lose weight (61,968)
MedGenMed,2005 Oct12;7(4):10MedGenMed,2005 Oct12;7(4):10 Only 40.3% of obese patients reported Only 40.3% of obese patients reported
being advised to lose weight. being advised to lose weight. Conclusion: Barriers to obesity counseling Conclusion: Barriers to obesity counseling
need to be identified and addressedneed to be identified and addressed
U.S. primary care physician’s diet, U.S. primary care physician’s diet, physical activity, and weight related care physical activity, and weight related care
of adult patientsof adult patients
American J Pre Medicine 2011 Jul;41:33-42American J Pre Medicine 2011 Jul;41:33-42 Fewer than 50% reported providing specific Fewer than 50% reported providing specific
guidance on diet, physical activity or weight guidance on diet, physical activity or weight controlcontrol
Conclusion:Further research is needed to Conclusion:Further research is needed to understand barriers to providing care and to understand barriers to providing care and to improve physician engagement. improve physician engagement.
Barriers reported by Barriers reported by physiciansphysicians
Lack of time during an office visitLack 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 materialsInadequate handouts and teaching materials Lack of knowledge for treating obesityLack of knowledge for treating obesity
Barriers reported by Barriers reported by physiciansphysicians
Availability of affordable weight loss programsAvailability of affordable weight loss programs Intimate saboteurs, (grandparents, friends) Intimate saboteurs, (grandparents, friends) Lack of Insurance coverageLack 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 staffLack of counseling training of physician and staff
Attitudes of physiciansAttitudes of physicians
Overweight physicians are less likely to make Overweight physicians are less likely to make the diagnoses of obesitythe 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 instructioninstruction
Barriers reported by patientsBarriers reported by patients
““My doctor did not mention my weight, I My doctor did not mention my weight, I didn’t think it was important.” (39%)didn’t think it was important.” (39%)
““Every time I see my doctor I get more Every time I see my doctor I get more medicine but have never been told to medicine but have never been told to change my diet or exercise.”change my diet or exercise.”
““I was told to lose weight but wasn’t told I was told to lose weight but wasn’t told how to do it.”how to do it.”
Barriers reported by patientsBarriers reported by patients
Their weight or obesity not acknowledged or Their weight or obesity not acknowledged or discussed y the providerdiscussed y the provider
No affordable diet/exercise plan givenNo affordable diet/exercise plan given Little or no education about obesity givenLittle 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 My arthritis, aches, pains keep me from
exercising”exercising”
Survey resultsSurvey results
Only 39 % of obese adults were ever told Only 39 % of obese adults were ever told by a doctor or or other health care by a doctor or or other health care provider that they were obeseprovider that they were obese
90% of those told to lose weight, only 1 in 90% of those told to lose weight, only 1 in 3 were given any guidance in how to do 3 were given any guidance in how to do thisthis
USPS Task ForceUSPS Task Force
Screen using BMI (waist size in some)Screen using BMI (waist size in some) Intensive, multi-component with behavioral Intensive, multi-component with behavioral
interventions for obese adults and childreninterventions for obese adults and childrenImproving knowledge of diet. Improving knowledge of diet.
diet or nutrition Addressing barriers to changediet or nutrition Addressing barriers to change Increasing physical activityIncreasing physical activity Strategizing how to maintain lifestyle changesStrategizing how to maintain lifestyle changes
From Mayo Clinic….From Mayo Clinic….
““you need to work with a team of health you need to work with a team of health professionals including a nutritionist, dietician, professionals including a nutritionist, dietician, therapist or an obesity specialist.”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 ..how many of our patients have access to these kinds of program. these kinds of program.
ObesityObesity
How many of you have a multiple How many of you have a multiple behavioral intervention in your office?behavioral intervention in your office?
How many have a person in your office How many have a person in your office dedicated to the treatment of obesity?dedicated to the treatment of obesity?
How many of you feel you personally How many of you feel you personally address obesity adequately with your address obesity adequately with your patients?patients?
Where are the programs that Where are the programs that are ?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?
Yellow pages Yellow pages Weight control under physiciansWeight control under physicians
All refer to bariatric surgeryAll refer to bariatric surgery Weight control (general)Weight control (general)
Hypnosis clinicHypnosis clinic Advanced ProductsAdvanced Products Body Solution SystemBody Solution System Jenny CraigJenny Craig Life Style Weight Control CenterLife Style Weight Control Center Overeaters anonymousOvereaters anonymous War on WeightWar on Weight
What I cannot and can doWhat I cannot and can do I cannot treat and educate a patient with complex I cannot treat and educate a patient with complex
problems….hypertension, diabetes, pulmonary disease, problems….hypertension, diabetes, pulmonary disease, AND BEING OVERWEIGHT in a 10-15 minute office AND BEING OVERWEIGHT in a 10-15 minute office visitvisit
I can acknowledge the weight problemI can acknowledge the weight problem I can provide information or guidance for directionI can provide information or guidance for direction I can schedule a separate office visit to discuss their I can schedule a separate office visit to discuss their
overweight issues or direct them to a weight loss overweight issues or direct them to a weight loss programprogram
Acknowledging the problemAcknowledging the problem
Obesity is the last disorder addressed in a Obesity is the last disorder addressed in a patients visit, (if at all), maybe it should be patients visit, (if at all), maybe it should be moved up moved up
Stressing its importance earlier in the visit Stressing its importance earlier in the visit may make it more important to the patientmay make it more important to the patient
If not brought, up patients assume being If not brought, up patients assume being overweight or obese is not important. overweight or obese is not important.
Addressing obesityAddressing obesity
Advise him/her of the life style changes needed Advise him/her of the life style changes needed to lose weight through printed materials, to lose weight through printed materials, direction to internet information or local direction to internet information or local programsprograms
Assist towards a program that fits their Assist towards a program that fits their affordability and accessaffordability and access
Arrange follow up by office visits, telephone or Arrange follow up by office visits, telephone or internetinternet
The 5 A’s of behavioral The 5 A’s of behavioral counselingcounseling
Assess risk, current behavior, and Assess risk, current behavior, and willingness to changewillingness to change
Advise change of specific behaviorsAdvise change of specific behaviors Agree to, and set goalsAgree to, and set goals Assist in addressing barriers and securing Assist in addressing barriers and securing
supportsupport Arrange follow upArrange follow up
Addressing obesityAddressing obesity Acknowledge the problem with weight, show concern, Acknowledge the problem with weight, show concern,
listen to his/her feelings about their weightlisten to his/her feelings about their weight Ask how their weight is affecting his/her life physically Ask how their weight is affecting his/her life physically
mentally and sociallymentally and socially Advise him/her of the relationship between their weight Advise him/her of the relationship between their weight
and present medical problem(s)and potential future and present medical problem(s)and potential future problemsproblems
Assess their interest in losing weight, discuss the Assess their interest in losing weight, discuss the benefits of sustained, long term weight lossbenefits of sustained, long term weight loss
AssistAssist
Providing or directing him/her to information Providing or directing him/her to information about dieting, identifying high caloric foodsabout dieting, identifying high caloric foods
Provide information about local programsProvide information about local programs Develop your own program in your officeDevelop your own program in your office Suggest internet programs and “aps” Suggest internet programs and “aps”
Weight loss “drugs” OTCWeight loss “drugs” OTC
Over 400 otcOver 400 otc From Abrexin to ZymeltFrom Abrexin to Zymelt Top 3Top 3
Apidexim, Phenpfedrin, 7DFBXApidexim, Phenpfedrin, 7DFBX ““Lifetime guarantee, all over 97% effective, Lifetime guarantee, all over 97% effective,
all 60-90$ MRSP but can be bought on all 60-90$ MRSP but can be bought on line for $24 or less” (If it is too good to line for $24 or less” (If it is too good to be……be……
Weight loss drugs by RxWeight loss drugs by Rx
Currently FDA approved drugs are for short term Currently FDA approved drugs are for short term use use with diet and exercisewith diet and exercise
Appetite suppressantsAppetite suppressants PhenterminePhentermine Phentermine + Topamax (Qsymia)Phentermine + Topamax (Qsymia)
Fat absorption inhibitorFat absorption inhibitor Xenical approved for longer use, safety not Xenical approved for longer use, safety not
established beyond 2 yearsestablished beyond 2 years
Human chorionic Human chorionic gonadatropingonadatropin
Although approved by the FDA, off label Although approved by the FDA, off label use for diet. Lots of illegal knock-offs. use for diet. Lots of illegal knock-offs. Dec 2011 “products are illegal, claims are Dec 2011 “products are illegal, claims are
false and misleading, hormone not regulatedfalse and misleading, hormone not regulated Made from urine of pregnant womenMade from urine of pregnant women Obtained through compounding Obtained through compounding
pharmaciespharmacies Significant side effects have been Significant side effects have been
reported. reported.
““The best investment you will The best investment you will ever make”ever make”
You will feel betterYou will feel better You will look betterYou will look better You will have more energyYou will have more energy You will decrease the chance of developing the You will decrease the chance of developing the
ravages of being overweightravages of being overweight You will enjoy a better quality of lifeYou will enjoy a better quality of life Save money by reducing money spent on Save money by reducing money spent on
overeatingovereating
Engaging patientsEngaging patients
How to tell a patient they are fat without using the words How to tell a patient they are fat without using the words fat or obese….fat or obese….
““I am very concerned about your weight. Are you I am very concerned about your weight. Are you concerned?”concerned?” Acknowledges the factAcknowledges the fact Shows compassionShows compassion Opens the door for discussion and sets in motion your plan for Opens the door for discussion and sets in motion your plan for
further actionfurther action
Educating patientsEducating patients
French Fries 500 cal 63 carbsFrench Fries 500 cal 63 carbs Coca Cola (12 oz) 110Coca Cola (12 oz) 110 Coca Cola (Large) 310Coca Cola (Large) 310 Big Breakfast 740Big Breakfast 740 Big Breakfast with hotcakes 1040Big Breakfast with hotcakes 1040 Walnut/apple salad 210 calWalnut/apple salad 210 cal
Educating patientsEducating patients
Walnut/apple salad 210 calories + Walnut/apple salad 210 calories + dressingdressing
Big Mac 540 calories 10 carbsBig Mac 540 calories 10 carbs French Fries 500 calories French Fries 500 calories Coca Cola Large 310 calCoca Cola Large 310 cal
Total 1350 caloriesTotal 1350 calories VsVs
Restaurants are not the only Restaurants are not the only problemproblem
USPS Task Force USPS Task Force Screening obesity in childrenScreening obesity in children
Screen children over 6 years of age with Screen children over 6 years of age with BMI indexBMI index
Overweight = age- and gender-specific Overweight = age- and gender-specific BMI at ≥85th to 94th percentileBMI at ≥85th to 94th percentile
Obesity = age- and gender-specific BMI at Obesity = age- and gender-specific BMI at ≥95th percentile≥95th percentile
ACH Obesity ClinicACH Obesity Clinic
First visit is a 4 hour visitFirst visit is a 4 hour visit Major initial thrust is to identify each and Major initial thrust is to identify each and
every “soda” or “pop” or other liquid that every “soda” or “pop” or other liquid that contains sugar and avoid as best as contains sugar and avoid as best as possible, including Gatorade and sport possible, including Gatorade and sport drinks. drinks.
Must keep it simpleMust keep it simple
More common cause of More common cause of childhood obesitychildhood obesity
Family dynamics, overweight parentsFamily dynamics, overweight parents Use of food to appease childrenUse of food to appease children Use of food for sleepUse of food for sleep
BullyingBullying Stresses of school, peersStresses of school, peers Depression and other psychosocial issuesDepression and other psychosocial issues
Pediatric Online sites for helpPediatric Online sites for help
Nutrition.gov Weight Management for YouthNutrition.gov Weight Management for Youth Fuel Up and PlayFuel Up and Play Healthy Youth, Healthy Topics:Childhood Healthy Youth, Healthy Topics:Childhood
OverweightOverweight Helping Kids Fight Obesity/Best Online SourceHelping Kids Fight Obesity/Best Online Source My Plate for ChildrenMy Plate for Children Helping Your Overweight ChildHelping Your Overweight Child
Obesity ManagementObesity Management Non-surgicalNon-surgical
Life style changes Life style changes
Life style changes with medicationLife style changes with medication
SurgicalSurgical Bariatric surgeryBariatric surgery
Lifestyle changesLifestyle changes
GoalsGoals
10% weight loss reduces cardiovascular disease risk10% weight loss reduces cardiovascular disease risk Weight loss medications alone are ineffectiveWeight loss medications alone are ineffective
Listing barriers to weight loss Listing barriers to weight loss needing changeneeding change
Write barriers down, keep adding to the list as Write barriers down, keep adding to the list as they appearthey appear Eating out frequentlyEating out frequently Snacking during the day or after dinnerSnacking during the day or after dinner Bedtime snackBedtime snack Special occasions, I.e. anniversaries, birthdaysSpecial occasions, I.e. anniversaries, birthdays Skipping mealsSkipping meals Alcohol with mealsAlcohol with meals
Ask “what did you eat/drink Ask “what did you eat/drink yesterday?”yesterday?”
BreakfastBreakfast Mid morning snackMid morning snack LunchLunch Afternoon snackAfternoon snack Before dinner snackBefore dinner snack DinnerDinner After dinnerAfter dinner
24 hour recall 24 hour recall (excuses,excuses)(excuses,excuses)
Looking for patterns of behaviorLooking for patterns of behavior Fruits and vegetablesFruits and vegetables Restaurants eating out frequentlyRestaurants eating out frequently Skipped meals, especially breakfastSkipped meals, especially breakfast SnacksSnacks Sugar containing popsSugar containing pops ExerciseExercise
In office programIn office programMake up your own diet/recommendationsMake up your own diet/recommendations
Keep it simpleKeep it simple
Weigh and chart your weight weekly or dailyWeigh and chart your weight weekly or daily Avoid eating out (one meal can erase several days of Avoid eating out (one meal can erase several days of
dieting)dieting) Omit all “sodas/pop” including diet drinks, fruit juicesOmit all “sodas/pop” including diet drinks, fruit juices Severely reduceSeverely reduce bread (use whole grain), crackers, bread (use whole grain), crackers,
pasta, potatoes, rice, corn, sugar containing deserts, pasta, potatoes, rice, corn, sugar containing deserts, beets, carrots, peas and beans/limit fruit,…if not beets, carrots, peas and beans/limit fruit,…if not losing….cut back more on these foodslosing….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 Exercise 30 minutes daily, as close to 7 days a week as
you canyou can
Foods for your weight loss dietFoods 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, You may eat most any fish/seafood, lean cuts of beef, pork, poultry,
or veal…. broiled, baked, boiled, no frying or veal…. broiled, baked, boiled, no frying Vegetables include asparagus, bell peppers, broccoli, cauliflower, Vegetables include asparagus, bell peppers, broccoli, cauliflower,
cabbage, celery, collards, cucumbers, pickles, onions, kale, cabbage, celery, collards, cucumbers, pickles, onions, kale, mushrooms, okra, radish, rhubarb, spinach, turnips, squashmushrooms, okra, radish, rhubarb, spinach, turnips, squash
Water, coffee, tea for liquids, canola, olive, grapeseed oil for Water, coffee, tea for liquids, canola, olive, grapeseed oil for cookingcooking
Seasonings: apple cider vinegar, any herbs, garlic, ginger, lemon, Seasonings: apple cider vinegar, any herbs, garlic, ginger, lemon, mustard, soy sauce, spices, white vinegar mustard, soy sauce, spices, white vinegar
Tips for patientsTips for patients
Keep a diet diary listing all that is consumed Keep a diet diary listing all that is consumed daily, food and liquidsdaily, food and liquids Learn and record calorie count Learn and record calorie count
Make a list of foods to omit, habits to be broken, Make a list of foods to omit, habits to be broken, substitutes to be usedsubstitutes to be used
Aim to exercise 7 days a week (we eat 7 days a Aim to exercise 7 days a week (we eat 7 days a week….Daaa! week….Daaa!
Avoid eating out, if you do have to eat out, stay Avoid eating out, if you do have to eat out, stay as close to your diet as you can as close to your diet as you can
Speaking of exercise…Speaking of exercise…
We EAT 7 days a week, thereforeWe 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!
ExerciseExercise
Aerobic exercise (minimum of 30 minutes a Aerobic exercise (minimum of 30 minutes a day….may be broken upday….may be broken up
Using pedometers….use all dayUsing pedometers….use all day 10,000 steps program10,000 steps program
Riding in a golf cart does not countRiding in a golf cart does not count Sit ups and push ups and pull upsSit ups and push ups and pull ups
Can you do this for 30 min??Can you do this for 30 min??
Portion controlPortion control
Discarding half the serving (save it for Discarding half the serving (save it for another meal)another meal)
Use smaller, partitioned plateUse smaller, partitioned plate Split plate with friend or family memberSplit plate with friend or family member
M.O.R.E.M.O.R.E.
MMore fruits and vegetablesore fruits and vegetables OOrganize snacksrganize snacks
Single servings (bought or made up)Single servings (bought or made up) RRamp up the fiberamp up the fiber
Fruits, vegetables, beans, grainsFruits, vegetables, beans, grains EExercise morexercise more
7 days per week7 days per week
PotholesPotholes
Eating outEating out Not drinking required amount of waterNot drinking required amount of water Skipping meals (breakfast the most common)Skipping meals (breakfast the most common) Skipping exercise sessionsSkipping exercise sessions Giving in to peer or family pressure on special Giving in to peer or family pressure on special
occasions.occasions. Eating more than allowed, losing portion controlEating more than allowed, losing portion control SnackingSnacking AlcoholAlcohol Weekend activitiesWeekend activities
Goal settingGoal setting
Process between patient and physician or coachProcess between patient and physician or coach Goal needs to be realistic for weight loss and Goal needs to be realistic for weight loss and
time, 10 % of your weight for starters. time, 10 % of your weight for starters. Goals can be changedGoals 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!
APS APS
Lose ItLose It Restaurant NutritionRestaurant Nutrition My Net DiaryMy Net Diary Fitness PalFitness Pal Daily BurnDaily Burn Fat SecretFat Secret Meal SnapMeal Snap TracknburnTracknburn
Important informationImportant information
Patients have to be reminded that once they Patients have to be reminded that once they reach maintenancereach maintenance They have succeeded because they abandoned old They have succeeded because they abandoned old
habitshabits They have changed meal planning eliminating high They have changed meal planning eliminating high
caloric, dense foodscaloric, dense foods They are exercising regularly and have to continue to They are exercising regularly and have to continue to
exerciseexercise They must continue the maintenance phase by They must continue the maintenance phase by
not veering far from the changed behaviorsnot veering far from the changed behaviors
Rx weight loss drugsRx weight loss drugs
All except Xenical are controlled All except Xenical are controlled substances with addictive potentialsubstances with addictive potential
All are recommended for short term useAll 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
Side effects of Rx loss drugsSide effects of Rx loss drugs Appetite suppressantsAppetite suppressants
Rapid heart rateRapid heart rate High blood pressureHigh blood pressure SweatingSweating ConstipationConstipation InsomniaInsomnia ThirstThirst AnxietyAnxiety HeadacheHeadache Dry mouthDry mouth
XenicalXenical Increase flatulenceIncrease flatulence Oily stoolOily stool Leakage (incontinence)Leakage (incontinence) Abdominal crampingAbdominal cramping Frequent BMsFrequent BMs Fecal urgencyFecal urgency Inability to control bowel Inability to control bowel
movementsmovements Fat soluble vitamin Fat soluble vitamin
deficiencydeficiency HepatotoxicityHepatotoxicity
Assess willingness/interestAssess willingness/interest
Some overweight patients want help, need Some overweight patients want help, need a push, and will be interesteda 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 Some are not the least bit interested at
this time….don’t give up, address it each this time….don’t give up, address it each time they are in the office. time they are in the office.
Coding for obesity counselingCoding for obesity counseling
GO 447 15 minute face to face counseling for GO 447 15 minute face to face counseling for obesity (BMI 30 or greater)obesity (BMI 30 or greater) One face/face weekly for 1 monthOne face/face weekly for 1 month One face/face meeting every 2 weeks for months 2-6One face/face meeting every 2 weeks for months 2-6 One face/face meeting every month for months 7-12One 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 Diagnosis codes use to support medical necessitynecessity V85.30 to V85.39 and V85.41 to V85.45V85.30 to V85.39 and V85.41 to V85.45
Medical Economics, June 25, 2012Medical Economics, June 25, 2012
Current dietsCurrent diets
Weight WatchersWeight Watchers AtkinsAtkins South BeachSouth Beach Ornish DietOrnish Diet Fat BurnersFat Burners Physicians Wt LossPhysicians Wt Loss Ideal Protein DietIdeal Protein Diet Jenny CraigJenny Craig Diet CenterDiet Center
Raw FoodRaw Food Volumetrics DietVolumetrics Diet Slim Fast DietSlim Fast Diet Vegan DietVegan Diet Dash DietDash Diet TLC DietTLC Diet Biggest Loser DietBiggest Loser Diet Ideal ProteinIdeal Protein
Maintenance is not the goalMaintenance is not the goal
Changing and keeping new life style habits Changing and keeping new life style habits is the goalis the goal
Patients must continue the Patients must continue the maintenance phase by not veering far maintenance phase by not veering far from their diet and exercise program. from their diet and exercise program.
What I have learnedWhat I have learned Multiple, affordable, accessible and applicable weight Multiple, affordable, accessible and applicable weight
loss programs need to be developed to be used in and loss programs need to be developed to be used in and outside the the medical communityoutside the the medical community
Physicians offices, institutions, communities..maybe Physicians offices, institutions, communities..maybe even families need a full time staff member (or family even families need a full time staff member (or family member) on site and responsible for implementing and member) on site and responsible for implementing and carrying out the programcarrying out the program
We must become proactive in addressing the marketing We must become proactive in addressing the marketing and delivery of high caloric foods that are fueling the and delivery of high caloric foods that are fueling the problemproblem
We must increase physical activity at all age levelWe must increase physical activity at all age level
Program directorProgram director
Someone who has had a weight loss Someone who has had a weight loss problem and has lost and maintained their problem and has lost and maintained their weight lossweight loss
Nurse, nutritionist, dietician, physician Nurse, nutritionist, dietician, physician assistant, coach …. Anyone with a burning assistant, coach …. Anyone with a burning desire to help patients lead a healthier life desire to help patients lead a healthier life style and lose weight. style and lose weight.
Physicians alone cannot Physicians alone cannot solve this problemsolve this problem
Patients and familiesPatients and families Parents, grandparentsParents, grandparents
The indulging divorced parentThe indulging divorced parent Industry/employersIndustry/employers TeachersTeachers SchoolsSchools Religious communitiesReligious communities Local, regional, state wide communitiesLocal, regional, state wide communities
In the meantime….In the meantime….
““Practice style” changes Practice style” changes Make it your habit to address each overweight Make it your habit to address each overweight
patientpatient Send them out with a diet or with informationSend them out with a diet or with information
Become better role models for our patients by Become better role models for our patients by losing weight and exercisinglosing weight and exercising Join patients in weight loss and exercise programsJoin patients in weight loss and exercise programs Encourage your staff to do the sameEncourage your staff to do the same
I am only one….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 I cannot do everything but still I can do
something… 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
Thank you! Thank you!