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