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!