Addressing the Elephant in the Room ?. Obesity

1. Addressing the Elephant in the Room?.Obesity

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

3. NHANES study • Data from 4,111 children and young adults ages 2-19 • 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 • 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 • IgE levels were higher in overweight and obese children • 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

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

6. Basic Metabolic IndexBMI • Underweight <18.5 • Normal <24.9 • Overweight >25 -29.9 • Obese >30 • Extremely obese >40

7. A Modern day epidemic • Current generation of children may have shorter life span than their parents • 1/3 of children in the US are expected to have diabetes • 1/4 Americans age 17-24 are unfit for military service…..obesity • White House Task Force on Childhood Obesity, Report to the President 2010

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

9. How did we get here? • Years of overeating and under exercising • Advertising to children and adults • The Bigger Better Burger • Larger cola drinks • Sugary cereals • Good news! Kids are watching less television • 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 • Family history positive for diabetes, heart disease, high cholesterol • 20 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 • 132/84 • Overweight… BMI 27 • 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 Weight has increased. BMI 29 Blood pressure now 144/92 Blood sugar is normal Total cholesterol now 230, TRI 180, LDL 130 Plan: Started on medication for mild hypertension “Advised to lose weight” “watch your blood pressure,” . “Lets check you in 6 months”

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

13. Road to illness • 6 months later in for his annual physical • 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 • Add second blood pressure medication, start cholesterol lowering medication • “You need to lose weight, increase your exercise” • 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, • 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? • Now what has happened?

15. Road to illness • Hypertension is being treated with 2 medications • Gout is controlled with Allopurinol • Hypercholesterolemia is treated with a statin • He is now obese with a BMI of 33 • Type 2 diabetes • Sleep apnea, using C-pap • On medication for depression • Insomnia is controlled with Zolpidem hs • 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 • Family history of diabetes, heart disease, elevated cholesterol • 20 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 • 132/84 • Overweight… BMI 27 • 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….. • I might have kept him from obesity and its associated illnesses.

18. “Chief complaints” • “I am here for… • “blood pressure” • “my diabetes check up” • “my annual physical” • “my chronic fatigue • “my depression” • “my headache” • “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.

19. Physicians addressing 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) 1576-8 • 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

21. Are health care professionals advising obese patients to lose weight (61,968) • MedGenMed,2005 Oct12;7(4):10 • Only 40.3% of obese patients reported being advised to lose weight. • 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 • 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.

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

24. Barriers reported by physicians • Availability of affordable weight loss programs • Intimate saboteurs, (grandparents, friends) • Lack of Insurance coverage • Lack of reimbursement for time and effort spent. • 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 discuss weight reduction or refer for diet instruction

26. Barriers reported by patients • “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.” • “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 • No affordable diet/exercise plan given • Little or no education about obesity given • “No time to cook or exercise” • “I am too tired to exercise” • “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 • 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) • 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 • 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.” • What planet are these folks living on???? • …..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 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?

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

33. Yellow pages • Weight control under physicians • All refer to bariatric surgery • Weight control (general) • Hypnosis clinic • Advanced Products • Body Solution System • Jenny Craig • Life Style Weight Control Center • Overeaters anonymous • 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 10-15 minute office visit • I can acknowledge the weight problem • 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

35. Acknowledging the problem • 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 • 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 • Assist towards a program that fits their affordability and access • 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 • Advise change of specific behaviors • Agree to, and set goals • Assist in addressing barriers and securing support • Arrange follow up

38. Addressing obesity • 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 • 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

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

40. Weight loss “drugs” OTC • Over 400 otc • From Abrexin to Zymelt • Top 3 • 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……

41. Weight loss drugs by Rx • Currently FDA approved drugs are for short term use with diet and exercise • Appetite suppressants • Phentermine • Phentermine + Topamax (Qsymia) • Fat absorption inhibitor • 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. • Dec 2011 “products are illegal, claims are false and misleading, hormone not regulated • Made from urine of pregnant women • Obtained through compounding pharmacies • Significant side effects have been reported.

43. “The best investment you will ever make” • You will feel better • You will look better • You will have more energy • You will decrease the chance of developing the ravages of being overweight • You will enjoy a better quality of life • 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…. • “I am very concerned about your weight. Are you concerned?” • Acknowledges the fact • Shows compassion • Opens the door for discussion and sets in motion your plan for further action

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

46. Educating patients • Walnut/apple salad 210 calories + dressing • Big Mac 540 calories 10 carbs • French Fries 500 calories • Coca Cola Large 310 cal • Total 1350 calories • 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 • Overweight = age- and gender-specific BMI at ≥85th to 94th percentile • Obesity = age- and gender-specific BMI at ≥95th percentile

49. ACH Obesity Clinic • 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. • Must keep it simple

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