Kendall L. Stewart, M.D. November 17, 2006

1. The Obese PatientSome Practical Psychiatric PerspectivesA Presentation for SOMC Medical Education Kendall L. Stewart, M.D. November 17, 2006

2. 65-percent of us weigh more than we should. Our tendency to gain weight is increasing. Obesity is causing 300,000 unnecessary deaths—and considerable disability—each year. Obesity increases the risk of Type 2 diabetes, High blood pressure, Stroke, Gallbladder disease, and Cancer of the colon, prostate and breast. Moreover, the social stigma is considerable After masteringthe information in this presentation, you will be able to Explain three practical implications for physicians, Explain when you should advise your patients to lose weight, Identify three practical strategies for helping your patients (and yourself) exercise daily, Identify three practical strategies for helping your patients (and yourself) decrease daily caloric intake, Explain why you and your patients should implement these strategies, and Explain how you and your patients can deploy them successfully. Why is this important?

3. What are the implications for physicians? • Most of our patients are either obese or at risk for becoming obese. • So are we. • We are losing this battle. • Motivational strategies and sustained behavioral changes are the only effective preventive interventions—for now. • We should inquire about strategies for exercising daily at every visit. • We should inquire about strategies for decreasing daily caloric intake at every visit. • We should remain positive, passionate, encouraging and relentless about these issues.

4. Why are physicians reluctant to make diet and exercise a major issue with patients? • We don’t take these issues that seriously. • We don’t care. • We feel helpless. • Nothing works. • These patients are not motivated. • There’s no medicine for it. • Talking about these issues in boring. • We don’t want to make our patients feel uncomfortable. • We are ashamed of our own example and personal lack of will power. • It takes too much time.

5. What approach with patients is most likely to be effective? • Confront the problem directly. • Make it personal and emotional. • Share your own struggles. • Request an individualized plan. • Ask for daily documentation. • Bring up these issues at every visit. • Reinforce any progress. • Remain positive, enthusiastic and hopeful. • Avoid scolding.

6. When should you encourage your patients to lose weight? • BMI1 > 27.3 in women • BMI > 27.8 in men • Body weight > 20% of ideal weight • WHR2 > 1.0 in men • WHR > 0.8 in women • Positive family history • Other coronary risk factors • When they are overweight (BMI > 25) • When they start to gain 1Body Mass Index (BMI) = weight in kg/(height in meters)2 2Weight-to-Height Ratio = Waist in centimeters/Hips in centimeters

7. Choose some exercise you enjoy. Combine exercise with an enjoyable distraction such as Reading Listening to music Watching TV Listening to lectures Listening to audio books Arrange to exercise during that part of the day when you have the most energy and motivation. Exercise with others. End with non-painful stretching exercises. Exercise alone. Document your progress. Keep a daily journal. Talk regularly with other exercise enthusiasts. Make an appointment on your daily calendar. Ask your colleagues to honor this important commitment. Set reasonable goals. Exercise daily. Incorporate walking and stair climbing into your daily routine. Use this as time to think, reflect or meditate. What practical exercise strategies might you suggest?

8. Begin with education Avoid all diets. Make lifelong changes. Eat smaller portions. Eat more slowly. Exercise daily. Continue in a social support network. Employ healthy distractions. Graph your weight weekly. Keep healthy snacks nearby. Keep a food journal. Predict temptation. Erect emotional barricades to impulsive eating. Order a child’s portion. Drink water. Share success stories. Prominently display a list of helpful options. Set realistic goals. Find a weight-loss partner. Psych yourself up. What practical eating strategies might you suggest?

9. What have you learned? • Obesity is a big problem. • And it is growing. • You are at risk too. • There is a lot you can’t do. • But you must do everything you can reasonably do. • First, face the problem and confront it. • Make a personal, emotional appeal. • Ask for a commitment. • Suggest practical strategies. • Ask for documentation. • Never, ever give up.

10. Where can you learn more online?1 • Sign up for a personalized health newsletter at http://www.somc.org/. • View or download this presentation online at http://www.somc.org/NRSOMCPress/Clinical.htm. • Take an outstanding CME course on the office management of obesity at http://www.obesitycme.org/. • Read an overview of the treatment of obesity at http://www.webmd.com/hw/weight_control/aa51052.asp?pagenumber=4#top. • Point and click through an overview of the problem of obesity at http://www.obesity.org/subs/fastfacts/obesity_what2.shtml. • Review the Surgeon General’s call to action at http://www.surgeongeneral.gov/topics/obesity/. • Learn about how successful losers have done it at the National Weight Control Registry (NWCR) at • http://www.nwcr.ws/. • Refer your patients (and yourself) to an incredible, free health and fitness site at http://sparkpeople.com/index.asp. 1Please visit www.KendallLStewart.comto download related White Papers and presentations.

11. How can you contact me?1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center President & CEO The SOMC Medical Care Foundation, Inc. 1835 27th Street Suite B-01 Portsmouth, Ohio 45662 740.356.8153 stewartk@somc.org Webmaster@KendallLStewartMD.com www.somc.org www.KendallLStewartMD.com 1All speaking and consultation fees are contributed to the SOMC Endowment Fund.

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