1. KORR Medical Technologies, Inc. www.KORR. COM Treating Obesity with Indirect Calorimetry Evidenced-based Solution for Primary Care Practice

2. KORR Treating the Overweight and Obese “ ” “When we win, I eat. When we lose, I eat. I also eat when we get rained out” Tommy Lasorda / Manager LA Dodgers Energy Intake is a major element in determining whether weight is gained, lost, or maintained….If your patient is like Tommy Lasorda, your major challenge is to help that individual manage their energy balance Reference: Kazaks, A. Obesity: Food Intake. In: Bray GA, ed. Office Management of Obesity. Philadelphia, PA: Saunders; 2004: 91-106.

3. KORR Role of Provider Provider Patient Disease MANAGER Provider Patient Disease CONSULTANT Typically the Primary Care Provider’s role is to Manage the disease. However, in treating obesity a more realistic role for the clinician is “consultant” or even “coach”. The patient must take the active role in managing their eating behavior. Reference: Bessesen DH. Applying Stages of Change theory to Office-based Counseling. In: Bessesen DH. Evaluation and Management of Obesity. Philadelphia, PA: Hanley & Belfus, Inc; 2002: 33-39

4. KORR Treating Obesity Guidelines for Primary Care from NIH / NHLBI Primary Care Physician Guidelines: Reference: National Heart, Lung, and Blood Institute (NHLBI) – National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight, Obesity in Adults – the evidence report. June 1998 Patient and Physician devise goals and treatment strategy for weight loss and risk factor control. Assess reasons for failure to lose weight. Set a diet that will create a 500-1000 kcal/day deficit, to yield a weight loss of 1-2 lbs per week Maintenance Counseling: Dietary therapy, behavior therapy, physical activity.

5. KORR What is Needed? When consulting the Overweight or Obese Patient: Make the 5 minutes that is spent with the patient as efficient and effective as possible. Remove the excuse “I have a slow metabolism” Provide the patient the exact caloric prescription that will lead to 1-2 lbs/week weight loss Consult the patient on the need to manage their energy balance. Motivate the patient to be more active

6. KORR Why use Indirect Calorimetry in Primary Practice? Set the patient on a diet that will create a 500-1000 kcal/day deficit that will lead to 1-2 lbs per week weight loss. Remove the excuse and the psychological barrier by showing the patient the problem is not a “SLOW METABOLISM” Teach the patient principles of Energy Balance using their own data. Assess reasons for failure to lose weight. Is it low energy expenditure or is it patient non-compliance?

7. KORR R EE V UE by KORR The ReeVue is the technological advancement that makes assessment of resting energy expenditure (REE): ACCURATE PORTABLE INEXPENSIVE The REEVUE is a “Metabolic Cart” stripped down to just the components necessary to perform an accurate resting energy expenditure (REE) measurement. Simplicity of use and maintenance are key.

8. KORR The Procedure Step 1 : Step 1 : Medical assistant conducts procedure. Patient’s exhaled gases are analyzed to measure the oxygen consumption and computation of Resting Energy Expenditure 1 (metabolic rate) Step 2: Step 2: Provider consults patients on results. Provider uses results to recommend a daily caloric intake. Also, the provider consults the patient on various aspects of Energy Balance. a. Procedure is very simple and can be performed by any medical assistant. b. Procedure and the consult is typically scheduled as a separate visit. Notes: c. Procedure is CPT Coded and is reimbursed by Medicare. 1 REE is calculated using the Weir equation with an assumed RQ=0.83. See “Weir, J.B., New Methods for Calculating Metabolic Rate with Special Reference to Protein Metabolism. J. Physiology, 1949 109: pages 1-9”

9. KORR The Report The patient’s data is presented in a graphical format that is designed to educate

10. KORR Energy Balance = Energy In – Energy Out Energy Out Energy In A balance scale is used to teach the concept of energy balance. “To lose weight, energy intake must be less than energy expended” The Report Reference: Kazaks, A. Obesity: Food Intake. In: Bray GA, ed. Office Management of Obesity. Philadelphia, PA: Saunders; 2004: 91-106. >

11. KORR The Report Patient’s data is presented in graphical format that creates a “forum for education” The patient’s measured metabolic rate Estimates of additional calories burned from lifestyle and exercise Maintenance Daily caloric requirement For patient to maintain their weight Patient’s Energy Balance Weight Loss Daily caloric requirement for patient to lose weight Energy OutputEnergy Intake

12. KORR Provider Consult Address Psychological Barriers Discuss a Weight loss Strategy Set a Caloric Prescription Discuss Behavioral Changes Send Patient home with Educational Materials The following slides show how the test results and the report can assist the caregiver in providing an effective consult. The power of the patient provider encounter should not be underestimated. If the patient is ready to make changes, the provider is in a key position to educate and motivate the patient. In the few minutes you have with the patient you may need to do the following:

13. KORR Provider Consult Address Psychological Barrier Remove the excuse of a slow metabolic rate. You might say… “ The test shows that you have a fast metabolic rate. You can lose weight! Now let’s discuss how to balance what you eat with what your body burns. ” The calculated predicative normal values are used for comparison.

14. KORR Provider Consult Discuss Weight loss Strategy “ To lose weight, you need to burn more calories than you eat. This is the most calories you can eat and still lose weight! ” You might say… The report recommends a range of calories for effective weight loss Weight loss Zone (kcal/day) This is calculated from the measured resting energy expenditure. Knowing the exact range for the individual may be the key to their success.

15. KORR Provider Consult Set a Caloric Prescription “ Each day you need to try and target this number of Calories. You should consider keeping a record of what you eat each day ” You might say… Provider uses the results of the test to establish a caloric prescription. Consult the Patient on the Amount of Daily Calories

16. KORR Provider Consult Discuss Behavioral Changes You might say… Caloric Deficit Discuss the benefits of being more active. Explain that they do not want to increase the calories when they Exercise. Let this add to the caloric deficit. “ Adding exercise and increasing activity will help burn more calories and will help the weight come off faster. ” This is not a diet. This is a new way of life!

17. KORR Provider Consult Maintenance Phase “ You have learned how to eat to your metabolism during the weight loss. Now we just need to increase your daily calories a little bit for maintaining your weight. ” You might say… Energy Balance: Like balancing a checkbook, it is a life skill Maintenance Zone (kcal/day) The number of calories needed to maintain weight is also determined by the REE measurement. The patient should be counseled to stay below the upper number of kcal / day