1. Integrating the Obese Patient into the Primary Care Setting Speaker notes included in notes section below

2. More than 60% of US Adults Are Overweight Flegal, K et al. JAMA, 2002. Obesity (BMI ≥ 30) Overweight (BMI 25 - 29.9)

3. Obesity Is Caused by Long-Term Positive Energy Balance Fat stores Energy intake Energy expenditure

4. Heritability of Body Weight

5. 16 oz32 oz44 oz52 oz64 oz 1 oz ≈ 12 calories

7. Coronary Heart Disease Morbidity mortality HypertensionDiabetesDyslipidemia 40% are obese 80% are obese50% – 70% are obese OBESITY Obesity and Coronary Heart Disease (CHD)

8. Abdominal Obesity Visceral Subcutaneous Abdominal Adiposity Courtesy of Steven Smith, M.D.

9. Visceral Obesity and Risk of Dyslipidemia Obese: level of deep abdominal fat Variable % Body Fat Deep Abdominal Fat Area (cm 2 ) 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.

10. 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

11. Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Gout Medical Complications of Obesity Idiopathic intracranial hypertension Stroke Cataracts Severe pancreatitis

12. 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-Adjusted Relative Risk Body Mass Index (kg/m 2 ) < 23 24 - 24.9 25 - 26.9 27 - 28.9 33 - 34.9 0 25 50 75 100 1.0 2.9 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 1.5 2.2 4.4 6.7 11.6 21.3 42.1 1.0 Men Women

13. Diabetes Prevention Program Research Group. N Engl J Med. 2002;346,393-403. Diabetes Prevention Program 40 30 20 10 0 00.51.01.52.02.53.03.54.0 Placebo Metformin Lifestyle Cumulative Incidence of Diabetes (%) Year

14. 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.

15. How Are We Doing as a Medical Profession? Obesity is under-diagnosed and under-treated

16. Percent of Patients Receiving PCP Advice by Obesity Classification Simkin-Silverman LR et al. Prev Med 2005;40:71-82.

17. 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

18. 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?”

19. Obesity Treatment Pyramid Surgery Pharmacotherapy Lifestyle Modification DietPhysical Activity BMI  40 35 30 25

20. One “Diet” Does Not Fit All

21. Comparison of Popular Diets Dansinger, et al. JAMA 2005;293:43-53. Mean Changes in Wt and Cardiac Risk at 12 Months

22. Meal Replacements Promote Long and Short term Weight Loss *1200–1500 kcal/d diet prescription A: conventional foods B: meal and snack replacement for 1 meal, 1 snack Fletchner-Mors et al. Obes Res 2000;8:399.

23. 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

24. 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.

25. 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

26. 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?

27. Assessing Readiness We are not good at predicting outcomes. Patients ultimately make the decision. Providers assess costs/benefits in a variety of contexts.

28. 5 Steps to Behavior Change 1. 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.

29. 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

30. The Office Environment Example of Waiting Room

31. 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

32. 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

33. Referrals Nutritionist Behavior therapist Psychiatrist Bariatric surgeon

34. 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