ADDRESSING OBESITY IN PRIMARY CARE Capella Crowfoot Lapham, FNP-C, - PowerPoint PPT Presentation

ADDRESSING OBESITY IN PRIMARY CARE Capella Crowfoot Lapham, FNP-C, DNP for the Nurse Practitioners of Oregon Annual CME Conference 10/13/2018

▪ Take a breath ▪ Review trends in obesity prevalence ▪ Describe current Clinical Practice Guidelines for treating obesity ▪ Review available pharmaceuticals for treating obesity ▪ Describe the risks of weight loss ▪ Propose a population health approach to treatment of obesity

▪ BMI is obtained by dividing weight in kilograms by height in meters squared. ▪ Normal weight: BMI greater than 18 to 24.9 kg/m2 ▪ Overweight: BMI greater than 25 to 29.9 kg/m2 ▪ Obesity class I: BMI of 30 to 34.9 kg/m2 ▪ Obesity class II: BMI of 35 to 39.9 kg/m2 ▪ Obesity class III (severe obesity): BMI greater than 40 kg/m2 (or >35 kg/m2 in the ▪ Presence of comorbidities) ▪ BMI classifications for Asian and South Asian people: ▪ overweight as BMI between 23 and 24.9 kg/m2 ▪ obesity as a BMI of greater than 25 kg/m2.13 (Smith & Smith, 2016)

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

Sturm & An, 2014. CA: A Cancer Journal for Clinicians.

▪ The population is roughly divided in thirds for each category: “normal weight”, overweight, and obese ▪ All social groups regardless of race, income, socioeconomic group, level of education, or geographic region have experienced increased rates of obesity ▪ Those groups with greatest rate of prevalence and/or increase are: ▪ Recent immigrants of any race ▪ Asian immigrants with a college education ▪ American Indians, African Americans, and Hispanics ▪ Females 40-59 years old of any race ▪ People with less education and/or less income (Ogden, Carroll, Kit, & Flegal, 2014; Singh, Siahpush, Hiatt, & Timsina, 2011; Sturm & An, 2014)

▪ According to a large systematic review and meta-analysis obesity is associated with all- cause mortality All-cause Mortality Hazard Ratio by BMI 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Normal Weight Overweight Grade 1 Grade 2 Grade 3 (Flegal, Kit, Orpana, & Graubard, 2013)

▪ Obesity is associated with a 4-7 year reduction in life expectancy ▪ BMI > 35.0 is has a 2x risk of cardiovascular disease ▪ 80% of those with diabetes are overweight or obese ▪ Being obese raises the risk of diabetes by a factor of 7 ▪ About 6% of cancers are estimated to be attributed to overweight and obesity ▪ In trauma patients, those with obesity have a 45% greater risk of mortality (Peeters, et al, 2003; Fruh, 2017; Hruby & Hu, 2015)

▪ Tobacco is leading cause of death in US ▪ Adiposity-based chronic disease costs the healthcare system double that of tobacco ▪ In a study of 30,000 Mayo clinic adult employees and retirees, smoking was associated with 20% increase in annual costs while those with BMI >40 had 50% greater annual costs (Spieker & Pyzocha, 2016)

▪ People living in counties with higher PCP supply have 20% less risk of obesity ▪ Only 30% of overweight and 42% of obese patients report receiving advice to lose weight (Jones & Sundwall, 2016; Gaglioti, et al, 2016)

▪ 36 year old white female with BMI 46 ▪ Clinically fits PCOS with irregular periods, facial hair, truncal obesity ▪ Has metabolic syndrome: 3/5 of the following: ▪ Waist circumference > 35 (>40 for men), TG’s >150, HDL <50 (<40 for men), BP > 130/85, or FBG >100 ▪ Desires pregnancy but no conception after 4 years of marriage ▪ Unable to stick to any diet plan or exercise, “I make goals but just can’t stay committed”

▪ Joint statement from the National Heart, Lung, and Blood Institute, the American Heart Association, and the American College of Cardiology ▪ Screen BMI annually ▪ Use BMI >25 as cut-off for intervention, waist circumference can indicate if greater risk ▪ Discuss risk of cardiovascular disease, diabetes, and all-cause mortality with all patients with BMI over 25 ▪ Recommend weight loss of 3-5% of body weight ▪ Prescribe a calorie-restricted diet ▪ Recommend a comprehensive lifestyle program ▪ Recommend bariatric surgery to those with BMI>40 and >35 if having related comorbidity (Jensen, et al., 2013) https://www.nhlbi.nih.gov/health-topics/managing- overweight-obesity-in-adults

▪ American Association of Clinical Endocrinologists and American College of Endocrinology CPG ▪ Improve adiposity-related complications rather than focus on weight-loss ▪ Screen BMI annually, use BMI >25 as cutoff ▪ Screen those patients for increased waist circumference, pre-diabetes, increased blood pressure, and elevated lipids ▪ In physical exam and history assess for cardiovascular risk factors, NAFLD, PCOS, infertility, OSA, asthma, OA, urinary stress incontinence, GERD, depression ▪ Dietary changes, increased physical activity, weight loss of 5-10%, and appropriate medications will produce clinically relevant improvements in adiposity-based chronic disease (ABCD) ▪ Refer those with BMI >40 or BMI >35 and serious comorbidity to bariatric surgery (Garvey, et al., 2016) https://www.aace.com/files/guidelines/ObesityExecutiveSu mmary.pdf

▪ Comprehensive life-style program: ▪ Face-to-face, individual or group ▪ Weekly visits for 6 months with an additional year of follow-up ▪ Focus on modifying eating and physical activity habits ▪ Several commercial programs have demonstrated efficacy: ▪ Weight watchers, Jenny Craig, and Nutrisystem (Wadden, et al, 2012) ▪ 10 year follow up typically shows weight was regained but lower prevalence of comorbidities

▪ The one the patient can do. ▪ Successful weight-loss is directly correlated with the rate of adherence to the dietary plan ▪ Head-to-head trials of low-fat, low-carb, low-glycemic, ketogenic diets show that although some have more rapid short-term effect, similar long-term outcomes ▪ Select dietary advice to support comorbidities (Wadden, et al, 2012)

▪ Physical Activity Recommendations: ▪ 30 minutes 5 days per week for adults ▪ 60 minutes daily for children and <2 hours per day screen-time ▪ Weight loss through exercise requires hours of high-intensity exercise ▪ However, increased physical activity is associated with long- term success in avoiding weight regain (Wadden, et al, 2012)

▪ MyPlate concept: ▪ Can be used to teach basic nutritional concepts ▪ To assist diabetics to adjust meals based on CBG results ▪ To assist in maintaining balanced diet while reducing portions ▪ For children parents can learn about health portion sizes at: https://www.healthychildren.org/english/healthy- living/nutrition/pages/default.aspx

▪ Physical Activity Vital Signs tool provides longitudinal information ▪ How many days during the past week have you performed physical activity where your heart beats faster and your breathing is harder than normal for 30 minutes or more? ▪ How many days in a typical week do you perform activity such as this? ▪ Scored as days this week / typical week: 0/0 to 7/7 ▪ HEVS: Health Eating Vital Signs provides information that is highly associated with excess BMI and are amenable to discussion in a clinic visit ▪ Questions focus on restaurant/fast food, soda, juice/punch, vegetables, fruit, breakfast (https://www.researchgate.net/publication/260214360_Healthy_Eating_Vital_Sign_A_New_Assessment_Tool _for_Eating_Behaviors)

▪ 5A model: shown to improve provider communication with patient regarding obesity ▪ Assess risk, current behavior, and readiness to change ▪ Advise change of specific behaviors ▪ Agree and collaboratively set goals ▪ Assist in addressing barriers and securing support ▪ Arrange for follow-up (https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-10-159) ▪ Psychosocial-life events focused history helps build tailored interventions: ▪ Patient can often chart their weight gain based on significant life events: ▪ Smoking cessation, pregnancy or menopause, change in marital status or new job ▪ Post-illness or when initiating a new medication (Kushner & Ryan, 2014)

▪ Reduced mortality with increased BMI: ▪ For ages 65-74 ideal BMI 27-30 for all-cause mortality and 25-35 for cardiovascular mortality ▪ However, higher BMI has increased risk for DM, OA, disability, and some fractures ▪ Weight loss is associated with increased function and improved lab values, however: ▪ Focus on adequate nutrition when reducing calories ▪ Important that include muscle strengthening activity in comprehensive weight loss plan ▪ Utilize 2 measures to diagnose diabetes since higher prevalence of conditions that compromise HgbA1C accuracy (Rothberg & Halter, 2015; Kalish, 2016)

▪ Share health promotion information for metabolic health with every patient ▪ Ask permission to discuss BMI ▪ Emphasize the importance of metabolic health over weight ▪ Brainstorm strategies to assist patient in achieving physical activity and dietary recommendations ▪ Set small goals and celebrate small achievements

▪ 69 year old Hispanic female with chronic conditions, BMI 34.0 ▪ DM2 that is controlled through dietary changes, occasionally checks CBG at home ▪ OA: takes celecoxib and gabapentin, can’t walk much due to knee pain