Obesity, Diabetes, & Diet COMBINING EVIDENCE FOR ALL THREE INTO IMPROVED PATIENT CARE Case Study Louis J. Aronne, MD, FACP Weill Cornell Medical College Columbia University College of Physicians and Surgeons Louis J. Aronne, MD, FACP Disclosures !! Research/Grants: Amylin Pharmaceuticals, Inc.; Arena Pharmaceuticals, Inc.; F. Hoffmann-La Roche, Ltd.; Metabolous Pharmaceuticals, Inc.; Norvo Nordisk; Orexigen Therapeutics, Inc.; Pfizer Inc.; TransTech Pharma, Inc. !! Speakers Bureau: None !! Consultant: Allergan, Inc.; Amylin Pharmaceuticals, Inc.; GI Dynamics, Inc.; GlaxoSmithKline Consumer Healthcare, LP; Johnson & Johnson Pharmaceutical Research & Development, LLC; NeuroSearch, Inc.; Novo Nordisk; Orexigen Therapeutics, Inc.; Roche Laboratories, Inc.; VIVUS, Inc.; Wyeth Pharmaceuticals, Inc. !! Stockholder: Cardiometabolic Support Network, LLC !! Other Financial Interest: None !! Advisory Board: Allergan, Inc.; Amylin Pharmaceuticals, Inc.; GI Dynamics, Inc.; GlaxoSmithKline Consumer Healthcare, LP; Johnson & Johnson Pharmaceutical Research & Development, LLC; NeuroSearch, Inc.; Novo Nordisk; Orexigen Therapeutics, Inc.; Roche Laboratories, Inc.; VIVUS, Inc.; Wyeth Pharmaceuticals, Inc. Father A.V. 04May09: 378 lbs, 5’ 11”, BMI = 53 !! Dx w/ DMII in 2004 !! Long history of obesity !! Can’t control his eating, binges !! HbA1c = 8.4% !! FPG = 166 !! TG = 241 !! UA Microalbumin = 973 !! “Can’t tolerate metformin” !! Considering RYGB, but afraid to have surgery DMII = diabetes mellitus type II; Hb = hemoglobin; FPG = fasting plasma glucose; TG = triglycerides; UA = urinalysis; RYGB = Roux-en-Y gastric bypass Father A.V. 04May09: 378 lbs, 5’ 11”, BMI = 53 !!Medications !!Insulin glargine 100 u QPM !!Insulin aspart 160 u BID !!Candesartan and hydrochlorothiazide 32/12.5 mg !!Pravastatin !!Pantoprazole Management Plan !!Low glycemic diet !!Start exenatide 5 mcg BID (" hour a.c.) !!Start slow-release metformin 500 mg QD to see if tolerable !!Cut short-acting insulin in half !!Sleep study Results !!Loses 20 lbs in 1 month !!Increase exenatide to 10 mcg BID !!Tolerates slow-release metformin, increase to 500 ER BID !!Titrate down insulin as he loses weight !!Sleep apnea–won’t use mask but sleeps better because of weight loss !!Good compliance with low glycemic diet Medication Changes Timeline Date 5/4/09 6/2/09 6/9/09 8/12/09 9/28/09 4/28/10 7/28/10 Weight (lbs) 378 349 329 311 291 290 284 HbA1c (%) 8.4% 8.3% 7.1% FPG 166 207 Insulin 23.9 TG 241 417 UA Microalbumin 973 337 Medications Insulin aspart Insulin aspart Insulin aspart reduced to reduced to Insulin aspart d/c 80 u BID 40 u BID 20 u QD Insulin glargine 100 u QPM; Insulin glargine Insulin glargine reduced to reduced to reduced to 25 u QPM 10 u QPM 50 u QPM (5/27) Exenatide Inc Exenatide Exenatide Exenatide Exenatide 5 mcg BID 10 mcg BID 10 mcg BID 10 mcg BID 10 mcg BID Metformin ER Metformin ER Metformin ER 1250 mg 1000 mg BID 1000 mg BID Pramlintide Add Pramlintide increased to 60 mcg BID 120 mcg BID Ursodiol 300 mg BID Candesartan Candesartan Candesartan Candesartan cilexetil 32 mg (d/c HCT) 8 mg QD 8 mg QD 8 mg QD Glyburide Glyburide 1 mg BID 1 mg BID Pravastatin Pravastatin 40 mg QD 40 mg QD Hb = hemoglobin; FPG = fasting plasma glucose; TG = triglycerides; UA = urinalysis Are We Doing Enough in Patient Visits to Prevent and Manage Obesity? Robert F. Kushner, MD Northwestern University Feinberg School of Medicine Chicago, IL Robert F. Kushner, MD Disclosures !!Research/Grants: None !!Speakers Bureau: None !!Consultant: Abbott Nutrition; Vivus, Inc. !!Stockholder: None !!Other Financial Interest: None !!Advisory Board: Allergan, Inc.; GI Dynamics; Orexigen Therapeutics, Inc. Medical Complications of Obesity Mental health issues Depression, anxiety, insomnia Pulmonary disease Idiopathic intracranial Abnormal function hypertension Obstructive sleep apnea Stroke Hypoventilation syndrome Cataracts Nonalcoholic fatty liver Coronary heart disease disease Diabetes Steatosis Steatohepatitis Dyslipidemia Cirrhosis Hypertension Gall bladder disease Severe pancreatitis Gynecologic abnormalities Cancer Abnormal menses Breast, uterus, cervix Infertility Colon, esophagus, pancreas Polycystic ovarian syndrome Kidney, prostate Osteoarthritis Phlebitis Skin Venous stasis Gout What Should the Primary Care Provider Do? !!Questions to consider: !!What is the role of the primary care provider? !!What resources do primary care clinicians need to provide effective obesity care? !!What is the best model for tackling the obesity epidemic? Kushner RF. Arch Intern Med 2010;170:121-123. Tackling Obesity !!Most assuredly, halting and reversing the obesity epidemic will require a comprehensive public health plan that addresses environmental, behavioral, and socioeconomic factors !!However, overweight and obese patients presenting to their primary care provider with comorbidities require treatment today Kushner RF. Arch Intern Med 2010;170:121-123. Guidelines and Recommendations Regarding Obesity Care !!Clinicians should screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults1 !!2010 HEDIS measures2 !!Adult body mass index (BMI) assessment !!Weight assessment !!Counseling for nutrition and physical activity for children/adolescents 1. US Preventive Services Task Force (USPSTF). Ann Intern Med 2003;139:930-932. 2. National Committee for Quality Assurance. Healthcare Effectiveness Data and Information Set (HEDIS) 2009. Mobilizing the Medical Community !!Measure BMI and explain connection with increased risk for disease & disability !!Record physical activity levels and stress importance of daily activity !!Assess & record information on dietary patterns !!Work as a team !!Ensure that patients are referred to resources that will help meet their psychological, nutritional, and physical activity needs Office of the Surgeon General. The Surgeon General’s Vision for a Healthy and Fit Nation 2010. U.S. Department of Health and Human Services (HHS). 2010:1-21. Mobilizing the Medical Community (cont.) !! Encourage clinicians & staff to practice healthy lifestyle behaviors and be role models !! Use best practice guidelines on how to counsel patients !! Promote effective prenatal counseling about maternal weight gain, breastfeeding !! Advocate for community strategies that improve nutrition and physical activity resources for patients !! Promote innovative ways to advocate for policy changes at local, state, and federal levels Office of the Surgeon General. The Surgeon General’s Vision for a Healthy and Fit Nation 2010. U.S. Department of Health and Human Services (HHS). 2010:1-21. Trends in Obesity-Related Counseling in Primary Care: 1995-2004 30 † 25 Any (p = .152 ) Diet (p = .085) 20 Exercise (p = .123) 15 % of Visits % of Visits 10 Weight (p = .009) 5 0 1995-1996 1997-1998 1999-2000 2001-2002 2003-2004 Data from the National Ambulatory Medical Care Survey (NAMCS) * Information about weight loss counseling not collected between 1997 and 2000 † p-value based on test for linear trend McAlpine DD, et al. Medical Care 2007;45:322-329. Percent of Patients Receiving PCP Advice By Obesity Classification 100 Specific Advice 90 84 80 Told Overweight 75 70 62 60 48 48 50 46 Percent 40 32 28 30 20 10 0 Overweight Obesity I Obesity II Obesity III (BMI 27.0-29.9) (BMI 30.0-34.9) (BMI 35.0-39.9) (BMI # 40.0) Told overweight: X2 (test for linear trend) = 16.5, p = .001 Gave weight loss advice: X2 (test for linear trend) = 5.5, p = .019 Simkin-Silverman LR, et al. Prev Med 2005;40:71-82. A Catch-22 Managing Obesity in Primary Care !!The phrase "Catch-22" is common idiomatic usage meaning "a no-win situation" or "a double bind” of any type 1 !!Uncommonly the chief complaint !!Limited insurance coverage !!Minimal to no physician training !!Few therapeutic options !!Sense of futility and avoidance !!No to minimal RD coverage !!Few office tools & resources 1. Heller J. Catch-22;1961. Barriers to Optimal Obesity Management Bardia A, et al. Mayo Clin Proc 2007;82:927-932. Overweight & Obese Treatment Multiple Options Self-help books/fad diets Community/park district/ church-based programs Over-the-counter medication/dietary supplements Internet programs Commercial programs Worksite programs Registered Dietitian Primary care provider Obesity medicine specialist Bariatric surgeon Obesity Treatment Pyramid Surgery BMI Pharmacotherapy Lifestyle Modification Diet Physical Activity A Guide to Selecting Obesity Treatment BMI Category Treatment 25-26.9 27-29.9 30-34.9 35-39.9 # 40 Diet, physical With activity, and comorbidity + + + + behavior therapy With Pharmacotherapy comorbidity + + + With Surgery comorbidity + NHLBI Obesity Education Initiative. The Practical Guide. 2001:1-94. Suggested Reading Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion. Assessment and Management of Adult Obesity: A Primer for Physicians Kushner RF. American Medical Association; Robert Wood Johnson Foundation. 2003. Developing a Chronic Care Model (CCM) of Care A Systems Approach !!Put Prevention Into Practice !!AHRQ !!http://www.ahrq.gov !!Improving Chronic Illness Care* !!http://www.improvingchroniccare.org !!Chronic care training manual !!ICIC Improving your practice manual !!Tools * Supported by The Robert Wood Johnson Foundation. Chronic Care Model (CCM) 2. Health System Health Care Organization 1. Community Resources 3. Self- 4. Delivery 5. Decision 6. Clinical and Policies Mgmt System Support Information Support Design Systems