Hello, my name is Elizabeth Bauer, and I'm an endocrinologist and assistant professor at the Naval Medical Center in San Diego. And I'm so pleased to talk to you today about how to start treating obesity in the office. I have no disclosures. Here are my objectives for the lecture. We'll review how to define and measure obesity and obesity-related complications. We'll develop a framework for the evaluation of obesity and overweight, which will then help us choose treatment options and weight loss goals. We will discuss practical tips for diet and exercise and behavioral modifications and briefly review some shared resources and how to bill for the encounter. So, as you learned in the Obesity 101 lecture, over 70% of the U.S. population has overweight or obesity, and the numbers are on the rise. At first glance, it looks like there's been a downtrend in overweight. But as you look at the trend of obesity, you see that we haven't been losing weight. It's actually the cohort of overweight has been gaining weight and are now in the obesity cohort. And obesity now accounts for over 40% of the population in the U.S. So, just like in many other chronic disease processes, the clinical evaluation consists of a diagnosis, and in this one, it's a little different in that there is a staging, or one of the recommended ways to evaluate is to also do staging, which looks at the complications of obesity, which will then help us choose a treatment which can consist of lifestyle modifications, medication, and surgery. So, BMI is the most commonly used diagnostic criteria for obesity. More information on the criteria and how to diagnose is also in the Obesity 101 lecture. And BMI is great from a population health standpoint. However, it cannot identify excess adiposity or establish a diagnosis of overweight and obesity in all settings. So, for example, it can overestimate the degree of adiposity in individuals with increased muscle mass, and it can underestimate the risk in elderly with loss of muscle mass, as you can see in this picture. It can also overestimate the risk in some populations that have higher visceral fat at lower body weight, such as South Asians. And so, to evaluate the risk, you would need to know the amount of adiposity and their adiposity-related disease risk. And for this, abdominal circumference can be very helpful in individuals, especially with a BMI less than 35. And this is because waist circumference is well correlated with the risk of metabolic and cardiovascular disease. In individuals with a BMI greater than 35, a waist circumference probably doesn't give additional disease risk, so measuring it may not be helpful. Although in my clinic, I measure it along with the weight and celebrate abdominal circumference the same and many times more than I would with weight loss on the scale. In individuals who have an abdominal circumference greater than 40 inches, for men, this is a diagnosis of obesity, and women greater than or equal to 35 inches. There are other ways to also calculate the amount of adiposity on the body, and I have a slide to go over some of these other ways. A practical tip about measuring waist circumference is this is sometimes difficult to measure accurately and to reproduce the same measurement. The measurement needs to be completed just at the top of the iliac crest, which in some individuals can be hard to palpate, and so what I do is I have the patient find the top of their hip, and I have them put their finger there, and I place the measuring tape right underneath where their finger is, and I have them turn around so that the tape can go around the body. It should be snug but not tight, and I take the measurement after I have them take a deep breath on exhalation so that they don't intentionally or unintentionally suck in their waist, and this just helps if you're going to reproduce it or you're going to measure it again in the future. Other ways to measure body composition and adiposity include the DEXA scan or bioelectric impedance. Or you can use air-water displacement plethysomography, such as the BOD-POD. CT and MRI can also be used to measure body composition, but with all of these different ways, the clinical utility is limited, and mostly by availability, by cost, insurance coverage, and then not really having validated cutoff points between the studies. However, they can be helpful especially in some individuals that are on those outskirts where the BMI is not accurate. So, for instance, in individuals who have higher muscle mass and they have a high BMI, body composition breaks down the amount of lean muscle mass, skeletal muscle mass, and the amount of body fat, and it can differentiate that, so at a high BMI, but where everything is muscle mass, then these individuals are not at a higher risk. However, it's usually the opposite. Individuals either think that they have a higher muscle mass and they don't, or individuals who have a lower body weight but have increased risk because of where they place their adiposity. So, we'll zoom into this example so you can see it a little bit better, and in this individual, they have a BMI of 26, but their percent body fat is almost 31 percent. You can see that this is the average, this is higher, and then this is lower on this scan, and then you can see up here where it is centralized, too, and so you can see that most of it is in the trunk and in the upper extremities, and so in this individual, even though their BMI is not that high, they have a higher risk of cardiovascular and metabolic disease because of where the adiposity is placed in the body. So, in addition to classifying obesity using BMI, you also want to evaluate for the medical complications of obesity, and sometimes it's easier to categorize these into biomechanical complications, cardiometabolic complications, than other complications, and many of these are ones you commonly see and treat in your practice, like obstructive sleep apnea, gastroesophageal reflux, diabetes, high blood pressure, but overall, there have been identified at least 236 obesity-related diseases, and this includes 13 different types of cancers. The severity of the complications can further be categorized into a stage, and there are two commonly used modalities, the first being the Edmonton Obesity Staging System, which categorizes individuals into stages 0 through 4, depending on end-organ manifestations, both medical, mental, and functional, and then the one that I will be discussing or using, which was proposed by the American Association of Clinical Endocrinologists, or ACE, in 2016 and updated this year, and this categorizes individuals into stages 1 through 3, based on their adiposity-based chronic diseases, shorthanded to ABCD, so you'll see in the earlier stages, you're working with the patient to lose adiposity to prevent complications, but then, as you move through the stages, you're not only trying to prevent complications, you're treating their current complications and also preventing further complications. Each stage is going to come with different suggested therapies based on their comorbidities to try to achieve this treatment goal, so, for example, an individual with a BMI of 32 with hypertension, diabetes, and non-alcoholic fatty liver disease, this would be a diagnosis of obesity class 1, but stage 3, stage adiposity-based chronic disease stage 3, and then your treatment discussion and goals would be with these complications in mind, so just like you are targeting a blood pressure goal and high blood pressure or A1c goal in diabetes, you would choose a weight loss goal based on the amount of weight needed to affect an improvement, so in this individual who has hypertension, diabetes, and non-alcoholic fatty liver disease, you are going to choose a starting weight of at least 10%, because this is, out of the three diagnoses, you can see that this is going to, 10% or more is going to be required in order to improve ketosis, inflammation, and fibrosis. This doesn't mean any type of weight. Any type of weight is going to improve many different things, but to start to see an improvement in this comorbidity, you need greater than 10%, and so having that weight loss goal greater than 10% will help you choose what treatments that you recommend to the patient, so lifestyle modifications can achieve two to five percent of sustainable weight loss, and then if you add on prescriptive nutritional interventions, like a referral to a dietician, you can get up to 10%, although usually this is closer to five percent. With pharmacotherapy, depending on the one that's used, you can get up to 20%, and then with the surgeries and the dyscopic procedures, you can get higher than 20% total body weight loss, and so for that example, you would know that you can't just do lifestyle modifications because that's not going to achieve that greater than 10% weight loss goal that you need, and so we talked about the prevalence of obesity and the complications that come from it, so why are we not having these discussions, and that is because it's difficult, right? Oftentimes, as providers, we fear starting the conversation because we fear how difficult it will be, and this is likely why less than 50% of patients with a BMI greater than 25 stated that they had received any type of weight loss advice from physicians over the last 12 months, and over the last five years, still only 71% of individuals have said that they had discussed weight with their primary care provider, however, by the time a patient comes to us for weight loss, they have already attempted it by themselves an average of seven times, and these studies have shown that patients who were advised to lose weight by their provider were more likely to report an attempt to lose weight, so having the discussion does make a difference. We just need to start having them, so to start the conversation, you can use the ABCDEF approach, which was also discussed in a previous lecture in more detail, and you can let the patient know that you were concerned about their health, so for example, you can say, I'm concerned that your weight is contributing to your health problems, so in our example, to your diabetes or your high blood pressure, non-alcoholic fatty liver disease, is this a good time to talk about your weight? Or you could say, like in the example that I showed you with the body composition with a BMI of 26.5, you could say, your body mass index is high, and I'm concerned that your excess weight will lead to future health problems. Is it okay if we talk about your weight today? So you're letting them know that you're concerned, but if they aren't ready to discuss it, that's okay. Keep the communication lines open, and allow them to come back and know that you'll be there to help them. You could say, I understand you're not ready to discuss this, however, I am concerned that your weight is contributing to your diabetes. There may be ways that we can work together, so please contact my office if you'd like to discuss your options, so that way you can tell them you are concerned, but you will still be here when they return, when they're ready to talk about it. So, just like any other disease process, make sure to evaluate for other contributing factors and medical conditions by taking a detailed history that includes weight history, prior weight loss attempts, current eating habits, eating disorders, social determinants of health, exercise, sleep. You would need to do a good physical exam to see if you have any physical exam or history findings that increases your suspicion for other medical conditions, like hypothyroidism or obstructive sleep apnea, and this is what is contributing to their wakening or at least their inability to lose weight. Obtaining all this information can take up most of the visits and is not realistic in our world today, where we have 15- to 20-minute visits, so you can use things like intake forms, where a patient is filling out this information in the waiting room while they're waiting to talk to you. Also, know that it is totally appropriate and actually recommended for you to schedule them a dedicated visit to discuss obesity. Don't feel like you need to try to get everything in the visit, especially since the reason they came to see you was probably not about their weight and was probably for another condition like the diabetes or high blood pressure in my example. The genetics of obesity is both fascinating and complicated, but the reality is that monogenic obesity syndromes are very rare, accounting for less than five percent of cases, and they result in class 3 obesity in early childhood, so they're usually identified before they become adults. However, there's a bunch of different inheritable factors, and there's a constant interplay between the environment and these behaviors, and this is known as epigenetics, and this can result in changes to your body's energy metabolism and the expenditure, but currently we don't have any commercial ways to measure these factors or the epigenetic changes, but we do know that these epigenetic changes are reversible, so those same factors that are causing the weight or weight-promoting changes, if you were to improve your sleep, improve your physical activity, you can reverse those epigenetic changes. Make sure to screen for weight-promoting medications. It's likely 15 percent of the obesity pandemic is thought to be for medications such as atypical antipsychotics or antiepileptics. Even common over-the-counter medications like antihistamines can be weight-promoting, and so I created this table to show, at least based on the systemic reviews that I saw, the amount of weight that is usually seen with these medications. However, for all these medications, you can see that there's alternative agents that can be used that are either weight-promoting or, sorry, weight-neutral or can help you help lose weight, and so common medications like diabetes medications, beta blockers, ones that we use very commonly, when you go to start a medication, think about this before you start, because if the individual has overweight or obesity, maybe start with a medication that is going to help them with some weight loss or at least be weight-neutral. If they are already on a medication, please do not discontinue the medication without discussing it with their prescribing provider. You have to use shared decision-making with the patient and the subspecialist and just try to find one that is going to work for the patient or, at a minimum, try to use the lowest effective dose of that medication, so for instance glucocorticoids. When an individual is on this chronically, you don't want to stop it, but you can maybe get it down to or work with a subspecialist to get it down to a dose that is not going to cause weight or at least be the lowest effective dose for their condition. Lab testing can help with screening for complications of obesity and other conditions that may be contributing. In first obesity visits, usually I'm checking a fasting CMP level, an A1c, TSH in the lipid panel, and then oftentimes I will check an insulin level to calculate the home IR or insulin resistance, and then other screening tests you would choose based on your clinical suspicion that you get from getting a good history and doing a good physical exam. Now that we have all the background information, we can move on to treatment strategies. In the first visit, it is really important to set realistic goals, and SMART goal is a good mnemonic for a goal that is specific, measurable, attainable, relevant, and time-based. An example SMART goal for the example patient we discussed earlier would be 19 pounds over six months, and this would meet all the standards as it is 10% total body weight loss, and it would improve for diabetes and high blood pressure and non-alcoholic fatty liver disease. You would be able to measure the improvement by the weight, but also by seeing their blood pressure and A1c improve. It's less than one pound a week, which can be done pretty effectively over six months, because six months is 24 weeks, and so that would be 19 pounds in 24 weeks, less than one pound a week, so it's achievable and it's time-based. Obesity is incredibly complex, and so it requires a multidisciplinary team approach, and this is what's going to be needed to get the best, most sustainable outcomes, So don't be afraid to call on your colleagues and refer to these colleagues, the dieticians, physiatrists, surgeons, to get involved with the care. There is no one diet fits all approach, and this has been shown in many studies, and I'll talk about two interesting ones. This first one had over 800 participants with a BMI over 25, and they were assigned to four different dietary groups. Each of them having a 750 kilocalorie dietary restriction. And over the course of the study, each group was given group and individual counseling, and each group was able to lose weight. And so you can see over six months, all of them achieved an average of about 7% weight loss, but over the next six to 24 months, in each group, they regained some weight. And at the end of the study, there was no statistically significant difference between the macronutrient groups. So this showed that a reduced calorie diet does result in weight loss in all the groups, and that is regardless the macronutrient composition. In this study, they looked into weight changes by dietary subtypes. And so just like that other one looking at the macronutrient percentages, this looked at diets, which also in general has macronutrient differences, high protein, low carb, et cetera. And this one also found that over the course of the study, over one year, everybody, on average, everyone lost weight, but the weight was regained, and none of them met statistical significance after the year. However, this study was pretty interesting because it showed that out of the different dietary patterns, you can see that some people gained weight on the same diet, didn't lose any weight, or lost a whole bunch of weight, and that is in the same diet. So each of these is a different diet. So the best diet is the one that you can adhere to. It's not the macronutrients, it's how much you adhere to it. So looking at this one, this is adherence, and this was weight. And so the more adherent the individual was, the more weight loss they had. You can see this individual down here, the most adherence, lost almost 30% of their total body weight, which is incredible. And then you see others up here in the same diet who gained weight, but their adherence was poor. So now to go over some practical tips that will hopefully help you in your discussions. A kilocalorie is commonly referred to as a calorie, and this is a measurement of the energy content of food. And so one pound is about 3,500 kilocalories. And each individual has a basal metabolic rate, so BMR, also referred to as an RMR, or resting metabolic rate, which is not exactly the same thing, but for all intents and purposes, it's usually used synonymously. And this is the energy required for performing vital body functions, like circulation, respiration. And then the total daily energy expenditure is that metabolic rate plus their physical activity. And so, for example, if you were to consume 2,000 kilocalories over 24 hours, and over the course of the day, and with a sedentary lifestyle, you burn 1,500 kilocalories, 500 of those calories would be excess, and the body would use that excess energy and put it into storage. If this individual were to do this over seven days, that would be 3,500 calories a week, and that would be one pound gained over the course of the week. Alternatively, if you were to consume 500 calories less than what you're burning, then it would be 500 calories burned. And it's not just taken from adipose tissue, unfortunately, but to keep it simple, this is usually how I explain it to patients. It would take the energy storage, you'd have to break it down to get that energy, because the body needs that energy because they expended it throughout the day. So doing that over the course of a week, they would lose one pound if they kept it up. So that's simple to explain, right? But it's not that simple, we know this. If it was that simple, then obesity would not be this difficult to get the weight off and keep it off. And that is because a calorie indicates how much energy is in the food, but not how much energy you get out of the food. So for example, 200 calories is going to expend a whole bunch more energy than just doing 200 calories of a simple carbohydrate. Also, everybody's ability to extract energy is different, and there's many different variables to this, including the time of day, stress levels, the quality of food. And so it's not as simple as calories in, calories out. There is metabolic adaptation that's possibly happening as well in the background. And I could go on and on and on, it's very complex. But you still need to have a deficit overall in order to get the weight off. For food, I like to talk to patients about this interesting study done by the NIH or the National Institute of Health, and where they enrolled 20 different people, and they put them into two different dietary arms. And over 14 days, one cohort ate only processed foods, and then 14 days of unprocessed foods. And whatever cohort they were originally in, they were crossed into the other one at the end of the 14 days. And they measured the amount of food that people ate during that time. So individuals were able to eat however much they wanted, and they found that in those that had an ultra-processed diet, they ate more than individuals with the unprocessed diet, where over the course of the two weeks, on average, individuals on the processed diets gained 0.9 kilograms, so about two pounds, and on the unprocessed diets, lost on average about two pounds just over the course of those two weeks. The only thing that was changed was the type of food in the same individuals. And so this shows that the quality of the food can also make a difference. Commonly, patients ask questions about, what about if I eat small meals compared to large meals? Does that make a difference? And it's whatever's gonna work for the patient, because if you're an individual that doesn't like to eat breakfast, and you're forcing yourself to eat breakfast, then that could actually be bad, right? You're eating more calories than you would have. And we don't have any conclusive evidence showing that small meals, multiple small meals throughout the day is better than few large meals. And so it needs to be whatever is going to work for the patient. So some practical tips. Schedule a dedicated visit to discuss obesity and then follow up with the patient every one to three months. You don't have to address everything in one visit. Try to give one recommendation per visit. Just remember it requires a multidisciplinary team. So use your local resources. A dietician is such an incredible resource and they can give both individual and group education. And each patient is different. Some patients love doing group therapy because it gives them that social outlet, but it also gives them the support that they need. And then other individuals don't want to have anything to do with a group. And they would prefer that individual one-on-one counseling. If time allows, there are some fast and easy ways to calculate daily caloric needs. And so you can use the calculator online. The NIH has a great one, or there's calculators on your phone that can do it. Also those body compositions that we discussed, they can also calculate a metabolic rate. And that is usually based off of skeletal muscle mass. Some dietary tips include no dieting. We don't use the word diet when discussing diets. And that is because our goal is to create health and sustainable eating habits. It is not to start a fad diet that's not going to be sustained after six months. So instead of focusing just on the calories, focus on the food quality. Meal prepping is so, so important. And in many individuals, it can be that single intervention that makes a large difference. Limit eating out, but don't make the patient feel like they have to eliminate it because it's not going to be sustainable. It's what we do socially. And we just need to focus more on making better health choices. Or you can do something like a tip that sometimes I give to patients is when you go to eat out, ask for a to-go container when you receive your food. And you put half of the food in that to-go container immediately. Then you spend the rest of that meal eating your food. You don't have to think about it. You don't have to feel guilty because you already restricted the amount of calories on there. And then you put that container in your fridge and you can eat it the next day. You can't eat it that same day. That's one tip. There's many other ways to do it. Things like increasing water intake and fiber is not only great for health reasons, but also it can increase satiety and decrease hunger. And so that works for some individuals. And then artificial sweeteners are still a bit controversial, but when we are just talking about weight loss, they are okay and probably actually do have a beneficial effect on weight loss. And that's all I'm gonna say about those. So talking about exercise, this is honestly what patients usually start talking about when you address weight. They say things like, oh, I need to go to the gym or I need to start running again. But when we're talking about weight loss, exercise is not good for it. So to do the amount of exercise that is recommended, which is 150 minutes per week of at least moderate weight loss exercise, you can lose a modest amount of weight of about two kilograms. But on an individual level, it is incredibly heterogeneous, meaning that that same 150 minutes per week can cause two kilogram weight loss in one person and then cause half of a kilo in another person. And so to produce clinically significant weight loss, there needs to be a lot of exercise. And for the general population, this is not practical or sustainable. However, we know that with lower volumes of exercise, even if the study didn't produce significant amount of weight loss, you still saw numerous health benefits, including glucose control, sleep quality, quality of life, mental health, et cetera. So I commonly tell patients that exercise is excellent for health reasons and for helping to keep the weight off. It's just not very important for getting the weight off, because again, you would have to do an incredible amount of exercise for that to happen. So tailor your physical activity recommendations to the patient. In many patients, you may decide to not focus on exercise right away and to just focus on physical activity with things like parking farther away from their office or taking a walk during their lunch break. And then you can work on increasing time and intensity over the next couple of visits. But in the beginning, it's focusing on kind of dietary changes, but then increasing their activity levels. The goal is 150 minutes of moderate intensity, which is for squawking, or 75 minutes of vigorous intensity exercising, such as like running. And this is per week. And then you also need to add on resistance training for two to three days of the week. And that is to keep the muscle mass so that it doesn't get lost with the weight as it comes off. And this last tip is an important one, because we definitely have studies showing that individuals who exercise eat more and they don't necessarily realize it. So make sure to caution against increasing your caloric intake with exercise. So I'm just gonna do a quick word on sleep. We'll talk about two studies that I find interesting, and I like to talk to patients about showing how sleep can affect or how it contributes to obesity. And so short sleep duration, like I said before, has been recognized as a risk factor. And that's because it increases ghrelin and decreases leptin levels, which leads to increases in hunger and appetite signals. But we have two cool studies here that this one there was over four weeks. They took a cohort of individuals who slept on average about six and a half hours a night. And they split them into two different groups. The first group just continued with what they normally did, and the second group tried to extend their sleep however much they could during the duration of the four weeks of the study. And over the course of the study, they found that in the extended sleep group, they lost on average 270 kilocalories per day more than the individuals who continued to do the average of six and a half hours a night. So extrapolated over three years, this would be 12 kilos of weight loss. So in other words, every one hour was 162 kilocalories of less calories, most likely because the time that they were sleeping, they weren't eating, and that's most likely what this study showed. But in this other study with the Nurses' Health Study of over 68,000 women who were followed over 16 years, at baseline and after age adjustment, they found that those sleeping five hours a night or less, they weighed on average of two and a half kilos compared to individuals who slept seven hours or more. When they followed these women over 16 years, they found that individuals who slept five hours or less on average were 32% more likely to have gained 15 kilograms in the last 16 years compared to those that slept seven hours or more. So obesity and sleep are closely connected, and sleep is something that has numerous effects on the body with obesity just being one of those and something that the patient can work on. There are many provider resources and clinical practice guidelines that can guide you in your management. You don't have to do it alone or try to remember everything that we discussed. There are wonderful guidelines that have tables and easy reference figures to help guide treatment. Here are some resources. It's not a comprehensive list, but one that I made that has both provider resources to help with management, but also some patient handouts that you can use in your clinic. Here's some example handouts. You can see Obesity Society. There's American College of Physicians, American Academy of Family Physicians, CDC. There's so many different resources. So don't feel like you have to go through so many different resources. So don't feel like you have to do it alone. Using these resources helps you to give education without overextending your visit and your appointment time. So I'll end my presentation similar to a patient encounter, and that is with billing. So as a lot of time is spent counseling in these appointments, it is important to know all the correct codes to reflect the time that you spent during that visit. So make sure to choose the right ICD-10 code, but also make sure that you're choosing the additional comorbidities that are discussed with obesity. So for instance, if the individual is coming in for diabetes and high blood pressure, and you just started the conversation and then scheduled them for obesity, those would be coded two different ways. The first way would be using the ICD-10 codes for all the diagnoses that you discussed, and then probably a time-based coding based on the amount of time that you did during that visit. Make sure that you're using the additional Z codes if you gave some dietary counseling. So in that first visit, you would use hypertension, diabetes, and then the obesity code, and then the BMI-Z code to specify the class of obesity that they have, and then the exercise or dietary counseling if it was done. On that follow-up visit, if they're coming in just for a discussion of obesity, evaluation and treatment, and the majority of that visit you're spent in counseling, then you would use the CPT code with the amount of time that was spent counseling along with the preventative care modifier of 33. So thank you so much for your time, effort, and care that each of you are putting in taking care of individuals who are overweight and obesity. As a team, we will work together to stop the rise in obesity by early identification and treatment. Thank you so much for listening. Have a good day.

obesity

treatment

diagnosis

complications

diet

exercise

resources