Completion of Cases A and B would be counted as 2 cases. Completion of only Case 35 B would only be counted as 0.5 case.
History
 |
Ms. Smith is a 40 y.o. female that comes to your preceptor’s office for a routine physical exam. She is an established patient. Before entering the room, you note that her blood pressure today is 156/94, consistent with prior readings. At a height of 5’6”, she weighs 250 lbs, which is up 5 pounds from her last visit 6 months ago. You note that on several visits to the office she has refused to have her weight checked. Looking at her “problem list” in the chart, you see no chronic medical problems recorded other than obesity. When you enter the room, Ms. Smith is standing and reading some health education materials posted on the exam room wall. After saying hello and introducing yourself, you invite Ms. Smith to take a seat in the chair. However, she prefers to sit on the exam table, because the exam room chairs are not large enough for someone her size. She needs your assistance getting up to the table. Once she is comfortable, you ask what brought her into the office today. Ms. Smith states that your physician preceptor had recommended a six month follow-up appointment for a weight and blood pressure evaluation following her last annual gynecology (PAP & pelvic) visit. She has no new physical complaints today, she denies any recent changes in her health, and she denies any chronic diseases or significant past medical history, other than obesity. When you ask how she feels about her health in general, she says that she feels ok. However, she would like to lose weight and feel more energetic. In your mind, you are formulating a list of questions that you should ask the patient, regarding her condition of obesity. Some of these questions relate to the history and development of her condition, some relate to a review of systems, and some relate to family and social history. Your questions should target those health risks that are associated with obesity. You should also address her understanding and concerns about her obesity, and any motivations or goals she might have concerning her weight.
|
Reference – U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality (www.ahrq.gov)
The U.S. Preventive Services Task Force “Guide to Clinical Preventive Services, 2006” (http://www.ahrq.gov/clinic/pocketgd/index.html) states the following:
SCREENING FOR OBESITY: Summary of Recommendations The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Rating: B Recommendation. The USPSTF concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. Rating: I Recommendation. This USPSTF recommendation was first published in: Ann Intern Med 2003;139:930-2. http://www.ahrq.gov/clinic/3rduspstf/obesity/obesrr.htm. |
--> The U.S. Preventive Services Task Force (USPSTF) grades its recommendations: A, B, C, D, or I for insufficient.
References –
Newman, Cathy. “Why Are We So Fat?” National Geographic, August 2004.
Louisiana State University Outpatient Management Manual http://www.sh.lsuhsc.edu/fammed/OutpatientManual.htm
George A Bray, MD. “Health Hazards Associated with Obesity in Adults.” UPTODATE.COM, updated 12/01/06.
Physical health risks associated with obesity:
- Individuals > 50% above their Ideal Body Weight (IBW) twice the mortality rate of the general population.
- Hyper-insulinemic states, glucose intolerance, & NIDDM; 85% of NIDDM patients are obese.
- Hypertension is three times more common in the obese population. The Framingham study reveals that, for every 10% weight increase above the "ideal," systolic blood pressure rises approximately 6.5 mm/hg.
- CAD incidence is increased in obese patients (> 50% increase) & morbidly obese (>90%)
- Other morbidities associated with obesity: emotional distress, reduced fertility, fatty liver disease, gall bladder disease, osteoarthritis/degenerative joint disease, LVH, cardiac dilatation, lipid abnormalities, stroke, sleep apnea, venous disease (including varicose veins and pulmonary embolism), cancer (endometrial (x3), breast, colon, prostate), and increased all-cause mortality.
Mental health risks associated with obesity:
- Psychological pain secondary to stigma, teasing, being socially ostracized
- Depression, especially in association with severe obesity, particularly in younger patients and in women
- impact on dating/marriage/sexuality
Socio-economic risks associated with obesity (from UpToDate):
- Increased disability and unemployment
- “Obese subjects are often exposed to public disapproval because of their fatness. This stigma is seen in education, employment, and health care, among other areas. In a study of over 10,000 adolescents, women who were overweight (defined as a BMI above the 95th percentile for age and sex) completed fewer years of school (0.3 year less), were less likely to be married (20 percent less likely), had lower household incomes ($6,710 less per year), and had higher rates of household poverty (10 percent higher) than the women who had not been overweight, independent of their baseline socioeconomic status and aptitude test scores [99] . Men who had been overweight were less likely to be married (11 percent less likely).
- In the Nurses' Health Study, women who gained weight had a deterioration in the quality of life, whereas those who lost weight, saw an improvement [100].”
History of present illness (HPI)
“CODIERS”: course, onset, duration, intensity, exacerbating/remitting factors, associated symptoms
- any recent weight gain or loss
- period of time at current weight
- any history of sudden weight gain
- history of childhood overweight/obesity
- weight at age 18-20 --> history of weight gain since 18-20
- anything associated with weight gain – pregnancy, health problems, medications, lifestyle changes
- any symptoms or conditions associated with obesity – joints, breathing/sleeping, menstruation/fertility, mental health – depression/anxiety, and social function – job/activities/relationships
- any attempts at weight loss
- any specific health concerns about her obesity; any specific motivations or goals concerning losing weight
- patient should describe her desire to feel “more energetic” more specifically – is she feeling chronic fatigue, easy onset fatigue, poor conditioning, depression, sleepiness, light-headedness? --> repeat CODIERS, if necessary
Past medical history (PMH)
“CHAMIS”: chronic diseases, hospitalizations, allergies, medications, immunizations, surgeries
- focus on risk factors – presence of underlying diseases/conditions, like CAD, PAD, AAA, carotid artery disease, DM or impaired fasting glucose, sleep apnea, gynecological abnormalities, osteoarthritis, stress incontinence, gallstones, cigarette smoking, hypertension, serum triglycerides, HDL & LDL, age (men >45 & women > 55)
- focus on causes of obesity – genetic/congenital disorders, endocrine disorders, psychiatric, iatrogenic
- genetic/congenital – Prader-Willi, leptin deficiency, etc.
- endocrine disorders – PCOS, Cushing’s syndrome, hypothyroidism or other thyroid problems, hypothalamic disturbance/surgery, hypo-gonadism, pseudo-hypo-parathyroidism
- any history of drugs known to cause weight gain (e.g., steroids)
Reference – George A Bray, MD. “Clinical evaluation of the overweight adult.” UPTODATE.COM, updated 2/13/06.
Many medications can cause weight gain, and several classes of medications contain particularly well-known offenders: neuroleptics/anti-psychotics, tricyclic anti-depressants, anti-convulsants, anti-diabetics, and steroids.
Copyright © 2001 George A Bray, MD. Reproduced with permission.
Social history (SH)
“HEADS” assessment: home environment, education/employment/eating/exercise, activities/arrests/alcohol, drugs (including tobacco products), sexuality/safety/suicide/spirituality
- focus on causes of obesity – dietary, lifestyle, and mental health
- unusual eating practices – such as overeating, night-eating syndrome, binge eating and other eating disorders
- unhealthy eating habits – high calorie, high fat, low fiber, low nutrient, fast/convenience foods, irregular meals
- mental health – depression, anxiety, eating disorders
- physical activity – sedentary lifestyle, exercise habits, post-operative inactivity, disability, aging, etc.
- weight of other household members, including spouse/partner
Family History (FH)
- other family members that are obese and any medical causes of obesity – endocrine, psychiatric, etc.
- medical concerns that can be affected by obesity – diabetes, heart disease, cerebralvascular disease, etc.
History Continued
History of Present Illness (HPI)
- as noted above, she has gained 5 lbs since her last office visit 6 months ago
- she seems to put a little more weight on each year, but she doesn’t really pay close attention by weighing herself regularly at home; she’s been over 200 lbs for at least 10 years; she thinks that the last time she was at 185 lbs was probably in her mid-20’s
- she’s experienced weight gain of a few pounds when she’s been placed on prednisone intermittently for severe “poison ivy”; she also notes that her mood becomes erratic and depressed when she is on the prednisone
- the most dramatic weight gain she experienced was when she was pregnant and had gestational diabetes when her daughter was born 15 years ago; she gained 50 lbs during the pregnancy and only lost 15 lbs following delivery
- she reports being a bit “pudgy” as a young girl and teenager, being self-conscious of her appearance, and occasionally being teased by her friends and scolded by her parents
- she thinks she gained another 10-15 lbs over 4 years of college, and reiterates that she was probably about 185 lbs in her mid-20’s; most of her significant weight gain has happened since then – about 65 lbs over 15 yrs (<5 lbs/yr)
- she attributes her initial significant weight gain to her pregnancy, but her gradual increasing weight she attributes to her lifestyle once she finished school and began working in an office setting
- she does think that her weight is to blame for her general lack of energy; she also feels that her weight affects her general enjoyment of life; she does feel “blue” from time to time, but hasn’t been frankly depressed; she says that she does not do many of the physical activities she did when she was younger, such as playing soccer or swimming or jogging, because of her weight; she feels that her weight has affected her social functioning, in that she doesn’t feel very confident anymore and no longer dates or thinks that she will remarry or have any more children; she is unsure if the weight has affected her breathing/sleeping, menstruation/fertility, or joints
- she signed up for “Jenny Craig” once, but she was unable to stick to the plan, because of eating out
Past Medical History (PMH)
- she has no other chronic illnesses of which she is aware; other than childbirth, she was only hospitalized on one other occasion – when her gallbladder was removed; she takes no medications right now, other than a woman’s multivitamin with iron; however, she has experimented with a couple of over-the counter appetite suppressants without any success; she is not allergic to any medications; she was fully immunized as a child, and she received a DTaP (diphtheria, tetanus, and acellular pertussis) booster at the time of gyn appointment 6 months ago
- she denies any genetic, congenital, or endocrine disorders
Social History (SH)
- Home Environment – She lives with her 15 year old daughter, with whom she is fairly close; she notes that her daughter (also a patient of the precepting physician) is also overweight. She does not often cook full meals, and she and her daughter eat a lot of frozen pre-prepared foods for dinner. She has both family and friends in the area, and she often goes out to dinner with them.
- Education/Employment – She went to college and now works in the development office for a large non-profit organization, doing a lot of grant-writing. Thus, she is very sedentary at work, and she is in an office environment with lots of “goodies” regularly around in the break room.
- Eating/Exercise – She rarely exercises anymore, because she does not really feel comfortable going to the gym and working out in public. She does not really feel that she could play any type of organized sports anymore, because she is so heavy and out-of-shape. However, she has no physical disability. She denies any unusual eating practices or eating disorders, except for binge-eating. She says that she does not eat a lot of fast food, but she does eat a lot of sweets both at work and at home. She also eats out a lot.
- Activities – She likes to read and to do volunteer work at the local museums and other community organizations. She likes to spend time with her friends and family, which usually revolves around meals, especially going out to dinner or having people over to dinner.
- Alcohol/Drugs/Tobacco/Caffeine – She does drink alcohol on occasion, but usually one 1 or 2 glasses of wine or beers. She has never smoked and does no drugs. She usually has 2-3 cups of coffee at work each day.
- Sexuality/Safety – She has not had sex in several years now, since her divorce, but she was sexually active with boyfriends prior to her marriage. She used birth control, and she has been screened for both HIV and other sexually transmitted infections, the results of which have been negative.
- Suicide/Depression – She feels that she borders on depression, and she is concerned about her eating habits, particularly when she binge eats; she feels that she eats more when she gets down. She’ll have difficulty with her sleep on occasion, when she is really worried about her bills. She denies suicidal ideation.
- Spirituality – She believes in God and grew up being very involved in her church, but her family stopped going once they moved and the kids got older and went to college. She says she would like to get involved in a church community, particularly for her daughter’s benefit.
Family History (FH)
- Her parents are in their 60’s and are both overweight. Her mother has diabetes and hypertension. Her father, who smokes too much, had a mild heart attack about a year ago. Her grandparents all died of heart attacks in their late 70’s and 80’s, and she thinks that most of them had high blood pressure and high cholesterol. No one has had a stroke, except for her grandfather’s sister in her late 70’s.
- Both of her grandmothers had breast cancer, but there is not history of endometrial cancer.
- Several members of her family – mother, aunt, cousins, and grandmothers – have suffered from depression, but there have been no suicides.
- Her younger sister is also overweight and has an underactive thyroid; she has also had her gallbladder removed.
References –
Newman, Cathy. “Why Are We So Fat?” National Geographic, August 2004.
George A Bray, MD. “Overview of therapy for obesity in adults.” UPTODATE.COM, updated 11/17/06.
Louisiana State University Outpatient Management Manual http://www.sh.lsuhsc.edu/fammed/OutpatientManual.htm
(a) Technology (TV/video games and cars/buses, washing machines, elevators, etc) allows for less energy expenditure, while increased prosperity, stable food supply/markets, and the rise of the food industry (prepared/packaged foods, snack foods, fast food, etc) has allowed for an increased intake in daily calories, sugar and fat, often with a coinciding decrease in nutrition and fiber.
(b) Countries with > 25% obesity: United States, Mexico, Russia, Turkey, Egypt, South Africa, Thailand, Samoa
(c) -->65% of the U.S. population is overweight; 20-40% of the U.S. population is obese
CDC’s annual telephone survey, “Behavioral Risk Factor Surveillance System (BRFSS)”:
~ 20% of the population self-identified data (i.e., weight) that qualified them as obese. Note that under-reporting weight and over-reporting height are common, which would case this data to under-estimate the true prevelance of obesity.
Direct measurement field-survey “National Health and Nutrition Examination (NHANES)”:
~ 30% of the population qualified as obese, and ~ 55% of patients with type II DM qualified as obese
From 1991 to 2004, the number of state with > 15% obesity dramatically increased from 4 states to all 50 states!
40% of the U.S. population is obese at 20+% above IBW
20% of the U.S. population is 40+% above IBW
Annual cost of obesity and its complications = ~ $40 billion, or ~ 5.5% of U.S. health care costs
Reference – George A Bray, MD. “Overview of therapy for obesity in adults.” UPTODATE.COM, updated 11/17/06.
“Framingham Heart Study” – For men and women ages 30, 40, and 50 who had a normal BMI at baseline, the risk of becoming overweight & obese was:
- at 4 yrs:
- 14-19% of women & 26-30% of men had become overweight;
- 5-7% of women & 7-9% of men had become obese (BMI > 30)
- at 30 yrs:
- 50% of all participants had become overweight;
- 25% had become obese (BMI > 30)
(a)
- Obesity rates are higher among low SES and minority groups
- Non-Hispanic White Adults: ~30%, Non-Hispanic Black Adults: ~45%, Mexican-Americans: ~37%
- Adult Men: no significant differences in prevalence for members of different racial/ethnic groups
- Adult Women: highest prevalence among non-Hispanic blacks (age 40+, > 50% obese & > 80% overweight)
- Children & adolescents: white rates of overweight/obesity inversely proportional to SES; inverse relationship between weight & SES now weakening and differences between those of high and low SES are becoming less pronounced; blacks > whites, across all socio-economic status (SES) levels
Reference #1 – Flegal KM, Carroll MD, Ogden CL, Johnson CL. National Center for Health Statistics, Centers for Disease Control. Prevalence and trends in obesity among US adults, 1999-2000. JAMA, 2002 Oct 9; 288(14): 1723-7.
“Survey of 4115 adult men and women conducted in 1999 and 2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared with 22.9% in NHANES III (1988-1994; P<.001). The prevalence of overweight also increased during this period from 55.9% to 64.5% (P<.001). Extreme obesity (BMI > or = 40) also increased significantly in the population, from 2.9% to 4.7% (P =.002). Although not all changes were statistically significant, increases occurred for both men and women in all age groups and for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did not differ significantly in the prevalence of obesity or overweight for men. Among women, obesity and overweight prevalence were highest among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or older were obese and more than 80% were overweight.”
Reference #2 – Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. National Center for Health Statistics, Centers for Disease Control and Prevention. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA, 2006 Apr 5; 295(13): 1549-55.
“Overweight among children and adolescents was defined as at or above the 95th percentile of the sex-specific body mass index (BMI) for age growth charts. Obesity among adults was defined as a BMI of 30 or higher; extreme obesity was defined as a BMI of 40 or higher. In 2003-2004, 17.1% of US children and adolescents were overweight, and 32.2% of adults were obese. The prevalence of extreme obesity (body mass index > or =40) in 2003-2004 was 2.8% in men and 6.9% in women. In 2003-2004, significant differences in obesity prevalence remained by race/ethnicity and by age. Approximately 30% of non-Hispanic white adults were obese as were 45.0% of non-Hispanic black adults and 36.8% of Mexican Americans. “
Reference #3 – Wang Y, Zhang Q. Center for Human Nutrition, Bloomberg School of Public Health, Johns Hopkins University. Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the association between overweight and family income between 1971 and 2002. Am J Clin Nutr., 2006 Oct; 84(4): 707-16.
“We examined secular trends in the relation between overweight and SES using nationally representative data collected in the National Health and Nutrition Examination Surveys (NHANES) between 1971 and 2002 for 30, 417 US children aged 2-18 y. Poverty income ratio tertiles at each survey were used to indicate low, middle, and high SES. Considerable race, sex, and age differences were observed in the association between overweight and SES. A reverse association only existed in white girls; African American children with a high SES were at increased risk. Socioeconomic disparities in overweight have changed over time, with an overall trend of weakening…Between 1988-1994 and 1999-2002, the ratio in the prevalence of overweight between adolescent boys with a low or high SES decreased from 2.5 to 1.1 and from 3.1 to 1.6 in girls. Consistently across almost all SES groups, the prevalence of overweight was much higher in blacks than in whites. Complex patterns in the association between SES and overweight exist. Efforts solely targeting reductions in income disparities probably cannot effectively reduce racial disparities in obesity.”
(b)
- Immigrants have higher rates of obesity the longer they live in the US.
Reference #1 – Goel MS, McCarthy EP, Phillips RS, Wee CC. Obesity among US immigrant subgroups by duration of residence. JAMA, 2004 Dec 15; 292(23): 2860-7.
“Among different immigrant subgroups, number of years of residence in the United States is associated with higher BMI beginning after 10 years. The prevalence of obesity among immigrants living in the United States for at least 15 years approached that of US-born adults… The age- and sex-adjusted prevalence of obesity was 8% among immigrants living in the United States for less than 1 year, but 19% among those living in the United States for at least 15 years. The association for 15 years or more was significant for all immigrant subgroups except foreign-born blacks. Additionally, immigrants were less likely than US-born individuals to report discussing diet and exercise with clinicians (18% vs 24%, P<.001; 19% vs 23%, P<.001, respectively). These differences were not accounted for by sociodemographic characteristics, illness burden, BMI, or access to care among some subgroups of immigrants.”
Reference #2 – Kaplan MS, Huguet N, Newsom JT, McFarland BH. The association between length of residence and obesity among Hispanic immigrants. Am J Prev Med, 2004 Nov; 27(4): 323-6.
“Newly arrived Hispanic immigrants are generally healthier than the U.S.-born population, but this distinction tends to diminish over time as immigrants adapt to a new and different sociocultural environment...A logistic regression model adjusted for smoking, physical inactivity, self-assessed health, chronic conditions, functional limitations, nonspecific psychological distress, several sociodemographic characteristics, and access to health services found that longer-term Hispanic immigrants (> or =15 years) experienced a nearly four-fold greater risk of obesity than did recent immigrants (<5 years)…The higher risk for obesity associated with length of residence may be due to acculturation processes such as the adoption of the unhealthy dietary practices (i.e., a diet high in fat and low in fruits and vegetables) and sedentary lifestyles of the host country.”
Reference #3 – Himmelgreen DA, Perez-Escamilla R, Martinez D, Bretnall A, Eells B, Peng Y, Bermudez A. The longer you stay, the bigger you get: length of time and language use in the U.S. are associated with obesity in Puerto Rican women. Am J Phys Anthropol, 2004 Sep; 125(1): 90-6.
“This cross-sectional study examined whether length of time in the U.S., language use, and birthplace (proxy measures of acculturation) were associated with body mass index (BMI) and obesity in a sample of 174 low-income Puerto Rican women from Hartford, Connecticut. The mean BMI for the total sample (N = 174) was 27.39 (S.D. = 5.07), and nearly 34% of the sample was considered obese (BMI > or = 30). There was a statistically significant increase in BMI with length of time in the U.S. (P = 0.012) and these differences were even greater among women born in Puerto Rico (P = 0.003). Moreover, obesity prevalence was highest among women who had been in the U.S. for 10 years or more (40%), as compared to those who had been in the U.S. less than 1 year (29%; P = 0.045).”
Reference – Newman, Cathy. “Why Are We So Fat?” National Geographic, August 2004.
- To gain an extra 10 lbs each year (approximately 1 lb. per month), you only have to consume an extra 100 calories (~ 1 small glass of juice) or burn 100 calories fewer per day (drive instead of walk or take the escalator instead of stairs).
Playing a video game (53 calories) vs. Playing basketball (280 calories)
Riding the elevator for 2 minutes. (3 calories) vs. Taking the stairs for 2 minutes. (19 calories)
Ordering take-out for dinner (1 calorie) vs. Cooking a meal at home (70 calories)
Loading a dishwasher for 10 minutes. (23 calories) vs. Washing dishes by hand (80 calories)
Going to a car wash (35 calories) vs. Washing a car at home (104 calories)
In 1960, less than 65% of adults drove to work, compared with almost 90% in 2000.
In 1960, more than 20% took public transportation or walked to work, compared with ½ that 2000.
CDC Report on Urban Sprawl and Public Health
http://www.cdc.gov/healthyplaces/articles/Urban%20Sprawl%20and%20Public%20Health%20-%20PHR.pdf
CDC’s National Center for Environmental Health (http://www.cdc.gov/nceh/eehs/)
“Designing & Building Healthy Places” (http://www.cdc.gov/healthyplaces/): As the leading public health agency in the United States, the Centers for Disease Control and Prevention (CDC) scientifically considers all factors that affect the health of the nation. As we embark into the 21st century, the interaction between people and their environments, natural as well as human-made, continues to emerge as a major issue concerning public health. Healthy places are those designed and built to improve the quality of life for all people who live, work, worship, learn, and play within their borders -- where every person is free to make choices amid a variety of healthy, available, accessible, and affordable options.
Health Issues as Related to Community Design
CDC recognizes several significant health issues that are related to land use, including--
- Accessibility of Community Resources, including Health & Social Welfare Services
- Children's Health & the Built Environment
- Elders' Health & the Built Environment
- Gentrification
- Health Impact Assessment
- Injury
- Mental Health
- Physical Activity
- Respiratory Health & Air Pollution
- Social Capital
- Water Quality
Built Environment and Land Use: Promotes healthy community design. Provides technical assistance for health impact assessments (HIAs), which can be used to evaluate objectively the potential health effects of a project or policy before it is built or implemented. The HIA process brings public health issues to the attention of persons who make decisions about areas that fall outside of traditional public health arenas, such as transportation or land use.
Reference – George A Bray, MD. “Clinical evaluation of the overweight adult.” UPTODATE.COM, updated 2/13/06.
- High blood pressure
- Abnormal cardiac exam, reflecting cardiomyopathy or ventricular hypertrophy
- Neck fullness/soft palate/uvular fullness – potential markers of sleep apnea
- Goiter/thyroid enlargement/nodularity – hypothyroidism is common in obese females
- Central obesity
- Stretch marks (striae) – reflect the tension on the skin from expanding subcutaneous deposits of fat.
- Incisional hernia at the site of her choecystectomy surgical scar
- Increased liver span/hepatosplenomegaly – may be non-alcoholic steatohepatitis (NASH) or “fatty liver”
- Acanthosis nigricans – deepening pigmentation around the neck, axilla, knuckles, and extensor surfaces, may occur in connection with obesity and reflects sustained hyperinsulinemia
- Hirsutism – male pattern hair growth and distribution in women may result from increased production of testosterone, which is often associated with visceral obesity
- Skin tags – commonly seen in patients with metabolic syndrome
- Varicose veins
- Peripheral edema
- Arthritis
Physical Exam
General: 40 y.o. well-developed obese (not well-nourished) female appearing her stated age; appropriate dress and hygiene; alert, oriented, pleasant, cooperative; appropriate speech and affect; no acute distress
HEENT: normocephalic, atraumatic; PERRLA; EOM intact; anicteric sclera; mucous membranes moist; good dentition; obese neck; no carotid bruits; no lymphadnopathy; no thyroid enlargement or nodules appreciated
Lungs: clear to auscultation bilaterally
Heart: regular rate and rhythm; no murmurs, rubs or gallops
Abdomen: obese with striae; soft, non-tender, and reducible incisional hernia at the site of open cholecystectomy scar (her gall bladder had been severely inflamed, so they were unable to remove it laproscopically); normal bowel sounds present in all 4 quadrants; non-tender, non-distended; no hepatosplenomegaly appreciated
Extremities: obese; equal bilaterally; no bruising, cyanosis, clubbing, or pitting edema; varicose veins present bilaterally on lower extremities; warm and non-tender to the touch; normal capillary refill (<5 seconds); distal pulses present
In order to better gauge the significance of her weight, you quickly plug her height and weight into the CDC’s online Body Mass Index (BMI) calculator at http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm.
Please answer the following questions regarding the patient’s BMI:
(a) What is this patient’s BMI, and what is the interpretation of that number?
(b) What weight would she need to have to be at a BMI < 30 or < 25? Thus, how much weight would she ideally need to lose to reach each of those goals?
(c) How do you define obesity and morbid obesity using BMI and Ideal Body Weight (IBW)?
References –
United States Government Center for Disease Control (CDC) http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm
Louisiana State University Outpatient Management Manual http://www.sh.lsuhsc.edu/fammed/OutpatientManual.htm
(a) Ms. Smith’s BMI = 40.3 = morbidly/severely obese.
(b) To be at a BMI > 30, she would need to weigh less than 185 lbs --> weight loss of 65 lbs.
(b) To be at a BMI > 25, she would need to weigh less than 155 lbs --> weight loss of ~100 lbs.
For patients that are morbidly obese, the amount of weight that they should ideally lose can be overwhelming. It may have been a long time since they were at a “normal” weight, they may never have been at a “normal” weight as an adult, and it may not seem realistic or attainable to achieve a “normal” weight. Thus, it may prove useful to use an intermediate goal weight, such as one that might qualify them as “over-weight” but non-obese. This too can be a challenging goal for many patients, including Ms. Smith. A more reasonable and realistic goal might be a 10 lb. weight loss in a 2 month period, followed by maintenance of weight loss, and then subsequent and similar weight loss increments.
(d) Obesity can be defined as a BMI > 30 or >20% above a person’s Ideal Body Weight (IBW).
(d) Morbid obesity can be defined as a BMI >40 or >50% above a person’s IBW or 100lbs above IBW.
Although BMI is becoming the standard weight calculation, you should be familiar with IBW:
IBW calculation for women* = 100 lbs for 1st 5 feet of height + 5 lbs for each additional inch about 5 feet
(* Does not account for bone structure or a person’s “frame”.)
Interpretaion: usually given as a range with +/- 10% of calculated IBW
Example: 5’6” = 100 + (5x6) = 130 lbs --> +/- 10% or 13 lbs --> 117 – 143 lbs. (up to 160 for large frame)
Reference – United States Government Center for Disease Control (CDC) http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/about_adult_BMI.htm
--> BMI calculation is the same for adults and children, but BMI interpretation using the standard weight status categories below is only appropriate for both males and females over the age of 20.
Reference – United States Government Center for Disease Control (CDC) http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/about_adult_BMI.htm
--> BMI calculation is the same for adults and children, but BMI interpretation using the standard weight status categories below is only appropriate for both males and females over the age of 20.
Reference – United States Government Center for Disease Control (CDC) http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm
BMI is calculated using the same formula for all ages. However, the interpretation of BMI is both age- and sex-specific for patients under the age of 20. BMI is calculated using weight and height and then used to find the corresponding BMI-for-age percentile for age and sex. BMI-for-age percentile shows how your child’s weight compares to that of other children of the same age and sex. For example, a BMI-for-age percentile of 65% means that the child’s weight is greater than that of 65% of other children of the same age and sex. A child with a BMI-for-age percentile of 85% or greater is considered to be at risk for overweight, and a child with a BMI-for-age percentile of 95% or greater is considered to be overweight.
BMI Percentile Calculator for Children and Teens – http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx
 underweight, less than the 5th percentile healthy weight, 5th percentile up to the 85thpercentile at risk of overweight, 85th to less than the 95th percentile overweight, equal to or greater than the 95th percentile |
Reference: American Family Physician, Journal of the American Academy of Family Physicians. July 1, 2004
(a) Yes, a higher BMI in adolescence is a predictor of adult obesity.
(b) Adult body weight is directly related to adolescent body weight, as is change in leisure time physical activity. Over the same time period, leisure time physical activity can also predict the risk for being overweight as an adult.
Excerpt by Karl E. Miller, MD in “Predictors of Obesity from Adolescence to Adulthood”:
“Kvaavik and associates tracked the BMI from adolescence to adulthood in a group of persons and examined the effect of identified risk factors for obesity. They also evaluated changes in lifestyle factors as predictors of adult obesity... The study was a longitudinal tracking of a cohort of persons from six schools in Oslo, Norway over a period of 18 to 20 years… The adolescent's BMI, the father's BMI, the subject's own leisure time physical activity, adult smoking, and sex explained a significant degree of the variation of the adult BMI. The participants who had a higher BMI as an adolescent had the highest risk for having an adult BMI of 30 or greater. Participants who were in the lowest two quartiles of BMI at adolescence were less likely to have a high adult BMI. Participants who increased their leisure time physical activity from adolescence into adulthood were less likely to be obese compared with those whose activity level was stable or decreased over the study period… The study findings suggest that adult body weight is directly related to adolescent body weight. Change in leisure time physical activity over the same time period can predict the risk for being overweight as an adult. According to the authors, the implication of this study is that physical activity should be emphasized during adolescence and should include the parents.”
Kvaavik E, et al. Predictors and tracking of body mass index from adolescence into adulthood. Follow-up of 18 to 20 years in the Oslo Youth Study. Arch Pediatr Adolesc Med December 2003;157:1212-18.
Reference – U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality (www.ahrq.gov)
The U.S. Preventive Services Task Force “Guide to Clinical Preventive Services, 2006” (http://www.ahrq.gov/clinic/pocketgd/index.html) states the following:
A number of techniques, such as bioelectrical impedance, dual-energy x-ray absorptiometry, and total body water can measure body fat, but it is impractical to use them routinely. Body mass index (BMI), which is simply weight adjusted for height, is a more practical and widely-used method to screen for obesity. Increased BMI is associated with an increase in adverse health effects. Central adiposity increases the risk for cardiovascular and other diseases independent of obesity. Clinicians may use the waist circumference as a measure of central adiposity. Men with waist circumferences greater than 102 cm (> 40 inches) and women with waist circumferences greater than 88 cm (> 35 inches) are at increased risk for cardiovascular disease. The waist circumference thresholds are not reliable for patients with a BMI greater than 35.
Reference – George A Bray, MD. “Clinical evaluation of the overweight adult.” UPTODATE.COM, updated 2/13/06.
Patients with a BMI < 30 are not generally considered obese. However, central adiposity is an independent risk factor for cardiovascular disease. Patients with a BMI < 30 can still be at risk if they have a large waist circumference. For adults with a BMI 22-29, a waist circumference > 32 inches for men and > 28 inches for women adds additional health risks. For adults with a BMI >35, waist circumference greater than 40 inches for men and 35 inches for women increases associated disease risk for diabetes mellitus type II, hypertension, and cerebral-vascular disease.
BMI: body mass index. The evaluation and adjustment of BMI for the added risk of central fat is done for individuals with a BMI below 30 kg/m2. By permission from George A Bray, MD.
A patient’s BMI may need to be “adjusted” to increase if there has been dramatic weight-gain after the age of 18-20, or if there are other obesity-related co-morbidities, such as osteoarthritis, sleep apnea, high blood pressure, or an elevated lipid ratio. These adjustments allow the BMI to better characterize the severity of the patient’s health condition.
--> Up to 3 points can be added onto a BMI in each of 5 categories, leading to a maximum increase in the BMI of 18 points.
Adjusted body mass index (BMI).
Adjusted scores for body mass index when taking into consideration other metabolic variables. For example, an individual with a BMI of 30 kg/m2 who also has sleep apnea would have an adjusted BMI of 33 kg/m2. By permission from George A Bray, MD
Reference – George A Bray, MD. “Clinical evaluation of the overweight adult.” UPTODATE.COM, updated 2/13/06.
--> Blood pressure, serum triglycerides, serum HDL-Cholesterol, fasting blood glucose
Clinical and laboratory data check-list for the evaluation of overweight patients:
Once you have reviewed Ms. Smith’s history and physical exam with your preceptor in the room, you need to formulate your assessment and plan. What statements are you going to make regarding the following aspects of her health care plan?
a) Like any other interaction between two people, the interaction between doctor and patient involves communication on a number of level s– not merely verbal. For example, a physician’s posture, facial expression, eye contact, tone of voice, and touch are all a part of communication with a patient. This non-verbal communication is often what indicates respect, interest, understanding, and empathy for the patient. Additionally, it is important for the physician to use “active” or “reflective” listening when taking a patient’s history, acknowledging and validating a patient’s specific concerns about their health. For example, you might say the following to Ms. Smith: “I understand that you are concerned about your weight and lack of energy; I can certainly understand how difficult and frustrating it can be to try and lose weight.”
(b) After acknowledging how her frustrations regarding weight loss, it is important to let the patient know that you would like to be able to support her in the process of losing weight and living a healthy lifestyle. Let her know that you can offer her a large body of professional advice that has worked for many patients and that you can work with her to identify various weight-loss strategies that might be appropriate for her situation and needs. Lastly, and perhaps most importantly, you can professionally advise her on the serious health, well-being, and quality of life problems that result from obesity, such as her own high blood pressure and limitations on relationships and activities.
It is important to acknowledge and address two general aspects of Ms. Smith’s obesity - her large weight gain with pregnancy, in addition to pointing out her gradual and persistent continued weight gain over many years. It is critical to ask her what environmental causes and personal behavior she feels have contributed to her slower, ongoing weight gain over the years. The patient must feel involved, engaged, and empowered in the health education and behavior change process. The physician can use prompts to make sure that she does not forget to think about several different areas of her life that might be contributing. For example, the physician might prompt the patient by saying, “what about your office/work environment?” The physician might lead the patient to think about her office/work environment by saying, “When you were talking earlier, you mentioned that there are often sweets in the break room.” Some causes to consider that can lead to being overweight include: having weight problems in the family; eating when lonely, sad, bored, or stressed; feeling pressured to eat by friends, family, co-workers, or other social situations; using food for recreation; eating just because food is available, regardless of hunger; taking medicine that causes hunger; hormone problems that slow metabolism. For future reference, it would be helpful to both patient and physician to note a list of causes that are identified and discussed.
A similar tact should be taken for Ms. Smith’s fatigue, or lack of energy. She should first be asked for her thoughts on its etiology. She should be asked if she feels that it might be related to her weight gain, physical conditioning, diet, etc. If needed, the physician should educate her on the relationship between obesity and fatigue. However, the physician should also explain that there are other conditions that commonly cause fatigue, such as iron deficiency anemia and hypothyroidism. The patient should be reassured that the physician will adequately investigate other possible causes of fatigue to identify and treat any conditions that might be present, other than obesity.
After discussing the causes of Ms. Smith’s obesity, it is again important to first ask for her input as to what she would like to pursue in terms of weight loss. She may or may not have healthy, realistic ideas about how she would like to lose weight, but it is very likely that she has thought about her weight and potential weight loss a great deal. Her own ideas must be elicited and addressed before the physician tries to give her new ideas. Remember, a physician’s advice is only as good as the patient’s implementation of that advice. Thus, the patient must be actively involved in a discussion such as this one. Only decisions that Ms. Smith embraces will she be likely to successfully implement. If you do not directly ask her about how she would like to lose weight, there may not be another opportunity during the office visit for you to find out how Ms. Smith is thinking and to obtain crucial information about her decision-making process.
This might also be helpful to specifically identify where she is in the 5 Stages of Change: pre-contemplation, contemplation, planning, action, maintenance. For example, she might say one of the following statements:
- Pre-contemplation – “I don’t want to lose weight.” or “I don’t want to change the way I eat or exercise.”
- Contemplation – “I would like to lose weight, but I am not ready to make changes right now.”
- Preparation – “I am ready to lose weight and change the way I eat and the amount I exercise.”
- Action – “I have already changed the way I eat and the amount I exercise.”
- Maintenance/Relapse Prevention – “I have successfully made lifestyle changes, and I am no longer obese.”
Ms. Smith identifies both her lack of physical activity and her consistent “unhealthy” eating as the major causes of her obesity. In particular, she identifies sweets as her major weakness and source of extra calories. At the office, she often eats doughnuts, breakfast pastries, cookies, cake, chocolates, and other such items that are available in the break room. She also likes to bake cookies and cakes at home, she and her daughter occasionally buy ice cream to have for desert, and she often orders desert when she goes out to eat dinner with friends and/or family. Additionally, Ms. Smith also recognizes that her fatigue is probably just because she is “so out of shape and overweight”. She often does not do any exercise after work, because she does not feel that she has the energy. However, she realizes that she would feel more energetic if she got more exercise and was stronger and healthier.
Ms. Smith would like to lose weight by eating healthier and getting more exercise, but she does not feel that she is able to successfully make those changes. She does not have confidence in her “will power” to overcome temptation and bad habits. She is discouraged, because she feels that she has thought about making lifestyle changes for so long and failed to ever implement them. She does not seem open to the idea of exercise and dietary changes. When you ask her about how she would like to lose weight, she says that she has been thinking about having gastric bypass surgery for some time and feels that this is the only way that she might be successful in losing weight.
Ms. Smith needs to be informed that surgery is rarely the first-line treatment for obesity. She needs to be educated on the dangers and complications of gastric surgery. The physician must also inform her as to the circumstances when this surgery is considered to be a clinically appropriate treatment for obesity by the medical profession.
Reference – Newman, Cathy. “Why Are We So Fat?” National Geographic, August 2004.
Gastric bypass surgery:
- major surgery that reduces the stomach’s capacity “from wine bottle to shot-glass size” and alters the small intestine
- reduces patient’s ability to eat large meals
- provokes “dumping syndrome that causes flushing, nausea, sweating” if patient eats sugar or fatty foods
- operation fails ~15% of patients; 2/3 of patients lose excess weight within one year of surgery
- surgical risks include: pulmonary embolus, pneumonia, infection, leakage from the altered intestinal tract, death
- 1/100 surgical cases results in death
Reference – Louisiana State University Outpatient Management Manual http://www.sh.lsuhsc.edu/fammed/OutpatientManual.htm
“Jejunoileal bypass resulted in significant weight loss for the majority of selected patients; however, it had a very high morbidity rate and considerable mortality risk. Gastric stapling procedures averaged an approximately 60% excess weight loss. Morbidity and mortality with this procedure are less than with the above procedure, but are still real considerations. The recidivism rate, regardless of the intervention, is high.”
Reference – U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality (www.ahrq.gov)
The U.S. Preventive Services Task Force “Guide to Clinical Preventive Services, 2006” (http://www.ahrq.gov/clinic/pocketgd/index.html) states the following:
“There is fair to good evidence to suggest that surgical interventions such as gastric bypass, vertical banded gastroplasty, and adjustable gastric banding can produce substantial weight loss (28 to > 40 kg) in patients with class III obesity. Clinical guidelines developed by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel on the identification, evaluation, and treatment of overweight and obesity in adults recommend that these procedures be reserved for patients with class III obesity and for patients with class II obesity who have at least 1 other obesity-related illness. The postoperative mortality rate for these procedures is 0.2 percent. Other complications include wound infection, re-operation, vitamin deficiency, diarrhea, and hemorrhage. Re-operation may be necessary in up to 25 percent of patients. Patients should receive a psychological evaluation prior to undergoing these procedures. The long-term health effects of surgery for obesity are not well characterized. “
(a) 10 treatment options: dietary restrictions, 500-800 calaries/day supervised diet, jaw-wiring, amphetamines, thyroid supplementation, diuretics, orlistat, sibutramine, gastric bypass, gastric stapling, and liposuction.
(b) “The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to help patients acquire the skills and supports needed to change eating patterns and to become physically active. The 5-A framework (Assess, Advise, Agree, Assist, and Arrange) has been used in behavioral counseling interventions such as smoking cessation and may be a useful tool to help clinicians guide interventions for weight loss…It is advisable to refer obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss. The USPSTF defined intensity of counseling by the frequency of the intervention. A high-intensity intervention is more than 1 person-to-person (individual or group) session per month for at least the first 3 months of the intervention.”
Reference – Louisiana State University Outpatient Management Manual http://www.sh.lsuhsc.edu/fammed/OutpatientManual.htm
Treatment of obesity:
- Multifactorial disease à multifaceted treatment approach: proper diet, behavior changes, and increased exercise +/- medications and even surgical interventions
- Exercise is essential to increasing energy expenditure and promote physical fitness.
- Mild to moderate dietary restrictions (i.e., in the range of 1000 to 2000 calories per day) necessitate little medical supervision in the otherwise healthy obese patient, as long as the diet fulfills all general nutritional requirements.
- A very low calorie diet (i.e., in the range of 500 to 800 calories per day) requires close medical screening and supervision. The so-called liquid protein diets often fit into this category (Table 1). Unsupervised, these diets can be very dangerous, and fatalities due to cardiac-related factors have been associated with them.
- Jaw wiring and in-hospital supervised starvation also have been used to treat this disease.
- Medications -- from amphetamines to thyroid preparations to diuretics -- have been employed to assist individuals in weight loss (Tables 2 and 3). These often can produce results; however, if abused they carry significant risks, and the results are often transient in nature -- so much so that restrictions are steadily growing concerning their use in this area. Nevertheless, research continues in this area, and a recent finding suggests that the seratonin uptake inhibitors may promote weight loss in some individuals.
- Surgical intervention -- from jejunoileal bypass to gastric stapling and bypass -- also have been employed. Jejunoileal bypass resulted in significant weight loss for the majority of selected patients; however, it had a very high morbidity rate and considerable mortality risk. Gastric stapling procedures averaged an approximately 60% excess weight loss. Morbidity and mortality with this procedure are less than with the above procedure, but are still real considerations. The recidivism rate, regardless of the intervention, is high.
Reference – U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality (www.ahrq.gov)
The U.S. Preventive Services Task Force “Guide to Clinical Preventive Services, 2006” (http://www.ahrq.gov/clinic/pocketgd/index.html) states the following:
Clinical Considerations
- The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to help patients acquire the skills and supports needed to change eating patterns and to become physically active. The 5-A framework (Assess, Advise, Agree, Assist, and Arrange) has been used in behavioral counseling interventions such as smoking cessation and may be a useful tool to help clinicians guide interventions for weight loss. Initial interventions paired with maintenance interventions help ensure that weight loss will be sustained over time.
- It is advisable to refer obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss. The USPSTF defined intensity of counseling by the frequency of the intervention. A high-intensity intervention is more than 1 person-to-person (individual or group) session per month for at least the first 3 months of the intervention. A medium-intensity intervention is a monthly intervention, and anything less frequent is a low-intensity intervention. There are limited data on the best place for these interventions to occur and on the composition of the multidisciplinary team that should deliver high-intensity interventions.
- The USPSTF concluded that the evidence on the effectiveness of interventions with obese people may not be generalizable to adults who are overweight but not obese. The evidence for the effectiveness of interventions for weight loss among overweight adults, compared with obese adults, is limited.
- Orlistat and sibutramine, approved for weight loss by the Food and Drug Administration, can produce modest weight loss (2.6-4.8 kg) that can be sustained for at least 2 years if the medication is continued. The adverse effects of orlistat include fecal urgency, oily spotting, and flatulence; the adverse effects of sibutramine include an increase in blood pressure and heart rate. There are no data on the long-term (longer than 2 years) benefits or adverse effects of these drugs. Experts recommend that pharmacological treatment of obesity be used only as part of a program that also includes lifestyle modification interventions, such as intensive diet and/or exercise counseling and behavioral interventions.
- There is fair to good evidence to suggest that surgical interventions such as gastric bypass, vertical banded gastroplasty, and adjustable gastric banding can produce substantial weight loss (28 to > 40 kg) in patients with class III obesity. Clinical guidelines developed by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel on the identification, evaluation, and treatment of overweight and obesity in adults recommend that these procedures be reserved for patients with class III obesity and for patients with class II obesity who have at least 1 other obesity-related illness. The postoperative mortality rate for these procedures is 0.2 percent. Other complications include wound infection, re-operation, vitamin deficiency, diarrhea, and hemorrhage. Re-operation may be necessary in up to 25 percent of patients. Patients should receive a psychological evaluation prior to undergoing these procedures. The long-term health effects of surgery for obesity are not well characterized.
- The data supporting the effectiveness of interventions to promote weight loss are derived mostly from women, especially white women. The effectiveness of the interventions is less well established in other populations, including the elderly. The USPSTF believes that, although the data are limited, these interventions may be used with obese men, physiologically mature older adolescents, and diverse populations, taking into account cultural and other individual factors.
After educating Ms. Smith about the clinical realities of gastric surgery, she admits that she was not aware that people could die from the surgery or that so many people had complications. She confirms that she would really hesitate to take the risks of undergoing such a surgery, and she now better understands the importance of trying other methods of weight loss.
You acknowledge how difficult it is to make lifestyle changes, especially long-standing habits that involve our environment and other people, including family, friends and coworkers. You ask her if she would be willing to discuss ways to change her diet and exercise habits, along with discussing various professionals who might be able to help her make these changes. When she agrees, you again give her an opportunity to share any ideas she might have about how she would like to lose weight, other than surgery. She mentions that she would like to have a walking partner – perhaps her daughter or her friend at work, since both of them are also overweight and have mentioned to her that they would like to lose weight.
You sense that she is tired and perhaps a bit overwhelmed by all of today’s discussion. You suggest that they identify 3 small changes that she would be willing to make right away and then have her come back for a follow-up visit in 1-2 weeks to see how she is doing. In the meantime, you will have some blood work done to better understand her current health and risk factors for chronic disease. You will check her blood sugar to screen for diabetes, check for high cholesterol, anemia, and hypothyroidism. At her next visit, you will go over the results with her, in addition to rechecking her blood pressure. You ask her if her daughter might be interested in talking to a doctor about losing weight, and she says that she is not sure. However, she does think that it would be helpful if she and her daughter were trying to make changes together. She says that she will ask her daughter to come with her to her next visit, so that she might become involved in her weight loss treatment – join in and/or offer support.
Reference – “Weight Control: The Power of Healthy Choices”, AAFP Family Health Facts – Information From Your Family Doctor, The American Academy of Family Physicians, Leawood, Kansas, September 2003.
The goal of physical activity is to burn calories, to improve physical conditioning to enjoy a better quality of life, and to reduce the risk of chronic diseases such as heart disease, diabetes, and cancer. “Being more physically active doesn’t mean you need to have a formal or complicated exercise program. Remember that the best kind of physical activity is the kind that you’ll keep doing. Whatever activity you choose, try to do it for at least 30 minutes per day on most days of the week.” The reason for this is to help strengthen your heart muscle and stamina. Walking is an informal, low-impact, safe, easy, and cheap way to get exercise. Many people enjoy getting outside and taking an early morning or evening/after-dinner walk. Others enjoy getting outside of their office building in the middle of the day. Exercise can also include activities such as yard work, house work, washing a car, etc.
”Physical activity builds muscles, so even if you don’t lose pounds, you will look and feel better when you are more active… Aerobic exercises, such as swimming, walking or jogging, raise your heart rate and help burn calories. The longer you exercise, the more fat your body will burn. Walking can be very helpful even if you don’t walk fast. Light weight training also has many health benefits. It helps add muscle mass to your body. Muscle burns calories faster than fat does.” Reference – “Weight Control: The Power of Healthy Choices”, AAFP Family Health Facts – Information From Your Family Doctor, The American Academy of Family Physicians, Leawood, Kansas, September 2003. “Long-term success is not about finding the “right” diet. It’s about identifying your behaviors that have contributed to taking in more calories than your body needs. It is also about making a plan to develop healthier eating and physical activity habits…You’re more likely to make changes in your habits if you set a specific goal for yourself…Once your new healthy behavior becomes a habit, you can move on to another goal.” Healthy habits to consider: From her history, you noted that both her work environment and her social activities with friends and family put her at risk for weight-gain, as there are often sweets and restaurants involved. Overall, her obesity has negatively affected both her mental and physical health, particularly through limitations on relationships and activities. Thus, her weight-loss plan may need to include some changes in her environment and social activities, which would include enlisting the support of her co-workers, friends, and family – particularly her daughter. She may also need professional support from a registered dietitian, a therapist/counselor, a personal trainer, etc. For Ms. Smith to consider: The Clinical Nutrition Section has several offices in the hospital. Personnel can be contacted by telephone or by pager. HOURS OF OPERATION HOURS OF ON-CALL COVERAGE GENERAL INFORMATION Ms. Smith decides on 3 changes (entirely under her control) that she would be willing to make right away:
She will also consider the following 3 changes (not entirely under her control):
Ms. Smith will return in for a follow-up visit in 1-2 weeks, possibly with her daughter!
Author: Heather Tindall, MSIV, Class of 2007 Reviewer: Peter Lewis, MD Editor: Shou Ling Leong, MD
Clinical Dietitian : 7:30 a.m. – 5:00 p.m. * Monday – Friday * On-call Friday evening, Saturday, Sunday & holidays
Diet Technicians & Clerks: 4:30 a.m. – 7:00 p.m. * Seven (7) days per week
A Clinical Dietitian is on-call each weekend and holiday 4:30 a.m. – 7:00 p.m. for any problems that cannot be handled by a technician or clerk.
Clinical Nutrition provides the following services:
Penn State College of Medicine
Associate Professor of Family & Community Medicine
Penn State College of Medicine
Professor of Family & Community Medicine
Penn State College of Medicine