Adult Obesity (Age 18) Practice Guideline. Assessment of Adult Patient to Evaluate for Obesity. Patient Is Ready to Lose Weight

Transcription

1 dult besity (ge 18) Practice Guideline ssessment of dult Patient to valuate for besity btain height, weight, blood pressure (BP), body mass index (B) (BL ) Underweight B < 18.5kg/m 2 ormal Weight B kg/m 2 verweight/bese B 25kg/m 2 V L U Sanford dult besity Underweight Guidelines B do not < 18.5% apply aintain weight trajectory and reassess annually anage risk factors ocus history and exam on risk factors, complications, and healthy behaviors/attitudes ssess for major and minor comorbid conditions (BL B) eview medications associated with weight gain (BL ) Screen patient with PHQ4; if positive, administer PHQ9 and/or GD7 and refer to Sanford nxiety or Sanford Depression Practice Guidelines btain ppropriate Laboratory ests valuate for etabolic Syndrome: Baseline G, chest x-ray, complete blood count (B), P, thyroid function tests and lipid profile ssess Patient eadiness or Weight Loss D Patient s eady to Lose Weight egotiate goals and strategy to achieve weight loss (BL D) efer to risk appropriate resources as needed Patient s ot eady to Lose Weight eview goals, risk factors, and counsel regarding weight referral anagement t ecommendations or Weight Loss onsider Health oach, Behavioral Health riage herapists or other trained professional for motivational interviewing to focus on lifestyle changes (BL ) onsider referral to egistered Dietitian onsider approved weight loss medications when appropriate (BL ) Periodic e-evaluation of Patient anagement ecommendations or Weight Loss onsider referral to Health oach, Behavioral Health riage herapists or other trained professional for motivational interviewing to focus on lifestyle changes (BL ) onsider referral to egistered Dietitian easure height, weight, and calculate B 1 evised his guideline is not intended to replace a provider s judgment, but rather to support the decision-making process,

2 dult besity (ge 18) Practice Guideline BL : easure Height and Weight, and alculate Body ass ndex alculate the body mass index (B) at least annually for screening and as needed for. lassification is based on the body mass index categories. B Less than 18.5 ategory Underweight Body ass ndex alculation Weight = kg lbs x 703 Height squared m 2 inches ormal weight verweight bese-class bese-class BL B : ssess for and ategorize inor and ajor onditions 40 or more xtreme obesity-class t is important to assess for other conditions as treatment decisions and outcomes may be influenced by their presence. Waist circumference greater than or equal to 40 inches for males and greater than or equal to 35 inches for females is an additional risk factor for complications related to obesity. o rule out depression and eating disorders, brief screenings: PHQ-4 and Starting he onversation (PPDX ) should be conducted if appropriate. ssessment should include a complete medical history including identifying medications that may induce weight gain or interfere with weight loss. Screening for sleep disorders should also be completed. inor onditions igarette smoking Hypertension (BP greater than or equal to 140/90) or current use of antihypertensives LDL cholesterol >130 mg/dl HDL cholesterol <40 mg/dl for men; less than 50 mg/dl for women Prediabetes amily history of premature coronary artery disease ge 55 years for males ge 65 years for females or menopausal females Diabetic (insulin, sulfonylureas, thiazolidinedione) any selective serotonin reuptake inhibitors (SS), tricyclic antidepressants () nti-psychotics nti-epileptics Steroid hormones (progestins and glucocorticoids) onsider alternative drugs not associated with weight gain: etformin Bupriopion opiramate xenatide BL : Drug lasses ssociated with Weight Gain ajor onditions Waist circumference (males 40 inches, females 35 inches) stablished coronary artery disease (, angioplasty, BG) Peripheral vascular disease bdominal aortic aneurysm Symptomatic carotid artery disease ype 2 diabetes mellitus bstructive sleep apnea 2 evised his guideline is not intended to replace a provider s judgment, but rather to support the decision-making process,

3 dult besity (ge 18) Practice Guideline BL D: reatment Grid and verview of anagement ecommendations ondition B utritional/physical utritional/physical edication utritional/physical edication utritional/physical 1-2 inor onditions ajor onditions 3 inor onditions utritional/physical utritional/physical he D approves drug therapy only for B >27 utritional/physical edication utritional/physical utritional/physical utritional/physical BL : verview of anagement ecommendations utritional/physical utritional/physical utrition (balanced healthy eating plan or lower calorie balanced eating plan) ncourage at least five servings of fruit and vegetables per day, whole grains with fiber intake of grams of fiber daily, less than or equal to 30% of calories from fat (7%-10% of calories from saturated fat, less than or equal to 1% from trans fat). or weight loss, encourage calorie reduction by evaluating portion sizes and journaling food intake. Provide tips for managing eating in social situations, dining out, take-out food and food label reading. Provide referral to a dietician, nutritionist or structured medically supervised weight loss program if available. onsider the use of meal replacements or very low calorie diet (VLD) under medical supervision to help achieve weight loss in patients who are interested in such programs. Physical ctivity inimally, all patients should be encouraged to do at least 10 minutes of physical activity above what they are already doing each day and gradually increase the amount of time, followed by an increase in intensity. deally, all patients should meet the current recommendations of 60 minutes of moderate-intensity activity on most days per week. his can by done in 10-minute increments. Patients with chronic activity limitations (e.g. arthritis, respiratory dysfunction, neuropathy, morbid obesity) should be evaluated and managed to establish or enhance patient mobility. Small bouts of physical activity, not generally considered exercise, such as taking the stairs, parking farther away, exercising while watching V, standing rather than sitting and activity breaks from screens (V, computer, other media) are also important for healthy body weight. Behavioral anagement dentify behaviors that may lead to increased weight gain; for example, stress, emotional eating, boredom and poor sleep. Help patients set specific, measurable, time-limited goals to decrease calorie intake and increased physical activity as appropriate. Suggest patients weigh themselves weekly and record the amount and type of food/beverages consumed and physical activity completed. Provide support and encourage patients to also seek support from family, friends and support groups in order to assist them with their eating, activity and weight goals. edication valuate for medications that may promote weight gain, and change when appropriate to a more weight-neutral alternative. Pharmacotherapy for weight loss should be included only in the context of a comprehensive treatment strategy that includes physical activity and nutritional support. Phentermine and orlistat are safe for most patients when carefully monitored by a physician. hey may be part of a program for weight or maintenance, which should include nutrition and physical when indicated. Surgery Bariatric surgery is indicated in carefully selected patients. Patients should be motivated, well informed in disease, psychologically stable and accepting of operative risks. 3 evised his guideline is not intended to replace a provider s judgment, but rather to support the decision-making process,

4 dult besity (ge 18) Practice Guideline BL : edications Used for Weight Loss he D approves drug therapy only for B >27 Drug echanism of ction isks/side ffects Phentermine ppetite suppressant: sympathomimetic amine ardiovascular, gastrointestinal Diethylpropion ppetite suppressant: sympathomimetic amine Palpitations, tachycardia, insomnia, gastrointestinal rlistat Lipase inhibitor: decreased absorption of fat Diarrhea, flatulence, bloating, abdominal pain, dyspepsia Bupropion ppetite suppressant: mechanism unknown Paresthesia, insomnia, central nervous system effects luoxetine ppetite suppressant: selective serotonin reuptake inhibitor gitation, nervousness, gastrointestinal Sertraline ppetite suppressant: selective serotonin reuptake inhibitor gitation, nervousness, gastrointestinal opiramate echanism unknown eratogenicity, paresthesia, changes in taste Zonisamide echanism unknown Somnolence, dizziness, nausea eferences 1. itch,., verling, L., ox,., Goldberg, J., Heim,., Johnson, K., Kaufman,., Kennedy,., Kestenbaun,., Lano,., Leslie, D., ewell,., onnor, P., Slusarek, B., Spaniol,., Stovitz, S., Webb, B. nstitute for linical Systems mprovement. Prevention and anagement of besity for dults. Updated ay Brethauer, S., Kashyap, S., Schauer, P. leveland linic Disease anagement Project: besity. etrieved from 3. HealtheamWorks (2011, arch 11). dult besity Guideline. etrieved from 4. Paxton,., Strycker, L., oobert, D., mmerman,., Glasgow,. (2011). Starting the conversation: Performance of a brief dietary assessment and intervention tool for health professionals. merican Journal of Preventive edicine, 40(1): evised his guideline is not intended to replace a provider s judgment, but rather to support the decision-making process,

5 dult besity (ge 18) Practice Guideline PPDX : Starting the onversation Scoring the S tools he scoring system for the S tool is listed to the right of each answer (0-1-2). nswers in the far left column for any question is scored a 0, middle column is scored a 1, and right column is scored a 2. he higher the score, the more unhealthy the patient s diet or more sedentary life style. he main purpose of the instrument is to guide counseling rather than use as a measurement tool. Providers and users of this tool could utilize a reduction in score to reinforce efforts in behavior change. 5 evised his guideline is not intended to replace a provider s judgment, but rather to support the decision-making process,