Diabetes Screening and Obesity Treatment. October 22, 2008 Dr. David Andrew Rometo

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1 Diabetes Screening and Obesity Treatment October 22, 2008 Dr. David Andrew Rometo

2 Review of Last Presentation Obesity is a common problem world-wide, wide, nationally, and in our clinic. It makes people sicker and harder/more expensive to treat, worsens/shortens their lives. Physicians tend not to address it because: It is so common they don t t have experience with/confidence in the treatments They doubt resources are available for successful weight-loss

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4 Treatments Goal: 5-10% weight loss, ½ to 2 lbs per week. easier management of comorbidities Improved quality of life, decrease morbidity, mortality Decreased costs of care Physical Activity Recommended 30 min/day, days/week. <1/3 of US adults get this much activity 40% of US adults get no leisure time physical activity Diet Various diets: Mediterranean, low carb, low fat, etc. Shai et al,, NEJM July 2008 Weight loss meds Sibutramine- appetite suppressant (HTN) Orlistat- intestinal lipase antagonist, fat malabsorption (steatorrhea)

5 Recommendations U.S. Preventive Services Task Force Screen all adult patients for obesity with BMI. Offer intensive counseling and behavioral interventions to promote sustained weight loss There is fair to good evidence that high-intensity intensity counseling about diet, exercise, or both together together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically kg for 1 year of more) in adults who are obese (BMI >30) 30). improved glucose metabolism, lipid levels, and blood pressure, from f modest weight loss Defined high-intensity intensity intervention as more than 1 person- to-person (individual or group) session per month for at least the first 3 months of the intervention.

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7 Bariatric Surgery Procedures Roux-en-Y gastric bypass Laparoscopic adjustable gastric banding Biliopancreatic diversion Laparoscopic sleeve gastrectomy Buchwald et al meta-analysis , 22,000 pts DM resolved/improved in 86%, lipids in 70%, HTN in 78%, OSA in 84% Operative mortality %

8 Bariatric Surgery Available at 3 local centers: UNC, Durham Regional, and ECU Generally for patients with BMI >40, or >35 with comorbidities, aged 18-60, well-informed, motivated Must fail lifestyle intervention for weight loss Medicaid requires 6 months of monthly PCP/Nutrition visits focused specifically on weight loss At UNC, cannot accept Medicare (not a center of excellence). Must weight < 440 lbs There are $150 -$250 application fees to get into these programs AFTER initial interview/info meeting.

9 Our clinic Review of 9390 patients seen by Internal Medicine at ACC in last 2 years (28.5%) have BMI < (30.8%) have BMI 25-30, overweight 1830 (19.5%) have BMI 30-35, 35, Class I obesity 1000 (10.6%) have BMI 35-40, Class II 1000 (10.6%) have BMI >40, Class III, extreme, severe, morbid That s s 40.7% of our patients are obese! 2 in 5! Assuming the obese are sicker and are seen more often, over half of all clinic visits are with obese patients! Are we following USPSTF guidelines? No.

10 Current Nutrition Database (Since 7/06) All BMI > 30 BMI > 30 w/ DM Patients BMI > 30 w/o DM Visits scheduled Visits completed

11 PDSA Cycle 1 Green Sheet for all obese patients seen in resident clinic on 9/3/08 attached to check-out sheet. Identified patient s s level of obesity, asked about co-morbid morbid conditions, and prompted resident to address the issue Data was collected and processed

12 Pilot day 9/3/08 61 scheduled visits 52 scheduled return visits 9 scheduled new visits 25 obese patients 27 under/normal/overweight patients 9 no show 16 show 1 had no green sheet printed 1 walked out without checking out 2 no green sheet returned 8 green sheets returned filled out 4 green sheets returned blank

13 Study 12 returned sheets 8 filled out 4 blank 6 w/ DM 2 w/ unknown DM status 4 w/ DM 4 obese 2 morbid obese 2 morbid obese 3 obese 1 morbid obese

14 BMI BMI >40 Told they were obese 2 4 Discussed comorbid factors 1 2 Set wt loss goal 2 0 Diet 1 2 Exercise 1 0 Wt loss med 0 0 D/C wt gain med 0 0 Nutrition referral 0 3 Other intense intervention 0 0 Bariatric surgery referral 0 0 Wt addressed at prior visit 0 1 Will address later 2 0 Won t t address later 0 0 See Nutrition today 0 0 See Nutrition later 2 2

15 Other Info Gained Several obese patients seen that day did not carry the diagnosis of diabetes, but had never been tested USPSTF only recs screening for adults with BP >135/80 ADA: adults >45yo q3yr, and overweight w/ RF at any age q1-3yr Major physician barrier to nutrition referral is belief in financial barrier of non-diabetic patients

16 Act: the Next Step Create database of all IM patients Create patient specific printed sheet that addresses disease management, including diabetes screening and nutrition referral for obese patients [Yellow Sheet for all!] Create High-intensity intensity Lifestyle Intervention that meets USPSTF guidelines provided by Enhance Care Nutrition

17 Additional Steps Weight loss surgery decision aid 37 min long DVD Focuses on risks and benefits of Roux-en en-y Y gastric bypass does not sugar coat or sell bariatric surgery Stresses that obesity is harmful to one s s health and should be addressed in some way

18 Diabetes Screening Cannot look-up fasting glucose in WebCIS unless we order Fasting Blood Sugar This can be added to our lab order sheets Hgb A1C not reimbursed by Medicare for screening purposes in non-diabetics. diabetics. FBS is. Costs $77 compared to $10 for FBS Self-pay patients get 35% discount Medicare pays $13.56 for A1C, $5.48 for FBS A1C not recommended for screening, does not identify pre-diabetes

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21 IGT vs. IFG Isolated IGT, isolated IFG, or both. Very variable estimates of isolated IGT in US. For IFG, 26% (57 million) adults. These distinct entities each has different pathophysiology. Insulin resistance: IFG have hepatic IR, IGT have muscle IR, Insulin secretion: both have abnormal early phase (30min), IGT has severe deficit in late phase IS (60-120min) Both are Pre-diabetes

22 OGTT Significant population of patients with isolated IGT (normal FPG) Increased risk of developing DM if IFG and IGT Can diagnose DM in pt w/ IFG 75G glucose load not on formulary at UNC I can fix that if the clinic/division will back me up. Then we can have a case on hand

23 Lifestyle Intervention Since cycle 1, Nutrition database has added identifier box to indicate high intensity program 3-44 visits in first 3 months Liz Thomas will be spending December special month interpreting data from this database comparing different interventions and weight loss obtained I will be working with Dr. Keyserling and Amy Bouthillette to define and improve our High- intensity Lifestyle Intervention (HLI).

24 HLI Frequent 1 on 1 visits with Amy Group meetings with curriculum (6 weeks?) UNC On-line weight-loss program Cardiac, Pulmonary rehab Info on community based programs (TOPS, Weight Watchers, Jenny Craig, L.A. Weight Loss, Over-eaters anonymous, Choose to Lose, Nutrisystem), local gyms

25 The Next Step 3 separate database algorithms Diabetes screening HLI (nutrition) referral Weight loss surgery referral (decision aid and providing contact info for local centers) Incorporating these into the diabetes yellow sheets, and creating sheets for non-diabetics diabetics Piloting the new sheet and working out the kinks

26 Diabetes Screening: BMI > 25 Age: > 45 < 45 Race: Non-White White DM RF: Yes No Prompt : 2 1* * Nursing Section: Does patient have any of the following risk factors for diabetes? Circle all that apply: Parent or sibling with DM Physical inactivity (less than 30 min/day of light activity) (female only:) Hx of > 9 lb baby Hx of DM during pregnancy No risk factors 1: No increased risk for DM. Screening not indicated. 2: Increased risk for DM. Screen with Fasting Plasma Glucose per ADA guidelines. DM RF = Diabetes risk factors: From ICD-9: Pre-diabetes (790.21, , ), Cardio/Cerebrovascular disease ( X), PCOS (256.4), Gestational diabetes (648.8X, 648.0X), Acanthosis Nigricans (701.2) From WebCIS: BMI > 40, HDL < 35, Triglycerides > 250 From Nurse Survey: Parent or sibling with DM, Hx of > 9 lb baby, Hx of DM during pregnancy, Physical inactivity Recommended Action: FPG at next AM visit [ ] If not, why?

27 Total w/ BMI > 25 No DM > 45 yo < 45 yo, Nonwhite < 45 yo, white, +RF * 850* 202* 294 < 45 yo, white, norf

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29 High-intensity Lifestyle Intervention Algorithm: BMI > 25 DM Status: DM Pre-DM No DM BMI: > Prompt: : Counsel to lose or maintain weight. 2: Weight loss and lifestyle changes reduce morbidity. Refer for High-intensity Lifestyle Intervention. 3: High risk for DM. Weight loss and lifestyle changes reduce risk and morbidity. Refer for Highintensity Lifestyle Intervention. 4: Weight loss and lifestyle changes improve DM control and reduce morbidity. Refer for Highintensity Lifestyle Intervention. Recommended Action: High-intensity lifestyle intervention [ ] If not, why?

30 BMI DM Pre-DM No DM > * 113* > *

31 WLS Algorithm: BMI >35, Age < 60 DM Status: DM Pre-DM No DM BMI: >35 > > BSCM: Yes No Yes No Prompt: : Not eligible for weight loss surgery. 2: Eligible for weight loss surgery, which reduces morbidity. Discuss with patient and refer if interested. 3: Eligible for weight loss surgery, which prevents the development of DM and reduces morbidity. Discuss with patient and refer if interested. 4: Eligible for weight loss surgery, which improves DM control and reduces morbidity. Discuss with patient and refer if interested. BSCM = Bariatric Surgery Co-Morbidities: HTN ( ), OSA (327.2X, ), OA (715.X) Recommended Action: Weight Loss Surgery referral [ ] If not, why?

32 DM status BMI Co- Morbidities DM > * Pre-DM No 4 Yes 12* > 40 27* No DM No 251 Yes 388* >40 614* #

33 46 AA yo M w/ OSA, BMI 37, DM status unknown [2,2,2] Nursing Section: (blank. Pt already has risk factors that warrant DM screening) Provider Section: Increased risk for DM. Screen with Fasting Plasma Glucose per ADA guidelines. Weight loss and lifestyle changes reduce morbidity. Refer for High-intensity Lifestyle Intervention. Eligible for weight loss surgery, which reduces morbidity. Discuss with patient and refer if interested. Recommended Action: check if yes FPG at next AM visit [ ] If not, why? High-intensity lifestyle intervention [ ] If not, why? Weight Loss Surgery referral [ ] If not, why?

34 44 white F w/ BMI 36, DM status unknown [1*,2,1] Nursing Section: Does patient have any of the following risk factors for diabetes? Circle all that apply: Parent or sibling with DM Physical inactivity (less than 30 min/day of light activity) (female only:) Hx of > 9 lb baby Hx of DM during pregnancy No risk factors Provider Section: No increased risk for DM. Screening not indicated. Weight loss and lifestyle changes reduce morbidity. Refer for High-intensity Lifestyle Intervention. Not eligible for weight loss surgery. Recommended Action: check if yes High-intensity lifestyle intervention [ ] If not, why?

35 32 AA M w/ DM, BMI 39 [X,4,4] Nursing Section: (blank. Has DM. No risk factor screening needed) Provider Section: Weight loss and lifestyle changes improve DM control and reduce morbidity. Refer for High-intensity Lifestyle Intervention. Eligible for weight loss surgery, which improves DM control and reduces morbidity. Discuss with patient and refer if interested. Recommended Action: check if yes High-intensity lifestyle intervention [ ] If not, why? Weight Loss Surgery referral [ ] If not, why?

36 Ideally An obese patient without diabetes and no risk factors pulled from WebCIS/billing info comes to clinic. Sheet is attached to check-out paper Nurse asks other risk factor questions, circles Hx of 9 lb baby Physician prompted to address obesity, discusses with patient and checks box for HLI Sheet is returned to front desk with billing sheet

37 What then? Sheets are collected by Enhanced Care Data entered manually into database Patient now identified as DM RF Yes in diabetes screening algorithm Care assistant makes appointment with dietician at patient s convenience At next visit, sheet no longer prompts HLI referral Sheet does prompt DM screening Provider checks box for FPG

38 Enhanced Care team member collects sheet Enters need to screen in database Receives list of tomorrow s patients with AM appointments who should come fasting for labs Calls patient to remind them to fast Yellow sheet prompts front desk to send patient to lab for FPG prior to visit Team member follows up on result, sends phone message to PCP if pre-dm or DM

39 What if BMI were 46? Provider would have been prompted to refer to weight loss surgery If box is checked, appointment is made with dietician and viewing of Decision aid is arranged at patient s convenience If patient is interested in hearing more after watching aid, phone number/meeting info of appropriate surgery center is provided by dietician

40 Goals All patients at risk for DM get screening within next 2 years (4751) All overweight and obese DM and Pre-DM patients referred to dietician, offered HLI in next year (1748 +?) All patients eligible for bariatric surgery to view decision aid in next year (2676 -?)

41 Improvements? Wider net, less specifics for easier action. Make it automated. Take all decisions away from providers. Just screen everyone over 45yo, and everyone with BMI > 25 q3y for DM w/ FPG. Show bariatric surgery decision aid and give referral info to every patient with BMI > 35.

42 Future CQI/PDSA Using new sheet and working out the kinks Tracking success of each arm (DM, HLI, WLS) Adding new issues of medical care of the obese Screening for OSA, osteoarthritis, hyperlipidemia, hypothyroidism, Cushing s, PCOS Changing from weight gain meds to weight neutral/loss meds Creating fitness groups, support groups within patient population

43 Suggestions?

44 Acknowledgements Annie Whitney Rob Malone Shaun MacDonald Amy Bouthillette Paul Chelminski Tom Keyserling Mike Gilchrist The American diet and lifestyle

45 Table 1 Distribution (%) of Hemoglobin A1C Levels According to the 2-Hour Glucose Concentrations on the Oral Glucose Tolerance Test in the MRG Data Set* 2-Hr Glucose (mg/dl) Number of Subjects % of MRG Data Set ULN ( 6.3) Hemoglobin A1C, % <1% Above ULN ( %) ULN + 1% ( 7.3) <140 7, , Distribution (%) of Hemoglobin A1C Levels According to the 2-Hour Glucose Concentrations on the Oral Glucose Tolerance Test in the NHANES III Data Set 2-Hr Glucose (mg/dl) Number of Subjects % of U.S. Population* ULN ( 6.1) <1% Above ULN (6.2% 7.0%) ULN 1 1% ( 7.1%) <140 2,

46 UKPDS 10 year follow-up Conventional therapy (dietary restriction) vs. sulfonylurea/insulin or metformin (for overweight patients) in new dx DM2 Sulfonylurea/insulin: RRR microvascular disease 24%, MI 15%, all cause mortality 13% Metformin: RRR MI 33%, ACM 27%

47 ADA: IGT and IFG 5-10% weight loss, ~30 minutes exercise daily Metformin if <60 yo, BMI > 35, and has other risk factor for DM Other medicines are not recommended 2/2 cost, side effects, or lack of evidence of persistent effect