By John K. Frederick, M.D.
If your clinic is anything like ours, we are being deluged with obesity and its downstream effects of diabetes, hypertension, obstructive sleep apnea, and heart disease. New evidence surfaces almost daily in the medical literature describing some new correlation between obesity and negative health consequences. This situation is also discouraging because there aren’t many good community resources that are both easy to access and effective. The inertia of poor diet and lack of exercise is overwhelming. Repeated advice and encouragement often seem useless, and eventually it feels as if there is no point. Even the employees in our own clinic seem to be disproportionately affected with this condition.
Several factors contributed to our recent action. Perhaps it was seeing how fast the box of doughnuts emptied in our break room. Or, maybe it was the Medscape article pointing out that overweight doctors tend to spend less effort on recognizing and treating obesity. That hit close to home!
But what is there to do?
A quick search in the AAFP journal produced all sorts of exhortations to us family doctors to create systems in the office to promote healthy lifestyles, including attaining and maintaining appropriate weight. I am action-oriented, so acronyms and counseling plans are often too vague and nebulous for me. The five As of dietary action in the office just did not seem aggressive enough. An editorial by Dr. Bray made me think more about this issue, and I decided it was time to pull out all the stops. Our patients and staff all are developing weight-related morbidity, and we are acting as though we are helpless!
After coming to this conclusion, we gathered some of our best folks—physicians and physician assistants—and sat down one day over a light lunch (of salad and fruit!). We began to discuss how to create a program to offer people struggling with obesity, a program of value. The ideas began to flow, and before we knew it, we had designed our own proprietary diet plan.
Our printed dietary instruction manual (and indeed the nucleus of our plan!) was based on counting calories of foods, partnered with an understanding of correct portions of the various food groups. We partnered with a local company in Austin, Mel’s Meals that creates prepackaged fresh portion control food and is available for pick-up or delivery.
We discovered that pedometers are inexpensive if purchased in large lots and they serve as a great way to start an exercise program. Austin is flush with exercise groups and gyms, and our printed material also included some encouragement to explore these options for those who wanted a more aggressive exercise regimen.
But what about “diet drugs?” Could we appropriately administer these medications to help folks who have previously failed so many other diets? Perhaps adding them to our plan could help people get started, encourage them with some early success, and move them to long-term action? Admittedly this challenged some of our preconceived notions. After all, the old simplistic paradigm that “they just need to eat less” still lingers.
However, we all felt intrigued by recent published data from clinical trials describing the combination of older well-established medication for the purposes of weight loss. The introduction of Qnexa (Vivus) encouraged us to think outside the box about combining topiramate and phentermine. We also read that the combination of buproprion and low-dose naltrexone has induced significant weight loss. Though we were not eager to be the first to prescribe these drugs, a call to one of our local compounding pharmacies reassured us that we were not. We reviewed the data on older medications such as diethylpropion, and discussed how aggressive treatment of metabolic syndrome with metformin or exenatide could have an anorexic effect in some cases. A reference to an interesting compounded Aminophylline cream seemed to offer a relatively harmless add-on.
After reading through this data, we wrestled with the issue of these medications being non-FDA approved (or not yet FDA approved) and of potential significant adverse effects. In the end, it seemed clear to us that the risks of being obese far exceed the risks of the medications, as long as the medications are used carefully, along with verbal and written informed consent. We eventually decided to prescribe medications for those who wanted them (and had no significant contraindications).
We struggled with pricing this service. On one hand, we desired for the program to be affordable to as many patients as possible. On the other hand, it seemed valuable to encourage patient accountability by designating an appropriate financial cost and by requiring regular “weigh-in” appointments. However, we did decide that our employees could sign up for a much-reduced fee.
Initially only two physicians and three PAs were involved in order to keep the information and business plan tight and deliberate. After our early successes, we have now trained at least one “diet plan” provider on each of our teams (a team being comprised of one physician and PA plus two MAs), and inclusion in the “diet plan” is a part of our emerging chronic disease management guidelines for PCMH.
The plan was introduced in November 2011 using our web portal, inter-office signage, and our Facebook business page. We quickly saw a brisk new business develop, and we now have about 100 active patients. The average weight loss at the six-week mark was estimated to be 5 percent of body weight, and average systolic blood pressure dropped by 5 percent as well. We have had few adverse events that we are aware of, as well as relatively few intolerable side effects of the medications.
At the three-month mark, our “biggest loser” had lost about 40 pounds (from 190 to 150) and the average BMI of all participants had dropped from 36.9 to 34.6. Data to assess changes in lipids and serum glucose have yet to be harvested. Interestingly enough, we do have a number of patients who have done very well without medications, and we believe this is a result of simply offering good advice with intensive follow up. I also suspect having to pay for something makes it more valuable!
This service has mostly been covered by insurers including Medicare, as long as claims are appropriately coded.
This entire development process has been engaging to many of our employees. Some new talents were discovered within the office in the realms of art, computer graphics, marketing, and social media. I was amazed at how much my staff already knew about franchised diet clinics, how they operate, and how much they cost. Lesson to self—people are looking for help! We have witnessed an atmosphere of hope and empowerment move through through our employee ranks.
We have many questions and concerns as we move forward. While our EHR (Greenway PrimeSuite) produces great data, we find it challenging to analyze this data in a meaningful way so that we can produce valid statistics. We also wonder if we should try to modify the plan to include children and adolescents. Why would we practice age discrimination given the monumental problems created by childhood obesity? Also, we recognize the challenge of staying focused on lifestyle changes and not prescriptive medications, given that patients tend to choose the easiest solution. Finally, we wonder what we should do at the six-month finish line for those individuals who have had success. If obesity is a chronic disease, should we continue medications indefinitely? Is this safer than allowing obesity to creep back in?
In conclusion, we are very encouraged so far, and we hope that our experience stimulates family physicians across the state to do the same.