Treating Obesity with Indirect Calorimetry

1. Treating ObesitywithIndirect Calorimetry Evidenced-based Solution for Primary Care Practice

2. Treating the Overweight and Obese “When we win, I eat. When we lose, I eat. I also eat when we get rained out” Tommy Lasorda / Manager LA Dodgers Energy Intake is a major element in determining whether weight is gained, lost, or maintained….If your patient is like Tommy Lasorda, your major challenge is to help that individual manage their energy balance Reference: Kazaks, A. Obesity: Food Intake. In: Bray GA, ed. Office Management of Obesity. Philadelphia, PA: Saunders; 2004: 91-106.

3. MANAGER CONSULTANT Provider Provider Patient Disease Patient Disease Role of Provider Typically the Primary Care Provider’s role is to Manage the disease. However, in treating obesity a more realistic role for the clinician is “consultant” or even “coach”. The patient must take the active role in managing their eating behavior. Reference: Bessesen DH. Applying Stages of Change theory to Office-based Counseling. In: Bessesen DH. Evaluation and Management of Obesity. Philadelphia, PA: Hanley & Belfus, Inc; 2002: 33-39

4. Treating ObesityGuidelines for Primary Care from NIH / NHLBI Primary Care Physician Guidelines: Patient and Physician devise goals and treatment strategy for weight loss and risk factor control. Set a diet that will create a 500-1000 kcal/day deficit, to yield a weight loss of 1-2 lbs per week Maintenance Counseling: Dietary therapy, behavior therapy, physical activity. Assess reasons for failure to lose weight. Reference: National Heart, Lung, and Blood Institute (NHLBI) – National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight, Obesity in Adults – the evidence report. June 1998

5. What is Needed? When consulting the Overweight or Obese Patient: Make the5minutes that is spent with the patient as efficient and effective as possible. • Remove the excuse “I have a slow metabolism” • Provide the patient the exact caloric prescription that will lead to 1-2 lbs/week weight loss • Consult the patient on the need to manage their energy balance. • Motivate the patient to be more active

6. Why use Indirect Calorimetryin Primary Practice? • Set the patient on a diet that will create a 500-1000 kcal/day deficit that will lead to 1-2 lbs per week weight loss. • Remove the excuse and the psychological barrier by showing the patient the problem is not a “SLOW METABOLISM” • Teach the patient principles of Energy Balance using their own data. • Assess reasons for failure to lose weight. Is it low energy expenditure or is it patient non-compliance?

7. REEVUEby KORR The ReeVueis the technological advancement that makes assessment of resting energy expenditure (REE): ACCURATE The REEVUE is a “Metabolic Cart” stripped down to just the components necessary to perform an accurate resting energy expenditure (REE) measurement. Simplicity of use and maintenance are key. PORTABLE INEXPENSIVE

8. Step 1:Medical assistant conducts procedure. Patient’s exhaled gases are analyzed to measure the oxygen consumption and computation of Resting Energy Expenditure1 (metabolic rate) Step 2:Provider consults patients on results. Provider uses results to recommend a daily caloric intake. Also, the provider consults the patient on various aspects of Energy Balance. The Procedure Notes: a.Procedure is very simple and can be performed by any medical assistant. b.Procedure and the consult is typically scheduled as a separate visit. c.Procedure is CPT Coded and is reimbursed by Medicare. 1REE is calculated using the Weir equation with an assumed RQ=0.83. See “Weir, J.B., New Methods for Calculating Metabolic Rate with Special Reference to Protein Metabolism. J. Physiology, 1949 109: pages 1-9” 

9. The patient’s data is presented in a graphical format that is designed to educate The Report

10. The Report Energy Balance = Energy In – Energy Out > Energy Out Energy In “To lose weight, energy intake must be less than energy expended” A balance scale is used to teach the concept of energy balance. Reference: Kazaks, A. Obesity: Food Intake. In: Bray GA, ed. Office Management of Obesity. Philadelphia, PA: Saunders; 2004: 91-106.

11. Maintenance Daily caloric requirement For patient to maintain their weight Estimates of additional calories burned from lifestyle and exercise Weight Loss Daily caloric requirement for patient to lose weight The patient’s measured metabolic rate Patient’s data is presented in graphical format that creates a “forum for education” The Report Energy Output Energy Intake Patient’s Energy Balance

12. Provider Consult The power of the patient provider encounter should not be underestimated. If the patient is ready to make changes, the provider is in a key position to educate and motivate the patient. In the few minutes you have with the patient you may need to do the following: • Address Psychological Barriers • Discuss a Weight loss Strategy • Set a Caloric Prescription • Discuss Behavioral Changes • Send Patient home with Educational Materials The following slides show how the test results and the report can assist the caregiver in providing an effective consult.

13. Provider ConsultAddress Psychological Barrier The calculated predicative normal values are used for comparison. Remove the excuse of a slow metabolic rate. You might say… “The test shows that you have a fast metabolic rate. You can lose weight! Now let’s discuss how to balance what you eat with what your body burns.”

14. Provider ConsultDiscuss Weight loss Strategy The report recommends a range of calories for effective weight loss Weight loss Zone (kcal/day) This is calculated from the measured resting energy expenditure. Knowing the exact range for the individual may be the key to their success. You might say… “To lose weight, you need to burn more calories than you eat. This is the most calories you can eat and still lose weight!”

15. ProviderConsultSet a Caloric Prescription Consult the Patient on the Amount of Daily Calories Provider uses the results of the test to establish a caloric prescription. You might say… “Each day you need to try and target this number of Calories. You should consider keeping a record of what you eat each day”

16. Provider ConsultDiscuss Behavioral Changes This is not a diet. This is a new way of life! • Discuss the benefits of being more active. • Explain that they do not want to increase the calories when they Exercise. Let this add to the caloric deficit. Caloric Deficit You might say… “Adding exercise and increasing activity will help burn more calories and will help the weight come off faster.”

17. Provider ConsultMaintenance Phase Energy Balance: Like balancing a checkbook, it is a life skill Maintenance Zone (kcal/day) The number of calories needed to maintain weight is also determined by the REE measurement. The patient should be counseled to stay below the upper number of kcal / day You might say… “You have learned how to eat to your metabolism during the weight loss. Now we just need to increase your daily calories a little bit for maintaining your weight. ”