The Miriam Hospital Weight Management Program

Transcription

25th
Anniversary
The Miriam Hospital
Weight Management Program
Vincent Pera, M.D., Director
Clinical Assistant Professor of Medicine
The Warren Alpert School of Medicine
Brown University
Diplomat, American Board of Obesity Medicine
25th
Anniversary
The Miriam Hospital
Conflict of Interest Disclosure
• The planners of this training have no financial interest in or affiliation
with any commercial interest to disclose.
• Dr. Vincent Pera has no financial interest or contractual relationships
with any commercial interest to disclose.
What’s 25 Years Old
and has
Lost over 500,000 Pounds?
The Miriam Hospital
Weight Management
Program
Established
September, 1987
Greater than 10,000 patients
treated in 25 years
Obesity Trends Among U.S. Adults
Between 1985 and 2010
Source of the data:
• The data shown in these maps were collected
through CDC’s Behavioral Risk Factor Surveillance
System (BRFSS). Each year, state health
departments use standard procedures to collect
data through a series of telephone interviews with
U.S. adults. Height and weight data are selfreported.
• Prevalence estimates generated for the maps may
vary slightly from those generated for the states by
BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly
different analytic methods are used.
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
BRFSS, 1990
No Data
<10%
10%–14%
BRFSS, 2000
No Data
<10%
10%–14%
15%–19%
≥20%
BRFSS, 2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Causes of Obesity
Genetics
Medical Illnesses
Environmental and Behavioral
Psychological
Causes of Obesity
Sedentary Lifestyle
High Calorie Food/Large Portions
On the Run Schedule
Causes of Obesity
Sedentary Lifestyle
High Calorie Food/Large Portions
On the Run Schedule
Psychological
Stress
Anxiety
Depression
Abuse (Physical and Sexual)
Eating Disorders
Obesity – A Chronic Disease
Definition:
“of long duration; continuing; lasting for a
long period of time or marked by frequent
recurrence”
Treatment: “Control” (not cure)
Example: Diabetes
As weight increases…..
...the frequency and severity of comorbid
conditions increase
The Miriam Hospital
• Clinical specialists: Psychologists, Physicians, Psychiatrists,
Physician Assistants, Nurses, Nutritionists, Exercise
Physiologists
• Integrated evaluation and treatment: Psychological, Medical,
Exercise, Nutrition, Psychiatric
• Spectrum of treatment: programs to address all levels of
obesity, psychological issues and comorbid medical
conditions.
• Ongoing intervention (Maintenance)
The Miriam Hospital
Group Treatment Programs
• LEAN Program
• Modified Fasting Program
• Full Fasting Program
• Diabetes Weight Management Program
• Individual Treatment
• Psychological Intervention
Program Evaluations
• Medical Evaluation
(Physician)
• Weight and Lifestyle Evaluation
(Psychologist/Nurse)
• Exercise Evaluation
(Exercise Physiologist)
Laboratory Studies
Exercise Tolerance Test
The Miriam Hospital
• Time commitment – 2 hours weekly
• Weekly weigh-in, vital signs
• Weekly psychoeducational group led by psychologist
(nutritionist, exercise physiologist)
• Ongoing medical visits per program protocol (physician on call
24 hrs/7 days per week)
• Ongoing visits with nutritionist
• Ongoing visits with exercise physiologist
LEAN Program
• Recommended for weight loss of 20-40 lbs.
• 20 Week Program - balanced deficit diet; all solid food, no
liquid supplement
• Women: 1,200 +/- calories/day
• Men: 1,500 +/- calories/day
• Weekly behavioral group sessions
• Medical visits on weeks 1, 10, 20
• Ongoing visits with nutritionist, exercise physiologist
• Average weight loss is 1-2 pounds per week
Modified Fasting Program
• Recommended for weight loss of 40 – 100 lbs.
• Combination of 3 Optifast products per day and 1 meal of
solid food daily.
• 20 week program, 16 weeks of Modified Fast, 4 weeks
reintroduction of food
• Medical visits week 1, 2 and every other week
• Average weight loss 2 –4 lbs. per week
Full Fasting Programs
• Recommended for weight loss of 75 lbs. or more.
• Full liquid diet, no solid food
• 2 versions, 28 or 20 weeks (20 or 12 weeks fast, 8 week
reintroduction of food)
• Weekly medical visits
• Average weight loss 3-5 lbs. per week
Diabetes Program
Certified Diabetic Outpatient Educators
Meredith Dixon, RN, CDOE
Theresa Jerominek, MA, RD, CDOE
Kathleen Kendra, PhD
Program focuses on behavior modification, diabetic nutrition,
appropriate, safe exercise and
extensive diabetes education (RIDOH Certified)
Psychological Intervention
• Additional psychological intervention is available for patients
who have been identified clinically in need of this treatment.
• Psychological intervention is provided individually in addition
to or instead of the group weight management intervention.
Psychoeducational Group Sessions
• Behavioral Intervention
• Didactic Informational Sessions
• Group Interaction
• Support
• Structure
Optifast Nutrition Supplement
The Masters Program
• Weekly group sessions led by Psychologist,
Nutritionist and Exercise Physiologist on a rotating
basis
• Topics and strategies focus on maintaining weight
loss (not losing weight)
• Patients attend as frequently as they need
• Included at no charge
• Includes individual meetings with nutritionist and
exercise physiologist
The Miriam Hospital
• Currently we have greater than 700 patients entering
treatment each year
The Miriam Hospital
treatment each year
• Female 79%, Male 21%, age 18 – 80 years
The Miriam Hospital
treatment each year
• We have a total of 26 group sessions per week (22
active treatment, 4 Masters program)
The Miriam Hospital
treatment each year
• We have a total of 26 group sessions per week (22
active treatment, 4 Masters program)
• Approximately 50% of patients are referred by their
physician, 50% self refer
Patient Demographics
Pretreatment
• Age/Gender: 46 years, 79% Female 21% Male
Pretreatment
• BMI:
All 40.3 (27.0 – 71.0)
Full Fast 44.1
Mod Fast 38.3
Pretreatment
• BMI:
All 40.3 (27.0 – 71.0)
Full Fast 44.1
Mod Fast 38.3
• Weight (lbs): All 247.3 (144.8 – 521.7)
Full Fast 278.0
Mod Fast 229.3
Pretreatment
Medical Diagnoses:







Arthritis 82.9%
Hyperlipidemia 51.2%
Hypertension 50.0%
Sleep Apnea 22.0%
Asthma 18.3%
Diabetes 9.2%
CAD 6.1%
Pretreatment
 History of Sexual Abuse: 19.5 %
 Psychiatric Diagnosis: 59.8%
Greater then 90% of patients enter our program
taking one or more prescribed medications
on a daily basis.
REDUCE OR
DISCONTINUE
MEDICATIONS.
High Blood Pressure Medications
Diabetes Oral Agents
Insulin
High Cholesterol Medications
GERD Medications
Antidepressants
The Miriam Hospital
Patient Experience and Outcome
Outcomes Data
September, 2011
Average Weight Reduction (lbs)
by Program Type for All Patients
at Sixteen Weeks of Treatment (N=656)
Change in Weight at 16 weeks of Treatment
N = 656
Initial Weight Range
(pounds)
136-496
Change in Weight
at Week 16 (pounds)
Percent Weight Change
+8 through -127 +3% through -29%
The Miriam Hospital
Weight Loss During Treatment
Total Number of Patients in Treatment
N = 327
(92 in treatment <4 weeks)
Weight Loss:
<25 pounds
25 – 49
50 – 74
75 – 99
100 – 149
>150
41 patients
108
52
17
14
3
Average Reduction in Systolic Blood Pressure
by Program Type for All Patients
at Sixteen Weeks of Treatment N = 664
Average Blood Pressures All Patients
N=664
Initial
Week 16
Change
130/79
116/72
-14/-7
Reducing Medications in the Obese
Population with Medically
Supervised Weight Loss
Clay Wiske, MPhil and Vincent Pera, MD
Miriam Hospital Weight Management Program
BROWN
Methods and Inclusion Criteria
Methods:
 This is a retrospective cross-over study of 589 patients enrolled in the
Miriam Hospital Weight Management Program between 2009-2010.
 Medication changes were based on clinical guidelines and/or widely
accepted criteria.
 Medication expenses were calculated using national average wholesale
prices in 2010.
 Only medications for gastroesophageal reflux disease (GERD),
hypertension, hyperlipidemia, and diabetes were taken into account.
Inclusion criteria:
 Patients completed 16-24 weeks of treatment.
 Patients were included regardless of whether they had diagnoses of
gastroesophageal reflux disease (GERD), hypertension, hyperlipidemia,
and diabetes.
Intervention Statistics
Intake Weight (lbs)
Weight Loss (lbs)
Duration of Treatment (wks)
MD Visits Attended
Total Medications at Intake
Mean
Standard
Deviation
247.4
64.5
44.4
27.92
4.5
3.9
22.2
11.9
2.9
7.4
100%
90%
Changes to Medications
80%
70%
60%
Discontinued
50%
Decreased
40%
Increased
No change
30%
20%
10%
0%
Hypertension
Hyperlipidemia
Diabetes
GERD
Medication Reduction by Degree of Weight Loss
Medications Decreased in Dose
or Discontinued
60%
50%
40%
30%
20%
10%
0%
Group A
Group B
Group C
<14.6% weight loss between 14.6% and >20.4% weight loss
20.4% weight loss
Changes in Monthly Medication Costs
Average 30 Day Medication Savings
300
Estimated Change in 30 Day Medication Cost (US $)
250
200
150
100
50
0
Diabetes (N=115)
Hyperlipidemia (N=277)
Hypertension (N=294)
GERD (N=261)
All Patients
Barbara
August 11, 2011
57 y/o female
Height 5’ 3” Weight 331.0
BMI 56 Super Morbid Obesity
Medical History:
Hypertension, Arthritis/DJD
• Medications:
Atacand 32 mg/day
•
•
•
•
Barbara
August 11, 2011
57 y/o female
Height 5’ 3” Weight 331.0
BMI 56 Super Morbid Obesity
Medical History:
Hypertension, Arthritis/DJD
• Medications:
Atacand 32 mg/day
•
•
•
•
Barbara
August 11, 2011
• Initial BP 130/78
• Initial Laboratory Studies
Total Cholesterol
HDL LDL
8/16/11 165
40
110
TG
77
Ratio
4.1
Barbara
• Begin Full Fast Program 8/16/11,
6 Optifast/day
• Weight 333.8 lbs.
• Blood Pressure 148/82
Barbara
Week Protocol Date
in Treatment
• 1
FF
Weight (lbs) Weight Blood Pressure
Change (lbs) (mmHg)
8/16/11 333.8
0
148/88
Medication
Atacand 32 mg/d
Barbara
Week Protocol Date
in Treatment
• 1
• 9
Change (lbs) (mmHg)
FF 8/16/11 333.8 0
148/88
FF 10/13/11 295.0 -38.8 112/69
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Barbara
Week Protocol Date
in Treatment
• 1
• 9
• 14
Change (lbs) (mmHg)
FF 8/16/11 333.8 0
148/88
FF 10/13/11 295.0 -38.8 112/69
FF 11/17/11 278.4 -55.4 114/62
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
Barbara
Week Protocol Date
in Treatment
•
•
•
•
1
9
14
21
Change (lbs) (mmHg)
FF 8/16/11 333.8 0
148/88
FF 10/13/11 295.0 -38.8 112/69
FF 11/17/11 278.4 -55.4 114/62
FF 12/29/11 258.2 - 75.6 136/70
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
1
9
14
21
22
Change (lbs) (mmHg)
FF 8/16/11 333.8 0
FF 10/13/11 295.0 -38.8
FF 11/17/11 278.4 -55.4
FF 12/29/11 258.2 - 75.6
FF 1/6/12 250.8 - 83.0
148/88
112/69
114/62
136/70
137/78
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
none
none*
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
1
9
14
21
22
25
FF
FF
FF
FF
FF
MF
Change (lbs) (mmHg)
8/16/11 333.8
10/13/11 295.0
11/17/11 278.4
12/29/11 258.2
1/6/12 250.8
1/27/12 241.6
0
-38.8
-55.4
- 75.6
- 83.0
- 92.2
148/88
112/69
114/62
136/70
137/78
127/62
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
none
none*
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
1
9
14
21
22
25
28
FF
FF
FF
FF
FF
MF
FF
Change (lbs) (mmHg)
8/16/11 333.8 0
10/13/11 295.0 -38.8
11/17/11 278.4 -55.4
12/29/11 258.2 - 75.6
1/6/12 250.8 - 83.0
1/27/12 241.6 - 92.2
2/16/12 234.0 - 99.8
148/88
112/69
114/62
136/70
137/78
127/62
128/73
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
none
none*
none
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
FF
FF
FF
FF
FF
MF
FF
FF
Change (lbs) (mmHg)
8/16/11 333.8 0
10/13/11 295.0 -38.8
11/17/11 278.4 -55.4
12/29/11 258.2 - 75.6
1/6/12 250.8 - 83.0
1/27/12 241.6 - 92.2
2/16/12 234.0 - 99.8
3/15/12 226.2 -107.6
148/88
112/69
114/62
136/70
137/78
127/62
128/73
124/73
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
none
none*
none
none
none*
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
44
FF
FF
FF
FF
FF
MF
FF
FF
FF
Change (lbs) (mmHg)
8/16/11 333.8 0
10/13/11 295.0 -38.8
11/17/11 278.4 -55.4
12/29/11 258.2 - 75.6
1/6/12 250.8 - 83.0
1/27/12 241.6 - 92.2
2/16/12 234.0 - 99.8
3/15/12 226.2 -107.6
6/14/12 195.2 -138.6
148/88
112/69
114/62
136/70
137/78
127/62
128/73
124/73
106/58
Medication
Atacand 32 mg/d
Atacand 16 mg/d
Atacand D/C
none
none*
none
none
none*
none*
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
44
50
Change (lbs) (mmHg)
Medication
FF 8/16/11 333.8 0
148/88 Atacand 32 mg/d
FF 10/13/11 295.0 -38.8 112/69 Atacand 16 mg/d
FF 11/17/11 278.4 -55.4 114/62 Atacand D/C
FF 12/29/11 258.2 - 75.6 136/70
none
FF 1/6/12 250.8 - 83.0 137/78
none*
MF 1/27/12 241.6 - 92.2 127/62
none
FF 2/16/12 234.0 - 99.8 128/73
none
FF 3/15/12 226.2 -107.6 124/73
none*
FF 6/14/12 195.2 -138.6 106/58
none*
MF/FF 7/26/12 179.4 - 154.4 123/68
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
44
50
59
Change (lbs) (mmHg)
Medication
FF 8/16/11 333.8 0
FF 10/13/11 295.0 -38.8 112/69 Atacand 16 mg/d
FF 11/17/11 278.4 -55.4 114/62 Atacand D/C
FF 12/29/11 258.2 - 75.6 136/70
none
FF 1/6/12 250.8 - 83.0 137/78
none*
MF 1/27/12 241.6 - 92.2 127/62
none
FF 2/16/12 234.0 - 99.8 128/73
none
FF 3/15/12 226.2 -107.6 124/73
none*
FF 6/14/12 195.2 -138.6 106/58
none*
MF/FF 7/26/12 179.4 - 154.4 123/68
none
FF/MF 9/27/12 161.8 - 172.0 114/65
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
44
50
59
65
Change (lbs) (mmHg)
Medication
FF 8/16/11 333.8 0
FF 10/13/11 295.0 -38.8 112/69 Atacand 16 mg/d
FF 11/17/11 278.4 -55.4 114/62 Atacand D/C
FF 12/29/11 258.2 - 75.6 136/70
none
FF 1/6/12 250.8 - 83.0 137/78
none*
MF 1/27/12 241.6 - 92.2 127/62
none
FF 2/16/12 234.0 - 99.8 128/73
none
FF 3/15/12 226.2 -107.6 124/73
none*
FF 6/14/12 195.2 -138.6 106/58
none*
MF/FF 7/26/12 179.4 - 154.4 123/68
none
FF/MF 9/27/12 161.8 - 172.0 114/65
none
MF 11/5/12 156.3 - 177.5 117/60
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
44
50
59
65
Change (lbs) (mmHg)
Medication
FF 8/16/11 333.8 0
FF 10/13/11 295.0 -38.8 112/69 Atacand 16 mg/d
FF 11/17/11 278.4 -55.4 114/62 Atacand D/C
FF 12/29/11 258.2 - 75.6 136/70
none
FF 1/6/12 250.8 - 83.0 137/78
none*
MF 1/27/12 241.6 - 92.2 127/62
none
FF 2/16/12 234.0 - 99.8 128/73
none
FF 3/15/12 226.2 -107.6 124/73
none*
FF 6/14/12 195.2 -138.6 106/58
none*
MF/FF 7/26/12 179.4 - 154.4 123/68
none
FF/MF 9/27/12 161.8 - 172.0 114/65
none
MF 11/5/12 156.3 - 177.5 117/60
none
Barbara
Week Protocol Date
in Treatment
•
•
•
•
•
•
•
•
•
•
•
•
1
9
14
21
22
25
28
31
44
50
59
65
Change (lbs) (mmHg)
Medication
FF 8/16/11 333.8 0
FF 10/13/11 295.0 -38.8 112/69 Atacand 16 mg/d
FF 11/17/11 278.4 -55.4 114/62 Atacand D/C
FF 12/29/11 258.2 - 75.6 136/70
none
FF 1/6/12 250.8 - 83.0 137/78
none*
MF 1/27/12 241.6 - 92.2 127/62
none
FF 2/16/12 234.0 - 99.8 128/73
none
FF 3/15/12 226.2 -107.6 124/73
none*
FF 6/14/12 195.2 -138.6 106/58
none*
MF/FF 7/26/12 179.4 - 154.4 123/68
none
FF/MF 9/27/12 161.8 - 172.0 114/65
none
MF 11/5/12 156.3 - 177.5 117/60
none
Barbara
Time in Treatment:
65 weeks
Start Weight:
333.8 lbs
Post Treatment Weight:
156.3
Medication Changes:
Discontinue
Atacand (BP Medication)
Barbara
Total Weight Loss: 177.5 lbs.
Time in Treatment:
65 weeks
Start Weight:
333.8 lbs
Post Treatment Weight:
156.3
Medication Changes:
Discontinue
Atacand (BP Medication)
25 years … What Comes Next?
• Data collection, long term outcomes
• Work with insurers to improve coverage for
obesity treatment
obesity treatment
• Improve, enhance Masters
obesity treatment
• Increase availability of Masters
obesity treatment
• New approaches to maintenance, ongoing
treatment
obesity treatment
• New approaches to maintenance, ongoing
treatment
• Integration with spectrum of weight
management services across Lifespan,
Bariatric Surgery

The Miriam Hospital Weight Management Program

Transcription

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