A Health Care Provider Intervention to Address Obesity in Patients with Diabetes

Obesity is associated with a significant increase in mortality. It increases the risk of type 2 diabetes mellitus (T2DM), hypertension, hyperlipidemia, and coronary artery disease.¹ T2DM is strongly associated with obesity in all ethnic groups.

Medical nutrition therapy and weight loss are very important for DM management.² This includes providing education about diet modification, increased physical activity, daily calorie intake evaluation, and consistent carbohydrate intake. For patients with T2DM, health care providers (HCPs) should emphasize lowering caloric intake and inducing weight loss for those who are overweight (body mass index [BMI] between 25 and 29.9) and obese (BMI ≥ 30). This can improve glycemic control by decreasing insulin resistance. Initial recommendations for weight loss and physical activity are to lose between 5% and 10% of initial body weight and to accumulate at least 30 minutes of moderate physical activity over the course of most days of the week.^3,4

Several formulas are available to estimate baseline caloric intake for weight maintenance. For weight loss of 1 to 2 pounds per week, lowering 500 to 1,000 calories from daily weight maintenance calories serves the goal. The American Diabetes Association (ADA) also suggests that HCPs recommend diet, physical activity, and behavioral therapy designed to achieve > 5% weight loss to overweight and obese patients with T2DM.⁵

Recognizing the clinical benefits of achieving weight loss in overweight or obese patients with T2DM, we aimed to increase the number of visits in the Endocrine Clinic at Central Arkansas Veterans Healthcare System (CAVHS) in Little Rock that addressed obesity, documented calorie goal for patients who are overweight or obese, and performed an intervention with further education for the patient.

Methods

The study population included veterans with either type 1 DM (T1DM) or T2DM with BMI > 25 on any DM control regimen. We performed a health record review of the eligible patients seen in the CAVHS Endocrine Clinic from June 1, 2016 to July 31, 2016 to determine the baseline percentage of visits that addressed obesity and provided weight loss advice to patients. We obtained a list of patients seen in the clinic during the study period from Strategic Management Service Services at CAVHS. We also obtained information that age, gender, medications, BMI, and last Endocrine clinic HCP assessment from the electronic health record. We reviewed the HCPs notes, including fellows and faculty who were involved in the patients’ treatment, to determine whether their notes documented a BMI > 25 and whether they discussed an intervention for overweight or obesity with the patient. The CAVHS Institutional Review Board reviewed and approved the initiative as a quality improvement study.

Intervention

Our clinic has a defined group of HCPs that we targeted for the intervention. After getting baseline information, during August 2017 we educated these HCPs on the tools available to calculate calorie goal for the patients. We advised the HCPs to use the Mifflin St Jyor equation for estimating energy expenditure and set a goal of initial weight loss between 5% and 7% of body weight. We gave specific instructions and advice to the providers (Table 1). HCPs also received educational material to distribute to patients that provided information on the healthy plate method, discussed how to count calories, and advised them on ADA goals with carbohydrate limitation. We encouraged HCPs to recommend that patients cut between 500 and 1,000 calories daily from their current diet. HCPs also received advice to seek help from clinical dieticians and the VA MOVE! Weight Management Program when appropriate.