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

Study of Effect of the Intervention

To study the effect of this intervention, we reviewed documentation by HCPs and assessed patient satisfaction. We obtained a list of patients and reviewed HCP notes on patients with BMI > 25 to assess whether providers addressed obesity in November and December 2017. We also evaluated whether HCPs offered a specific intervention to address the problem, such as providing education material to the patient or an estimate of daily calorie goal, or referring them to clinical dietician and/or the MOVE program. Patients received a 5-question survey that assessed their understanding and satisfaction at the end of the visit (Table 2).

Results

Of the 100 charts reviewed prior to intervention, HCPs discussed obesity management with only 6% of patients. After the intervention, we collected data again through chart review of the patients who were overweight or obese and seen for DM in the same clinic during a 2-month period. Of the 100 charts reviewed, we noticed that recognition and management of obesity improved to 60%.

To evaluate the impact of this intervention, patients received a questionnaire at the end of the visit. Nearly all (97%) patients mentioned that the provider discussed weight management during that visit. Most (83%) patients mentioned that weight management was discussed with them during prior visits, while 70% of patients felt their knowledge on working on weight loss had improved. Almost half (46%) were interested in further referral to a dietician or the MOVE program if they did not achieve desired results, but 78% were confident that they could implement the discussed weight management measures.

Discussion

Increased body weight is associated with worsening of DM and can result in poor glycemic control. Achieving weight loss in overweight or obese patients with DM can lead to clinical benefits; however, this is a challenge. In one study, a DM prevention program with lifestyle intervention leading to weight loss significantly reduced the rate of progression from impaired glucose tolerance to DM over a 3-year period and improved cardiovascular risk factors like elevated blood pressure and dyslipidemia.⁶ A randomized trial of an intensive lifestyle intervention to increase physical activity and decrease caloric intake vs standard DM education in people with T2DM showed a modest weight loss of 8.6% of initial weight at 1 year.⁷ This weight loss was associated with significant improvement in blood pressure, glycemic control, fasting blood glucose, high-density lipoprotein (HDL) cholesterol, and triglyceride levels and significant reductions in the use of DM, hypertension, and lipid-lowering medications.⁷ Obesity attributes to dyslipidemia with increased levels of cholesterol, low-density lipoprotein, very low-density lipoprotein, triglycerides, and decreased levels of HDL by about 5%.⁸ Obesity also is associated with hypertension, coronary heart disease, heart failure, and cardiovascular and all-cause mortality.⁹

Limitations

Limitations of this study include the small sample size and that multiple HCPs were involved. The nature of intervention might have differed with different HCPs or in a different setting than a VA clinic. In addition, we did not evaluate the effect on weight loss in specific patients as we only reviewed charts to check whether HCPs addressed weight loss. Nevertheless, our intervention was effective because it improved patient and provider awareness. It also gave us the opportunity to create framework for further collaborations and community building. The Endocrinology department at CAVHS is currently collaborating with the MOVE program, which is a part of the nutrition and food services. We hope to have an endocrinologist involved to provide guidance on medication management for obesity.