Lifestyle and Weight Management:: Helping Patients Find Their Way To Live Well
Lifestyle and Weight Management:: Helping Patients Find Their Way To Live Well
Lifestyle and Weight Management:: Helping Patients Find Their Way To Live Well
This care process model (CPM) was created by a multidisciplinary team of physicians and
other healthcare providers at Intermountain Healthcare. Its purpose is to summarize and Algorithm
including supporting 2–3
promote evidence-based approaches to lifestyle and weight management, and to facilitate notes and
implementation in routine primary care. The CPM moves beyond WHAT to do — it assessment tools
focuses on WHY it matters and HOW to be successful. The emphasis is on improved
health and well-being, not just weight loss. Building a Framework
for Success
What’s New in this CPM? Purpose
4–5
• Expansion in scope from the previous CPM: Rather than focusing only on weight & Principles
management, this CPM encompasses lifestyle behaviors that lead to overall health Team Strategies 6–7
and well being — the same behaviors that support healthy weight management. & Tools
In addition to physical activity, nutrition, and weight, new sections focus on other
lifestyle factors not previously highlighted: sleep, stress, social support, mental health, Behavior Change
8–11
and alcohol and tobacco use. Techniques & Tools
• Added focus on WHY and HOW, not just WHAT: The augmented sections in this
CPM were driven by feedback from physicians who asked, “What can we do to Evidence-based Guidelines
be more effective? How can we stay engaged in the challenge to promote healthy
behaviors in our patients? How can we keep patients engaged?” Physical Activity
12–15
& Sedentary
–– Purpose and principles: Includes information to promote understanding of key
motivating factors for physicians and patients; in other words, finding the “WHY.”
Behavior
–– Team strategies and tools: Includes ideas for helping clinics work as a team: Nutrition & Healthy 16–17
setting a team goal, identifying roles, and defining a workflow process that Eating Habits
can complement existing practices for chronic disease management.
Other Important 18–20
–– Behavior change techniques and tools: Includes information and examples of
Lifestyle Factors:
ways to engage patients in behavior change: motivational interviewing, readiness
Sleep, Stress, Social
to change, and an adaptation of a 5As behavior-change model. The 5As model is Support, Mental
integrated throughout the document to provide examples of how the principles of Health, Alcohol Use,
behavior change can be applied across all areas of lifestyle management. Tobacco Use
• New evidence: Each lifestyle section summarizes the latest evidence and provides Weight 21–27
practical tips and tools specific to that lifestyle area, including guidance on efficiently Management
addressing the topic with your patient when your time is limited. Strategies
• More comprehensive resources and ideas for success: New information includes
ideas for patient follow-up, including team huddles; billing and coding tips to Resources and Referral
improve reimbursement; referral resources; information on the revised
Weigh to Health® program; and ideas for education, online support, motivational Communication,
tools, and community resources. Follow-up, and 28–29
Referral
METRICS — HOW WILL WE KNOW WE’RE SUCCESSFUL? Healthcare Reform
Intermountain will be collecting and tracking a variety of metrics to help measure and report Requirements & 30–31
process and outcome successes for both providers and patients. Metrics are marked with this
symbol on the algorithm on page 2, and are summarized on page 31.
Success Measures
ALGORITHM This symbol indicates an Intermountain process or outcome measure. See page 31 for more information.
pages 6–7
Lifestyle and Disease Management Clinic Environment Tips:
FACT SHEET FOR PATIENTS AND FAMILIES
Clinic Team Process Worksheet Lifestyle and Weight Management
Use the tips below to assess your clinic environment for factors that foster effective lifestyle and weight management.
1. Identify area of focus and supporting materials Jot ideas for improvement, within budget and space limits, in the panels at right.
Worksheet Tips
(such as Prevention, Cooking Light, Health, Heart-Healthy Living, Psychology Today)
DVDs or video clips that support wellness and lifestyle management
pages 8–11
3. Identify clinic team roles; plan for provider and staff education Waiting room displays stocked with patient education materials on
wellness/prevention
Below, identify who will oversee the process and communication, who will coach and educate patients, and make a plan for physician
and staff training. Also, consider using the table to note how the various roles on your team can assist in the process overall. Doing this Patient education materials stocked and ready to distribute in exam rooms
may spark ideas to help you create the process flow in Step 4. Links on the clinic website to information, resources, and apps that support
activity, good nutrition and stress management
Process coordinator (oversees the process flow, coordinates communication within the team and also with specialists
or group programs):
Communication with patients Potential improvements, within
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015a - 05/13
LiVell
LiVe Well Lifestyle and Health Risk Questionnaire
We
1
Link to
Patient presents for well check or routine visit:
Physical Activity
On average, how many days per week do you exercise or days per week: Provider notes:
do physical activity?HELP2 , PAVS
On average, how many minutes of physical activity minutes per day:
or exercise do you perform on each of those days?HELP2, PAVS
At what intensity (how hard) do you usually exercise?HELP2, PAVS light (casual walk) moderate
(brisk walk) vigorous (jog/run)
Lifestyle and
What types of physical activity do you do?HELP2 List:
How often do you do muscle strengthening activities or exercises? day/week:
minutes per day:
How many “screen-time” hours do you have each day: TV, video screen-time hours per day:
games, sitting at the computer (not counting work and school)?HELP2
Health Risk
On a scale of 1-10, where 1 is low and 10 is high, how ready, willing,
and able are you to to improve your activity habits and stick to it? (1-10):
Nutrition
On average, how many days a week do you eat a healthy breakfast?HELP2 days per week: Provider notes:
On average, how many 12-ounce servings of sweetened drinks servings per day:
do you have each day? HELP2 servings per week:
Questionnaire
On average, how many servings of fruits and vegetables do you eat total servings per day:
each day?HELP2 (fruits: /day; veggies: /day)
On average, how many meals per week do you eat with your family?HELP2 meals per week:
On average, how many servings of low-fat dairy do you have each day? servings per day:
On average, how many drinks of alcohol do you have each day?HELP2 drinks per day:
(1 drink = 12-ounce beer, 5-ounce wine, 1.5-ounce liquor) drinks per week:
How often do you eat while doing other things like watching TV? rarely occasionally often
Do you ever eat in secret? no yes
On a scale of 1-10, where 1 is low and 10 is high, how ready, willing, and
able are you to improve your nutrition habits and stick to it? (1-10):
1
*50113*
Pat Qst 50113 © 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015b - 05/13
1. ASSESS lifestyle and health behaviors, risks, and concerns. Document screening results in patient record.
Assess Lifestyle and Health Risks (a), Screen for depression (h), sleep apnea (i), eating disorders (j),
including Physical Activity Vital Sign - PAVS (b). and tobacco and alcohol use. If screens are positive, activate clinic
Measure BMI and waist circumference (c) and assess for weight-related team or refer to specialist or other CPMs for guidance.
comorbidities (d) and contributing conditions (e) and medications (f). Ask about patient concerns and readiness to make lifestyle changes.
2. ADVISE on personal health risks and recommend evidence-based interventions. Document counseling in patient record.
PHYSICAL ACTIVITY WEIGHT MANAGEMENT NUTRITION SLEEP, MENTAL HEALTH, etc.
Advise on importance of PA and Address comorbidities (d), Advise on key evidence-based Explain the significance of other
to start or increase PA to meet contributing conditions (e), and nutrition guidelines to address lifestyle risk factors and comorbidities
recommended >150 minutes of medications (f) concurrently. patient’s highest risk areas: in relation to overall health and
moderate or vigorous aerobic Advise on the health risks of obesity –– Eat a healthy breakfast weight management.
PA per week in bouts of at least 10 and the proven interventions and –– Eat more fruits and vegetables Advise on evidence-based behavior
minutes per session. success factors for behavior change, –– Limit sweetened drinks recommendations and resources:
Advise to reduce sedentary physical activity, and nutrition — –– Eat meals with family
behaviors (sitting, screen time). including increasing physical activity –– Get 7 to 9 hours of sleep per day
–– Practice mindful eating –– Manage stress
Advise to add 2+ days of strength to 250 to 300+ minutes per week.
–– Learn and limit portion sizes –– Engage social support
and flexibility exercise and to increase Refer patients with BMI >30 –– Access mental health resources
aerobic activity to >300 minutes a to intensive, multicomponent Consider referral for nutrition
counseling. –– Quit tobacco and limit alcohol
week for more health benefits. behavioral interventions.
more on pages 12–15 more on pages 21–27 more on pages 16–17 more on pages 18–20
Use this worksheet to help you choose a healthy lifestyle goal that you’re ready to work on. WHERE I’M STARTING: Activit y level: minutes/week Weight: pounds Sleep: hours/day
Narrow concerns and behaviors. The Readiness Worksheet can be used as a tool.
MY KE Y RISK ARE A S AND POSSIBLE GOAL S
NARROw YOuR CONCERNS Physical Activity Nutrition
What are your biggest health concerns? Moderate to vigorous aerobic physical activity: Eat a healthy breakfast times per week
A B Brisk walking or Eat or drink MORE of these:
Link to
C D
Days/week x Minutes/day fruits: servings/day vegetables: servings/day
Link to
= Total minutes per week: (build up to at least 150) other:
Which concern are you most ready, willing, and able to work on NOW? Eat or drink LESS of these:
Strength training 2 or more days per week:
On the ruler, write the letter of each concern above a number What: sweetened drinks - less than 12-oz servings/week
to show how ready you feel to work on it right now. other:
Reduce total sitting time
from hours a day to hours a day Eat meals together as a family times per week
Rx to LiVe
B C A
Other: Other:
Readiness
Circle the concern you marked farthest to the right.
Choose to work on this concern.
O t h e r I m p o r t a n t L i f e s t y l e Fa c t o r s Weight Management
Sleep hours per night nights per week Lose % of body weight or pounds
(aim for 7 to 9 hours every night)
by (date)
N A R R O w YO u R B E H AV I O R S Manage stress by:
Record weight at least once per week for weeks
What specific behaviors or actions would help you with this concern? Find a friend or family member to support my commitment:
ACTIVATE CLINIC TEAM
Worksheet Well
Talk with your healthcare providers for ideas about what’s proven to help most.
Reduce alcohol intake to less than drinks per week Target calories/day: Target carb gms/day:
Document mutually agreed upon goals on a written prescription or care plan that both you and the patient sign.
___________________________________ ___________________________________ Quit tobacco: Method: Quit date: Record daily physical activity for weeks
___________________________________ ___________________________________ Reward myself for small changes and successes Target minutes/week: 250 300 Other:
How:
Which behavior or action are you most ready, willing, and able to do NOW? Other:
Consider the ruler again. Other:
4. ASSIST in making an action plan, promoting accountability, and identifying resources. LiVe Well Action Plan
Advise patient to make a detailed Action Plan, including how they will overcome barriers and setbacks and enlist support.
Example:
Link to
• What is the specific action for your goal?
Walk around my office building for 20
• How and when will you do this? minutes at lunchtime. Each week I walk
• What will your milestones be? 4 times it is a milestone.
•
How will you track and report your progress?
• How will you keep track? Example:
Tracking: Every time I go I’ll put a check
• Who will you report to and how often? mark on the calendar at my desk.
Action
• How will you reward yourself? Reward and report: Each milestone
• Who will support you? This might include healthcare providers, family members, I’ll buy new music to listen to while
Promote accountability by emphasizing the importance of a daily tracking (or journaling) and reporting plan.
friends, or group leaders. walking. After 3 weeks, I’ll email my
doctor with the good news and I’ll make
Person or team How they can help a new goal with more minutes.
Support: My co-worker will remind me
to go. Every night I’ll tell my wife if
I walked.
Plan
What might get in the way?
• In what situations will this be most • What can you do in these situations? Example:
difficult for you? How could you overcome this? I might not feel like walking when I’m
Provide or identify education and motivation tools and community resources to support goals. See resources on page 32.
discouraged. When this happens, I’ll
invite a co-worker to go with me.
I might not be able to walk at lunch if I
have a meeting during that time. When
this happens, I’ll walk after work.
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015e - 05/13
(a) Lifestyle and Health Risk Questionnaire (g) Weight-related risk and recommended interventions
•• Follow clinic processes to distribute and collect Intermountain’s Lifestyle BMI and Normal Overweight Obese Extremely
and Health Risk Questionnaire or another health risk assessment (HRA) or Obesity Weight 25.0–29.9 30.0–39.9 Obese
Class 18.5–24.9 25–29.9 >27 with 30–34.9 35–39.9 40 or more
collection form. Depending on your processes, this could be prior to the visit or
in the waiting room. Intermountain clinics have the ability to document many comorbidities Class I Class II Class III
of these questions in the HELP2 Preventive/Social Hx tab. Intervention Low Moderate Mod–high Severe
•• At a minimum, assessment should include major lifestyle habits and risks related Risk risk risk risk
to activity, nutrition, sleep, mental health, weight, and related comorbidities.
Behavior
Activity
(b) The Physical Activity Vital Sign (PAVS)
Nutrition
1. On average, how many days a week do you perform physical activity or exercise?
Medication Consider
2. On average, how many total minutes of physical activity or exercise do you
perform on each of those days? Surgery Consider with
comorbidities
3. At what intensity (how hard) do you usually exercise? Light (like a casual walk),
moderate (brisk walk), or vigorous (jog or run) See page 22 for more information on risk level and evidence-based interventions.
Patient Name:
Address:
STOP-BANG Questionnaire
Sex:
City:
Date of birth (mm/dd/yyyy):
State: Zip:
YES NO
1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed
STOP-BANG
doors)?
Obstructive sleep apnea (see Table i) for men or <50 for women)
2. Tiredness/fatigue: Do you often feel tired, fatigued, or sleepy during the daytime, even after
•
a “good” night’s sleep?
Questionnaire
5’1” 185 5’11” 250
6. Age: Are you older than 50 years? 5’2” 191 6’ 258
7. Neck size: Does your neck measure more than 5’3” 197 6’1” 265
Peripheral vascular disease • and/or sleep testing. See Obstructive Sleep Apnea CPM.
5’5” 210 6’3” 279
8. Gender: Are you male?
•
5’6” 216 6’4” 287
5’7” 223 6’5” 295
Weights shown in the tables above correspond
to a BMI of 35 for a given height.
• •
Sleep Sc 50383
STOP-BANG QUESTIONNAIRE
Questionnaire adapted with permission from Chung F, Yegneswaran B, Liao P,
Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. Anesthesiology. 2008;
108(5):812-821.
S.T.O.P. B.A.N.G.
CPM031b - 05/30/13 Patient and Provider Publications 801-442-2963
(f) Weight-related contributing medications (j) Eating Disorders Screen: The Modified ESP
Medications Examples: Eating disorders, especially binge eating, may complicate treatment for obesity.ICSI The
Diabetes, insulin • Sulfonylureas • Thiazolidinediones Modified ESP (Eating Disorders Screen in Primary Care) questionnaire is effective
resistance • Glitazones • Insulin in identifying patients who require further evaluation.COT Refer to Intermountain’s
Eating Disorders CPM for more guidance.
Depression, • Tricyclic antidepressants • Lithium
mood disorders • Atypical antipsychotics • Paroxetine Modified ESP 1. Are you concerned about your eating patterns?
(e.g., Zyprexa, • Some SSRIs/SNRIs questions: 2. Do you ever eat in secret?
Risperdal, Clozaril) • Mirtazapine 3. Does your weight affect the way you feel about yourself?
4. Have any members of your family suffered from an
Hypertension • Beta blockers • Calcium channel blockers eating disorder?
Other • Oral contraceptives • Antiepileptics (e.g., valproic Scoring: 0–1 ”Yes” responses: Eating disorder ruled out
• Oral glucocorticoids acid, carbamazepine) 2 or more “Yes” responses: Eating disorder suspected,
See page 25 for more information, examples, and alternatives. evaluate further.
Find the “WHY” for your clinic: Find the “WHY” for your patients:
It can be helpful for the clinic team to discuss your Each patient’s “WHY ”is a little different.
core reasons for helping patients adopt healthier Motivation comes from a patient’s own concerns
lifestyles. Based on this discussion, consider and desires, informed by a provider’s advice given
developing a “WHY” statement that can renew in a collaborative approach. Pages 8–11 present
your energy when you encounter barriers. strategies to assist in this process.
PRINCIPLES: Understanding through PRACTICE (the “HOW”) Lifestyle & Weight Management
Recognizing and meeting the challenges TOOL KITS
• Weight loss is not the only measure of success. Your team is successful if you can
Throughout this CPM, you’ll find a list
implement small goals in promoting lifestyle management, one step at a time. Your of tools at the end of every section.
patients are successful if they can move closer to adopting healthier lifestyle habits, These tools are available individually, or
one stage of change at a time. Successful adoption of healthier habits in and of itself as part of a Clinic Implementation Kit
improves health and counts as success — even without weight loss! and/or a Patient Tool Kit. The contents
of both of these Kits can be accessed
• Change is an ongoing process, not a single event. This CPM provides tools to online or ordered from i-printstore:
help your clinic and your patients successfully plan, implement, and evaluate ongoing • To access online: The tools and a
lifestyle changes. range of other resources are linked
online at
• Outlining a workflow process can help with time limits. This CPM promotes a team
www.intermountain.net/lifestyle
approach that can ease the individual PCP burden of promoting lifestyle management and
during the appointment. The process takes some planning, but the investment pays off. www.intermountainphysician.org/
lifestyle
• This CPM provides coding advice to make reimbursement easier. See page 31 for a
link to a guide to payer algorithms and coding for lifestyle and weight management. • To order: Order the kit
contents and refills as needed from
Following a general process — the “5As” i-printstore.com.
Beginning with the algorithm on page 2, this CPM presents and reinforces a process
Clinic Implementation Kit
based on the “5As” behavior management approach, originally used for smoking cessation
in primary care,JAY and successfully adapted for alcohol counseling, weight management, The Clinic Implementation Kit includes
and nutrition counseling.CAR,SCHL This model is endorsed by the Centers for Medicare and tools to help you integrate lifestyle
Medicaid Services and the United States Preventive Services Task Force.SCHL,USPS and weight management into your
clinic processes and culture. This
The 5As do not represent rigid linear steps, but rather help shape an ongoing conversation
includes the CPM, clinic worksheets,
that promotes successful behavior change, partly by helping patients find their “WHY.” slide presentations, and coding
• Assess lifestyle and health risks, behaviors, and concerns. reimbursement guide — along with a
sample copy of each of the tools from
• Advise on personal health risks and evidence-based interventions and behaviors. the Patient Tool Kit.
• Agree on 1 to 3 specific goals based on personal preferences and readiness to change.
Patient Tool Kit
• Assist in making an action plan, promoting accountability, and identifying resources.
• Arrange for referrals, reporting mechanisms, and follow-up appointments. The Patient Tool Kit includes all the
tools you’d actually use with patients
or give to patients — including
questionnaires, worksheets, patient
HOW TO USE THIS CPM education, and trackers.
• Team strategies and tools (pages 6–7): This section and its associated tools will help
you implement lifestyle management as a clinic team — identifying roles, setting a team goal, and
defining a workflow process. MORE SUPPORT
• Behavior change techniques and tools (pages 8–11): This section and its Initiatives aimed at shifting the culture
associated tools will help you use motivational interviewing techniques to assess and promote toward wellness can support your efforts in
readiness to change, help patients identify and narrow their concerns, and help patients set promoting lifestyle management.
achievable goals. The end of the section provides ideas for adapting the 5As to fit your time.
• Public LiVe Well campaign: In
• Evidence-based guidelines (pages 12–27): Each section — Physical Activity, 2013, Intermountain and SelectHealth
Nutrition, Weight Management, etc. — summarizes evidence-based recommendations and began rolling out public messages
provides practical tips and tools for efficiently following the 5As. focused on wellness and lifestyle
choices.
• Advice and tools for follow-up, communication, and billing and coding
• National initiatives: Messages for
(pages 28–35): This section provides ideas and tools to plan efficient “team huddles” and
the public (such as letsmove.gov),
patient follow-up — and use billing codes that result in better reimbursement.
and resources for providers (such as
exerciseismedicine.org).
•
Potential improvements, within
Tips to provide a comfortable, effective environment for treating obese patients: budget /space limits
and inspire patients. See the sidebar for more information, including a link to Clinical
properly mounted grab bars
Environment Tips.
activity, good nutrition and stress management
ideas.
Tips to improve your communication with patients related to lifestyle/weight: budget /space limits
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015a - 05/13
•
FACT SHEET FOR PATIENTS AND FAMILIES
Clinic Team Process Worksheet
Team Process Worksheet (see TOOLS) to facilitate the following steps: • Onsite gyms or other facility
Who will review these materials, and by what date?
improvements
How and when we’ll measure results, and how we’ll know we’ve met the goal:
3. Identify clinic team roles; plan for provider and staff education
Below, identify who will oversee the process and communication, who will coach and educate patients, and make a plan for physician
Process coordinator (oversees the process flow, coordinates communication within the team and also with specialists
or group programs):
Patient coach role (coaches and educates patients; several people may share this role):
T e a M M e M b e R Ro L eS P Ro C eSS n oT eS
Primary care provider/s (MD, DO, PA, NP)
Nurse / MA
Other:
1. Team resources / communication: Dr. Jones will act as process coordinator, Emily will be coach
Gather Intermountain care process models, guidelines, or other evidence-based materials to review:
Management
Gather Intermountain patient education materials (see www.i-printstore.com or www.intermountain.net/cp):
for most patients. Team brainstormed exercise programs for referrals and made a list of community rec
Resources Specialists
something else). If your team has set a goal, document it below.
How and when we’ll measure results, and how we’ll know we’ve met the goal:
3. Identify clinic team roles; plan for provider and staff education
Below, identify who will oversee the process and communication, who will coach and educate patients, and make a plan for physician
and staff training. Also, consider using the table to note how the various roles on your team can assist in the process overall. Doing this
centers. Susan (receptionist) will order copies of patient education on physical activity (PA).
may spark ideas to help you create the process flow in Step 4.
Process coordinator (oversees the process flow, coordinates communication within the team and also with specialists
Worksheet
or group programs):
Patient coach role (coaches and educates patients; several people may share this role):
T e a M M e M b e R Ro L eS P Ro C eSS n oT eS
Primary care provider/s (MD, DO, PA, NP)
Clinic manager
Nurse / MA
2. First team goal: Measure and record the physical activity vital sign (PAVS), share result with
Other:
patient, and recommend 150 min physical activity/week. If patients want tips, give education and Clinic Environment Tips:
Lifestyle and Weight Management
list of resources and add note in HELP2. Measure success in 3 months (using HELP2 records). Future
Furniture and equipment Potential improvements, within
Tips to provide a comfortable, effective environment for treating obese patients: budget /space limits
Management Clinic
Exam equipment: large-size blood pressure cuffs, extra-long
phlebotomy needles
goal: For sedentary patients, add brief conversation around readiness or goal-setting.
Lavatory with floor-mounted toilet, specimen collector with handle,
properly mounted grab bars
Environment Tips
wellness/prevention
Patient education materials stocked and ready to distribute in exam rooms
Links on the clinic website to information, resources, and apps that support
activity, good nutrition and stress management
3. Process:
Communication with patients Potential improvements, within
Tips to improve your communication with patients related to lifestyle/weight: budget /space limits
• Amy (RN): During vitals/check in, briefly mention purpose of PAVS (1 min) Lifestyle and Weight Management
• Dr. Jones: Share PA questionnaire results and briefly share recommendation of 150 minutes of
intermountain.net/lifestyle or intermountainphysician.org/lifestyle for the most current version. Email [email protected]
to report any changes needed. This guide covers the following lifestyle and weight management services:
• Preventive visits (see page 2):
– For patients with commercial/private plans. These visits involve a comprehensive history/exam (focused on risk
factors and not problem management), screening tests and vaccines appropriate to age and risk as required by the
Accountable Care Act (see section below), plus risk factor interventions such as lifestyle and weight management
Management Coding
counseling.
– For patients with Medicare plans. See the CMS Quick Reference for Medicare Preventive Services for frequency, coding, and
coverage for Medicare preventive services, including the Initial Preventive Physical Exam (“Welcome to Medicare”
visit), annual wellness visits, screening exams, tobacco cessation counseling, and so forth.
• Lifestyle and weight management visits (see pages 2–4), which can focus solely on counseling and coaching patients
activity each week; ask patient if they’d like tips or help with this (2 min)
in setting goals and making lifestyle changes:
– For patients with commercial/private plans. These include individual counseling, group counseling, and medical
nutrition therapy.
– For patients with Medicare and Medicare Advantage plans. These include intensive obesity counseling, medical
nutrition therapy, and annual depression screening.
– For patients with Utah Medicaid. See page 4 for coverage notes and a link to local information.
• Bariatric surgery coverage. See page 4 for a summary of coverage and criteria for commercial/private payers,
Medicare, and Utah Medicaid.
and Reimbursement How healthcare reform affects lifestyle and weight management services
The Affordable Care Act stipulates that new commercial and individual health policies (beginning on or after September 23,
2010) must cover preventive services with “strong scientific evidence” of health benefits under a preventive benefit where the
patient has no cost sharing (no copayment, co-insurance, or deductible). Services with “strong scientific evidence” are defined as
• John (APRN): For patients who answer yes to physician question, give/explain handout and list
those recommended by the USPSTF with an A or B rating.
Required services include the following:
• For patients with BMI >30: Intensive, multicomponent counseling and behavioral interventions to promote
sustained weight loss. Required components include behavioral management, improving diet/nutrition and increasing
physical activity, addressing barriers to change, self-monitoring, and strategies for maintenance. Guidelines stipulate 12 to
26 individual or group sessions in a year, provided by primary care clinicians or specialists, such as dietitians who participate
Guide
in a multicomponent behavioral intervention program.
The Weigh to Health® is a good way to meet this ACA requirement. This program meets USPSTF guidelines and is
coded and billed appropriately with no patient copay. If The Weigh to Health® is not available, recommend your patient
contact their insurer to ask about an appropriate program. If a program is not available and you provide this service, you can
bill using the codes described in the table above; however, it is challenging to combine appointments on your own for a
of community rec centers; answer questions and refer to group program if desired (2 to 5 min)
program that meets these ACA requirements and is coded appropriately for no copay.
• For patients with diet-related chronic disease: Intensive behavioral dietary counseling provided by a dietitian or
specially trained primary care clinician. Guidelines stipulate at least 2 to 3 group or individual sessions of at least 30 minutes
each. To bill for dietitian services that meet this requirement, use the medical nutrition therapy (MNT) code in Table 2, page 2.
SelectHealth commercial coverage includes 5 visits to a registered dietitian with no copay.
1
• John or Amy: Record PA results in HELP2 Preventive/Social Hx tab; make note if education was
given (2 min) • Creating a Lifestyle
• Team huddles: 10 min at end of day on patients, brown bag every 2 weeks on process
Management Team
(presentation for
4. Clinic environment: Susan will set up place to post information about local charity walks, fun team meetings)
runs or rides, and other active events that patients or staff can sign up and train for.
TABLE 1. Assessing and promoting patient readiness for behavior change KUS
PATIENT READINESS ------------------------------------------------------------>
Not ready ------------------------> Unsure ---------------------------> Ready
What the PATIENT Patient does not realize the Patient is aware of the Patient has decided to Patient is actively trying to Patient has changed the
may think or say: issue is a problem, or is not problem, but may not feel change and is thinking change the behavior. behavior but may relapse.
interested in changing. ready or able to change yet. about how to do it.
“I can’t even think about “I know I should do this. “I’ve been thinking more “I’ve been getting ready “I‘m doing it. I really
changing that right now.” My spouse wants me to about making this change.” and I have a plan.” messed up, but I started
do it.” again the next day.”
Possible PROVIDER Help patient start to Help patient resolve Help and troubleshoot Help build skills in self- Help normalize
interventions think about change. ambivalence and find barriers and increase monitoring, stimulus relapse and plan for
and dialogue to internal motivations self-efficacy related to control, and problem maintenance.
this change. solving.
help move patients
forward on the
readiness scale: “That’s okay. What “Can I give you more “What might make you “Great. Let’s discuss “Great job. What helped
change could you consider information about how feel more ready or able?” the details of your plan.” you get back on track?”
right now?“ this change could
benefit you?”
health, social support, tobacco, alcohol, and weight. This may include
Provider notes: Height (inches): Weight (lbs): BMI: SB5
Physical Activity
On average, how many days per week do you exercise or days per week: Provider notes:
do physical activity?HELP2 , PAVS
On average, how many minutes of physical activity minutes per day:
Nutrition
On average, how many days a week do you eat a healthy breakfast?HELP2 days per week: Provider notes:
On average, how many 12-ounce servings of sweetened drinks servings per day:
do you have each day? HELP2 servings per week:
information.
On average, how many servings of fruits and vegetables do you eat total servings per day:
1
*50113*
•
1
including BMI, waist circumference, and other labs and tests to The Lifestyle • Set one to three goal. Choose
and Health Risk
assess lifestyle-related comorbidities such as obesity, hypertension, goals you feel confident you can
Questionnaire
dyslipidemia, sleep disorders, and depression. asks evidence- achieve. Experiencing success
based questions with one goal will increase your
• Ask about patient concerns and readiness to make lifestyle related to the confidence that you’ll be able to
issues addressed
changes to improve health. Using open ended questions, ask patients achieve the next one.
in this CPM.
to tell you what they are most concerned about. Demonstrate active • Make an action plan. You’re
listening by clarifying and amplifying the patient’s experience without much more likely to succeed if you
judging, criticizing, or imposing your own values. make a detailed plan for success.
2. ADVISE on personal health risks and relevant evidence-based • Track and report. Keeping a
interventions and behavior changes. food, activity, and/or weight journal
— and being accountable to record
• Discuss personal health risks and why they are so important. Explain the results and report your progress to another
of your assessment in whole health terms — how patients’ current risks affect their person — are proven success factors
whole health picture — and the consequences of not addressing them. See the sidebar for behavior change.
for a tool that can be used to show patients how their habits affect their health.
• Discuss and recommend interventions and behavior changes Rx to LiVe Well
MY NAME: MY DOCTOR: TODAY’S DATE::
your advice to what might be important to the patient. Ask for the
Strength training 2 or more days per week: Eat or drink LESS of these:
What: sweetened drinks - less than 12-oz servings/week public healthpredictor
problem of all
ofcauses of mortality
the 21st century.
Reduce total sitting time other:
from hours a day to hours a day Eat meals together as a family times per week A large study showed that low
Reduce screen time (TV, video games, Internet) Keep a food journal for days 18 cardiorespiratory fitness levels contribute
Attributable fractions (%)
from hours a day to hours a day 16 Men to more deaths than do other major
Reduce portion sizes by using a smaller plate or:
Other: Other: Women chronic conditions.
14
12 This graphs shows the estimated number of
O t h e r I m p o r t a n t L i f e s t y l e Fa c t o r s Weight Management deaths that could have been avoided if each
10
risk factor had not been there.
rol
Smoker
fitness
ion
choleste
Other:
rtens
Hype
8
In all three weight groups, the men with the
7 lowest fitness levels were the most likely to
6 die. The surprising finding is that obese men
5 Low fit – with high — or even moderate — fitness
normal were much less likely to die than normal-
4 weight men with low fitness.
3
Use motivational interviewing skills to help elicit the patient’s own concerns
High fit – The value of physical activity is not just to
REFERENCE
2 obese
help you lose weight. Activity increases your
•
1 cardiorespiratory fitness, which is important to
0 your health whether or not you lose weight.
High /
Low
High
Low
High
Low
rate
rate
rate
Mode
Mode
and reasons to change — in other words, help them find their own “WHY.” © 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015i - 06/13
Let patients make their own case for taking steps to reduce their personal health The Lifestyle Risk
risks, in their own words. Ask, “What do you think might happen if you make a Graphs tool can
be used to advise
change? Or if you don’t make a change?” your patients how
inactivity and other
Note: Patients may not be ready to work on the concerns that are the top priorities for the lifestyle factors
physician. The Patient Readiness table on page 8 provides ideas to increase patients’ readiness to affect their health.
address important concerns. However, remember that patients are more likely to succeed when
working on their own priorities — and experiencing success with one concern will increase self-
efficacy for addressing other concerns.
C D
___________________________________ ___________________________________
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015d - 05/13
changes to 1 or 2.
Physical Activity Nutrition
Moderate to vigorous aerobic physical activity: Eat a healthy breakfast times per week
Brisk walking or Eat or drink MORE of these:
Days/week x Minutes/day fruits: servings/day vegetables: servings/day
= Total minutes per week: (build up to at least 150) other:
quest, not a sprint. Set a goal the patient has a good chance of
Strength training 2 or more days per week: Eat or drink LESS of these:
What: sweetened drinks - less than 12-oz servings/week
Reduce total sitting time other:
from hours a day to hours a day Eat meals together as a family times per week
Reduce screen time (TV, video games, Internet) Keep a food journal for days
from hours a day to hours a day Reduce portion sizes by using a smaller plate or:
ARRIVE AT A GOAL
Other: Other:
Handouts given:
make a plan.
Referrals: Nutrition counseling: Dietitian Phone
Weigh to Health program: Location Phone
•
Tracking method: Report or follow up: In weeks / months with
Signed: (patient) (provider) (date)
*50280* Give the patient a copy of this Rx, and keep a copy in the patient’s chart.
Pt Inst 50280 © 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015f - 05/13
prescription or care plan that both you and the patient sign. Rx to LiVe
The bottom section of the Rx to LiVe Well provides a space for Well is a tool
this purpose. Keep a copy of the signed prescription in the for prescribing
health behaviors
patient’s chart. (Agree) and
referring to
4. ASSIST in making an action plan, promoting specialists
accountability, and identifying resources. (Arrange).
• Advise patients to create a detailed action plan for reaching LiVe Well Action Plan
their goals. The LiVe Well Action Plan is a tool that can be used
Once you’ve chosen a goal, the most important next step is to make a detailed plan
for reaching it. Take your time and think carefully about your plan.
Example: 20 minutes of exercise at least
Write your goal here: 4 times a week. Do this for 3 weeks.
for this purpose. If office time is limited, the patient can complete
• How and when will you do this? minutes at lunchtime. Each week I walk
• What will your milestones be? 4 times it is a milestone.
•
How will you track and report your progress?
• How will you keep track? Example:
Tracking: Every time I go I’ll put a check
• Who will you report to and how often? mark on the calendar at my desk.
• How will you reward yourself? Reward and report: Each milestone
• Who will support you? This might include healthcare providers, family members, I’ll buy new music to listen to while
––
have a meeting during that time. When
this happens, I’ll walk after work.
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015e - 05/13
patient make a
Meal I’m also tracking
if with family
Food item (portion size) calories
Vegetables
Activity
Breakfast Activity:
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
plan to reach a
at work/school
––
Date: (circle one) S M T W T F S Sleep Number of hours I slept last night:
Meal I’m also tracking
if with family
Food item (portion size) calories
Vegetables
Activity
Activity:
goal (Assist).
Breakfast
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner
Breakfast Activity:
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
––
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 HH016- 05/13
More health information is available at intermountainhealthcare.org/wellness.
The LiVe Well Making a plan for how to get started again can prevent
1-Week Habit discouragement. Counsel patients to consider relapses as instructive;
Tracker helps relapses can help patients identify risky situations to avoid in the future,
patients track and how to get back on track.
sleep, nutrition,
physical activity, • Promote accountability through tracking and reporting. Discuss the importance
and weight goals. of daily tracking and identify a person the patient will report progress to.
• Provide or identify resources to support goals. This could include handouts,
websites, motivational aids, and community groups.
10 ©2015 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
J U N E 2 013 LIFEST YLE AND WEIGHT MANAGEMENT CPM
5. ARRANGE for referrals, reporting mechanisms, and follow-up appointments. ENGAGE YOUR TEAM —
Behavior change is most successful with intense follow-up. Pages 28 and 29 provide REFER WHEN NEEDED
more details and ideas for follow-up, but here are a few tips: Individualize your treatment of patients
• Specify a follow-up plan on the patient’s Rx to LiVe Well. Keep a copy in the based on your patient’s physical and
patient’s chart and share it with the practice team as appropriate. social/emotional complexity and level of
family support — as well as the comfort
• Determine when to manage patients yourself, engage others on the team, or level of you and your team. Remember,
refer to specialists: you don’t need to go it alone. Engage
–– Try to move the patient along the readiness scale. If the patient is unwilling or your team every step of the way. Use
tips in this section to move your patient
unable to make critical behavior changes, use tips from Table 1 on page 8 to try to
along the readiness scale — but refer to
increase readiness. Enlist your team for support based on your clinical processes. comprehensive programs and behavior
–– Consider referral to a care manager, health coach, dietitian, or behavior change change experts as needed. Clinic tools
specialist (see sidebar). Refer patients with possible contraindications, mobility presented on pages 6 and 7 help you work
with your team to identify such resources.
problems or other special needs to appropriate specialists for evaluation and advice.
TIME-EFFICIENT 5A S:
At many office visits, the time available to discuss behavior change is limited. But even very BEHAVIOR CHANGE
brief behavioral counseling is better than none at all — and will increase patient motivation
and reinforce the importance of patient responsibility for modifying behavioral risk factors.
TOOLS
Clinic Implementation Kit
60
TABLE 2. Integrating the 5As behavior change approach into a busy • Motivational
office environment interviewing
6-minute video
If you have Then
demonstration
No time Point out your concerns and arrange follow-up.
“Your exam showed some wellness issues that I’d like to discuss with you at a
future appointment. My MA will give you a handout and can help you schedule an Patient Tool Kit
appointment where we can talk.”
1 minute ADVISE briefly on one of the patient’s most important risks.
• Lifestyle and Health
LiVell
LiVe Well Lifestyle and Health Risk Questionnaire
We
Risk Questionnaire
Physical Activity
On average, how many days per week do you exercise or days per week: Provider notes:
do physical activity?HELP2 , PAVS
On average, how many days a week do you eat a healthy breakfast?HELP2 days per week: Provider notes:
On average, how many 12-ounce servings of sweetened drinks servings per day:
do you have each day? HELP2 servings per week:
On average, how many servings of fruits and vegetables do you eat total servings per day:
each day?HELP2 (fruits: /day; veggies: /day)
On average, how many meals per week do you eat with your family?HELP2 meals per week:
On average, how many servings of low-fat dairy do you have each day? servings per day:
each week is important to your health, and it looks like you’re only getting about 60
On average, how many drinks of alcohol do you have each day?HELP2 drinks per day:
(1 drink = 12-ounce beer, 5-ounce wine, 1.5-ounce liquor) drinks per week:
How often do you eat while doing other things like watching TV? rarely occasionally often
Do you ever eat in secret? no yes
On a scale of 1-10, where 1 is low and 10 is high, how ready, willing, and
able are you to improve your nutrition habits and stick to it? (1-10):
1
*50113*
Pat Qst 50113 © 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015b - 05/13
minutes. Here’s some information to help you increase your activity level. I’d like to
1
Rx to LiVe Well
discuss this more with you at a future appointment. How does that sound?” • Rx to LiVe Well MY NAME:
WHERE I’M STARTING: Activit y level:
Physical Activity
MY DOCTOR:
minutes/week
Nutrition
pounds
prescription and
Days/week x Minutes/day fruits: servings/day vegetables: servings/day
= Total minutes per week: (build up to at least 150) other:
Strength training 2 or more days per week: Eat or drink LESS of these:
What: sweetened drinks - less than 12-oz servings/week
Reduce total sitting time other:
2 to 5 Above plus:
from hours a day to hours a day Eat meals together as a family times per week
Reduce screen time (TV, video games, Internet) Keep a food journal for days
from hours a day to hours a day Reduce portion sizes by using a smaller plate or:
Other: Other:
O t h e r I m p o r t a n t L i f e s t y l e Fa c t o r s Weight Management
Sleep hours per night nights per week Lose % of body weight or pounds
follow-up plan
(aim for 7 to 9 hours every night)
by (date)
Manage stress by:
Record weight at least once per week for weeks
Find a friend or family member to support my commitment:
Who: Record food intake every day for days
minutes
Reduce alcohol intake to less than drinks per week Target calories/day: Target carb gms/day:
Quit tobacco: Method: Quit date: Record daily physical activity for weeks
AGREE mutually on a goal and document the goal and a follow-up plan on a brief
*50280* Give the patient a copy of this Rx, and keep a copy in the patient’s chart.
Pt Inst 50280 © 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015f - 05/13
prescription such at the Rx to LiVe Well; save a copy in the patient’s chart. LiVe Well Readiness Worksheet
For example: “You know, 150 minutes of moderate-intensity physical activity each
A B
Worksheet
C D
Which concern are you most ready, willing, and able to work on NOW?
On the ruler, write the letter of each concern above a number
to show how ready you feel to work on it right now.
Example:
Not ready Unsure Ready
week is important to your health, and it looks like you’re getting only 60 minutes.
B C A
N A R R O w YO u R B E H AV I O R S
What specific behaviors or actions would help you with this concern?
Talk with your healthcare providers for ideas about what’s proven to help most.
Can you think of a way to increase your activity that you feel ready to take on?” …..
___________________________________ ___________________________________
___________________________________ ___________________________________
Which behavior or action are you most ready, willing, and able to do NOW?
Consider the ruler again.
“Great. I’ll keep that goal in your record. I’d like you to keep track of how you’re
SET YOuR GOAL
My goal:
doing, and then I’d like to check on your progress in a few months.”
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015d - 05/13
5 to 10 Above plus:
What will you do to meet your goal?
to help patients
• What is the specific action for your goal? Example:
Walk around my office building for 20
• How and when will you do this? minutes at lunchtime. Each week I walk
• What will your milestones be? 4 times it is a milestone.
•
How will you track and report your progress?
• How will you keep track? Example:
Tracking: Every time I go I’ll put a check
• Who will you report to and how often? mark on the calendar at my desk.
• How will you reward yourself?
minutes
Reward and report: Each milestone
outline steps to
friends, or group leaders. walking. After 3 weeks, I’ll email my
doctor with the good news and I’ll make
Person or team How they can help a new goal with more minutes.
Support: My co-worker will remind me
to go. Every night I’ll tell my wife if
I walked.
or more
invite a co-worker to go with me.
I might not be able to walk at lunch if I
For example: “I’m noticing a few issues that put you at risk for other health
program at my work.
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015e - 05/13
problems. It looks like you’re not getting enough physical activity or sleep, and you’ve
• The LiVe Well 1-Week
LiVe Well 1-Week Habit Tracker
mentioned you drink a lot of soda. Which of these concerns you the most?” ….. Nutrition. Eat more vegetables,
fruits, and other high-fiber foods.
Watch your portions, and cut back on
sweets. Give yourself a when you eat
with your family.
My daily goal:
My goal this week:
Activity. Work up to at least
150 minutes of aerobic activity
a week — or 250 to 300 minutes if you
want to lose weight or maintain weight
loss. Sit less and move more throughout
the day.
Weight. If you need to lose
weight, take it slowly. One or two
pounds a week is a good goal. Weigh
yourself once a week.
My weight today:
“You’d like to get more active — that’s great. What are some ways you could increase
Tracking Tips
• Keep track of what’s important to you. If you want to lose weight, you may want to track calories. Or, you might track other nutrients
such as carbs, fiber, or salt. And don’t forget about sleep. You might be surprised at how your sleep can affect your other health habits.
• Be honest. You don’t need to impress anyone. You just need an accurate account of your daily choices.
• Be complete. Write down everything that goes in your mouth — especially when you don’t want to. Include portion sizes.
• Revisit your goals. Remember where you’re headed, and keep at it. Day by day, you CAN improve your habits — and your health.
Breakfast Activity:
your activity?” …. “Okay, out of those, which do you feel you are ready and able to patients track sleep,
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
at work/school
Snacks outside work/school
Breakfast Activity:
Minutes: (aim high)
do?” …. “Great. Let’s write that as your goal. Here’s a prescription and an Action
Lunch Intensity: Light
nutrition, physical
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
at work/school
Snacks outside work/school
Breakfast Activity:
Minutes: (aim high)
Plan — people who make a plan often do better with their goals. My MA can help
Lunch Intensity: Light
Fruits Moderate Vigorous
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 HH016- 05/13
More health information is available at intermountainhealthcare.org/wellness.
you with a follow-up appointment so I can check on your progress in a few months.”
16 Men
9
for all causes of death
REFERENCE
2 obese
Promote the message: none is 0
1
bad, some is good, and more
tes
ity
l
er
ion
s
stero
0
fitnes
Smok
Obes
Diabe
rtens
rate/
Low
Low
Low
High
High
is better.
rate
rate
chole
Low
High
Mode
Mode
Hype
Mode
High
Exercise A form of physical activity that is planned and structured; the term “exercise” is often used synonymously with “physical activity.”
The light-intensity activities of daily life, such as standing, walking slowly, and lifting lightweight objects. May also include short episodes of moderate or
Baseline vigorous activity, such as climbing a few flights of stairs, but episodes aren’t long enough to count toward meeting recommended physical activity levels.
activity However, emerging literature demonstrates clear physiological benefits to increased amounts of baseline or light-intensity activities, more research
remains to be done to qualify and quantify these effects.
Inactivity The absence of moderate or vigorous physical activity above “baseline activity.”
Sedentary Activities — such as sitting, lying down, and watching television — that do not increase energy expenditure substantially above the resting level. This is
behaviors different from “inactivity” (see above).
The multi-organizational Exercise is Medicine initiative coordinated by the American • For further health benefits,
College of Sports Medicine (ACSM) supports the focus on encouraging primary add other activities like muscular
strengthening exercises, weight-
care physicians and other healthcare providers to routinely include assessment and
bearing exercise for bone health,
prescription of physical activity in every patient care visit. More information and and activities to improve balance
supporting tools can be found at www.exerciseismedicine.org. and flexibility.
1.00
Survival probability
The 2008 Physical Activity Guidelines
right). SCHO While strengthening Both aerobic and
for Americans divide the amount of activities by themselves did not
strenghthening
0.95
Aerobic only
aerobic physical activity an adult gets significantly reduce mortality
each week into 4 categories: inactive, risks, they appear to provide
0.90
Strengthening only
0.85
of thumb for how total amount of
Some is clearly better than 0 20 40 60 80 100 120
1.00
6). SCHO However, even lower
Survival probability
amounts of physical activity
0.95
>300 minutes per week
0.90
Additional benefit
0.85
No aerobic leisure-time
activity
More than 300 minutes health benefits occur as the
per week of moderate- 0 20 40 60 80 100 120
Medium level (see the top line in Figure 6 ). SCHO Studies provide clear evidence of a dose-response
At least 150 minutes per relation between PA and weight loss, with most studies showing that at least 250
week of moderate-intensity to 300 minutes a week are necessary for successful weight loss and long-term
activity in bouts of at least weight maintenance. See page 24 for more activity-related success factors for
10 minutes at a time.
weight management.
Low level TABLE 5. Physical activity recommendations HHS1, CDC2, HAS, ICSI
Some benefit
No physical activity of at
Though more research is needed about the effects of various levels of sedentary behaviors on overall
least 10 minutes per week
or more beyond baseline health and a healthy weight, the following are reasonable goals based on what we do know:
• Aim for less than 2 hours of screen time (not counting work/school computer time) per day.
• Aim for less than 6 hours of sitting per day (including time spent sitting at work).
• If you have a sedentary job, take an activity break for 2 to 3 minutes every 30 to 60 minutes, or
as often as possible.
ALSO ADVISE: • Try to move more all day: take the stairs, park farther away, get outside and play.
SIT LESS, MOVE MORE!
Other types of activity:
Even if patients meet recommended
• Muscular strengthening (resistance) activities: Moderate-intensity to high-intensity
levels of physical activity, other
strengthening activities involving all major muscle groups, performed on 2 or more days a week,
sedentary behaviors may independently
can provide added survival benefits and help build or maintain bone and muscle mass, which is
increase their risk for health problems.
especially important for older individuals or those trying to lose and maintain weight.
See Table 5 for suggested goals for
• Neuromotor activities: To improve flexibility and balance, aim to do activities such as yoga,
reducing sedentary behaviors.
tai chi, and stretching a couple of times each week.
• Bone strengthening activities: Weight-bearing activities put force on the bones to promote
bone growth and strength. These activities can also be aerobic or muscle-strengthening; examples
include jumping jacks, running, brisk walking, and weight-lifting.
• Use the F.I.T.T. mnemonic to advise gradual increases. Although Reduce total sitting time
from hours a day to hours a day
guidelines have shifted away from using specific frequencies and Reduce screen time (TV, video games, Internet)
duration, the F.I.T.T. mnemonic can help you counsel patients to from hours a day to hours a day
gradually increase their total amount of physical activity by modifying Each hour at work stand up and walk
Other:
around for 2 minutes
one or more of the fit factors: more Frequent, more Intense, more Time,
or a different Type. Remember that aerobic physical activity shows
the most health benefits; so in most cases, it’s best to focus on it first.
• Document mutually agreed upon goals on a written prescription or care plan that
both you and the patient sign. The Physical Activity section of the Rx to LiVe Well can
PHYSICAL ACTIVITY
be used for this purpose. TOOLS
Patient Tool Kit
4. Assist the patient with ways and resources to meet their goals.
• Encourage the patient to increase chance of success by making a detailed plan • Intermountain’s
to reach their goal — including what they’ll do, when, with whom, and how they Live Well,
will overcome anticipated barriers. The LiVe Well Action Plan is a good tool for this Move More Patient
purpose. Fact Sheet can be
accessed and ordered
• Provide education materials and a list of local fitness programs and resources on i-printstore.com or
See the TOOLS at right for ideas. linked to via HELP2.
• Suggest tools for accountability, such as the following (see TOOLS for ideas):
Other resources and links
–– Pedometers and electronic activity monitors. Pedometers are a proven tool
to help keep patients motivated and accountable for exercise. Walking 10,000 • Exercise is Medicine website:
steps a day is a way many people can choose to meet the activity guidelines. An www.exerciseismedicine.org
increasing number of electronic activity monitors automatically track steps and • Utah Department of Health
other activity and upload data. The TOOLS box at right lists examples. www.choosehealth.utah.gov.
–– Trackers. These can include simple paper trackers such the Weigh to Health Habit • Pedometers and electronic
Tracker, or any of a multitude of free online tracker applications. monitors. Inexpensive analog
pedometers — as well as more
–– Social or community support — such as an exercise buddy, an online forum, a
sophisticated electronic activity
group class with workmates, family, or friends — can be helpful to some patients. monitors (such as Jawbone Up,
Nike FitBand, and Fit Bit) — are
5. ARRANGE for referrals and follow-up. available at most pharmacies,
• Refer patients with possible cardiovascular contraindications or chronic activity sporting goods stores, or online.
limitations to appropriate specialists (physical therapist or exercise physiologist) for • Online trackers. Popular online
further evaluation before beginning an exercise program.ICSI,EIM Also see the activity and nutrition trackers
Exercise is Medicine Physical Activity Questionnaire for a sample screening tool. include SparkPeople, MyFitnessPal,
FitDay, Fitocracy, RunKeeper, and
• Refer to appropriate specialists or provide suggestions for adapting exercise Endomondo.
based on unique physical and health needs. A physical therapist or exercise Patients can find links to many
physiologist can help create an appropriate exercise plan. See the Exercise is Medicine of the above tools from the
Your Prescription for Health Flier Series.EIM www.intermountainhealthcare.org/
wellness page. See page 32 for links
• Set a specific time to follow up with you or another member of the healthcare team.
to other resources.
• Ask about readiness to TABLE 6. Key nutrition questions to include in a health risk assessment:
change and agree on goals.
•• On average, how many days a week do you eat a healthy breakfast?
• Assist patients with an •• On average, how many servings of fruits and vegetables do you eat each day?
action plan and resources to help •• On average, how many servings of sweetened drinks do you have per day or week?
them reach their goals. •• On average, how many meals per week do you eat with your family?
• Arrange for referral for nutrition
counseling or programs such as The
Weigh to Health®. Set up a plan for
2. Advise on the key evidence-based nutrition habits (see Table 7) relevant to
reporting progress and schedule your patient’s identified risks. Encourage small incremental changes that will have the
any follow-up appointments. most impact and that the patient is likely to be able to maintain for the long term.
of sweetened hypertension, and cardiovascular disease in both children and adults. The results
drinks of several studies provide a strong impetus for efforts to reduce consumption of • Practice mindful eating. Eat
sugar sweetened beverages (and alcohol), especially excessive portions served only when you’re physically hungry,
at low cost.CAP plan meals, enjoy your food.
Eat Instead of focusing on forbidden foods or exact nutrient amounts, focus on • Be accountable by keeping a
MORE eating more nutrient-rich food, and fewer foods and beverages that are nutrient food journal, enlisting support, and
healthy poor (empty calories) or that may have other adverse affects.USDA1 The “Choose reporting your progress.
(nutrient-rich) My Plate”10-Tip series can help support specific goals in this area (see TOOLS).
foods and MORE of these: LESS of these:
FEWER •• fruits and vegetables •• sweetened drinks NUTRITION TOOLS
nutrient-poor •• whole grains •• processed foods with added fat,
foods (empty •• lean proteins and fish sugar, or sodium Patient Tool Kit
calories) •• nuts, seeds, and legumes •• alcohol
•• low-fat dairy products and water •• other energy-dense foods • LiVe Well, Eat Well
patient fact sheet
Stick to healthy Evidence shows no optimal proportion of nutrients for weight loss, as long as
covers key messages
ratios of fat, patients stay within healthy ranges: fat 20%to 35%; protein 10% to 35%; and
from this section
protein, and carbohydrates 45% to 65%. The key is to find what works for the individual;
carbohydrates for example, an insulin-resistant patient may respond better to a lower- • Choose MyPlate
carbohydrate diet.DGAC 10 Tips fact sheet series
Eat meals with Regular family meals are strongly associated with healthier eating patterns. support specific goals
family A meta-analytic review of 17 studies of over 180,000 children and adolescents (e.g., Add More
showed that those who share 3 or more family meals per week are 12% less likely Vegetables to Your Plate)
to be overweight, 20% less likely to eat unhealthy foods, 35% less likely to engage
• Food & Feelings
Food & Feelings
in disordered eating behaviors, and 24% more likely to eat healthy foods.HAM
O n e - D ay j O u r n a l
This journal can help you track what you eat and how it connects to your feelings over the course of a day. Make copies, if desired, for other days.
eating — and
HOW and WHY you eat
and eating choices, evaluating hunger levels before eating, slowing the pace of
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 HH020 - 05/13
journal
Nutrition. Eat more vegetables, Activity. Work up to at least Weight. If you need to lose
fruits, and other high-fiber foods. 150 minutes of aerobic activity weight, take it slowly. One or two
empowerment and enjoyment with regard to eating, improve self-esteem, and Habit Tracker to help
Watch your portions, and cut back on a week — or 250 to 300 minutes if you pounds a week is a good goal. Weigh
sweets. Give yourself a when you eat want to lose weight or maintain weight yourself once a week.
with your family. loss. Sit less and move more throughout
My daily goal: the day.
My weight today:
My goal this week: My goal this week: My goal this week:
Tracking Tips
• Keep track of what’s important to you. If you want to lose weight, you may want to track calories. Or, you might track other nutrients
such as carbs, fiber, or salt. And don’t forget about sleep. You might be surprised at how your sleep can affect your other health habits.
• Be honest. You don’t need to impress anyone. You just need an accurate account of your daily choices.
• Be complete. Write down everything that goes in your mouth — especially when you don’t want to. Include portion sizes.
• Revisit your goals. Remember where you’re headed, and keep at it. Day by day, you CAN improve your habits — and your health.
successfully lose weight and maintain weight loss.COLE Portion control and caloric
Meal I’m also tracking
Breakfast Activity:
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
at work/school
Snacks outside work/school
Breakfast Activity:
Minutes: (aim high)
balance are natural outgrowths of mindful eating. Keeping a food journal to they eat, along with
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
at work/school
Snacks outside work/school
Breakfast Activity:
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
record emotional triggers, hunger levels and responses, and actual food intake
at work/school
physical activity,
Snacks outside work/school
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 HH016- 05/13
More health information is available at intermountainhealthcare.org/wellness.
and patterns is a proven success factor for diet-related behavior modification sleep, and weight
and weight loss.ICSI
Other links and resources
Learn and limit Portion control at meals and snacks results in reduced energy intake and weight
portion sizes loss, and should be included as part of a comprehensive weight management • Intermountainhealthcare.org/
program.AND Research shows that eating more at one meal doesn’t lead to nutrition includes a list of
eating less at subsequent meals, significantly increasing daily energy intake and registered dietitians, classes, and
promoting weight gain. Portion size awareness and simple interventions like links to other resources. See page
using a smaller plate for meals can make a big impact. 32 for more resource links.
–– Some mental health medications can cause weight gain — Find a friend or family member to support my commitment:
my husband
Who:
particularly some mood stabilizers, antipsychotics, and antidepressant
Reduce alcohol intake to less than drinks per week
medications. See page 25 for more information and alternatives.
Quit tobacco: Method: Quit date:
• Evidence-based recommendations: Reward myself for small changes and successes
–– Screen for depression and other mental disorders using the get the latest book in my series
How:
PHQ-2. Refer to the Depression CPM and Mental Health Other:
Integration CPM for information on referral and treatment.
–– Recognize that mental health affects, and is affected by, weight management
WHAT IS MENTAL HEALTH
and behavior change. Make adjustments to care with this awareness in mind.
INTEGRATION?
–– Promote physical activity. Particularly for those with depression, substantial Mental Health Integration is a team
research indicates physical activity provides both mental and physical health benefits. process that incorporates mental health
• Resources and referral: If depression or other mental health disorders are suspected, as a component of wellness in a primary
care setting. Primary care offices who have
refer to an MHI care manager or a mental health specialist. Patient handouts are
implemented MHI have shown improved
available on depression and a range of other mental health conditions. See TOOLS on the mental health outcomes, as well as higher
following page. patient and provider satisfaction scores.
Alcohol use
• Why it’s important:
OTHER IMPORTANT LIFESTYLE –– For general health: Heavier than moderate alcohol use (more than 1 drink a day for
TOOLS women and 2 for men) can lead to increased risk of health problems, including some
cancers; relationship or work problems; and increased risk for motor vehicle accidents,
Patient Tool Kit violence, and drowning.
–– For weight loss: Since alcohol contains sugar and empty calories, it can contribute to
• LiVe Well, Sleep Well weight gain the same way sweetened drinks can. Heavier than moderate alcohol use
patient fact sheet over time is associated with weight gain and obesity, regardless of the type of alcohol
used.USDA1 Lifetime alcohol use is associated with increased waist circumference and
abdominal adiposity in both men and women.BER A new study shows that Americans
tend to eat more calories and fat on the days they also have alcoholic drinks.BRE
• LiVe Well,
• Evidence-based recommendations:
Stress Less
patient fact sheet –– Ask all patients about alcohol use. Advise alcohol users to do so moderation — up
to 1 drink per day for women, and up to 2 drinks per day for men. One drink is 12
ounces of beer, 5 ounces of wine, or 1.5 ounces of hard liquor.USDA1
–– Advise patients to monitor calorie intake from alcoholic beverages and any
• Your Weight, Your accompanying mixers. Reducing alcohol intake is a strategy that can be used by
Medications: Healthy adults to consume fewer calories.USDA1
Resources
• Resources and referral:
–– For more information on screening and counseling for alcohol use and abuse —
including the CAGE and SMAST questionnaires — see Intermountain’s Preventive
Care Recommendations.
• Mental Health –– For advice on where to send patients for alcohol and drug treatment, contact
Depression
I n f o r m at I o n f o r pat I e n t s a n d fa m I l I e s
INsIDe:
patient handout:
What are the symptoms
Depression
Family or friend? and get the support you
What you can do ...................7 need to manage it.
members, call 800-876-1989 or 801-442-1989. For all other patients, call 211 for
Self-management
action plan ..........................8
DepressIoN Is a
FamIly aFFaIr… What is depression?
When you have depression, your depression is an illness caused by problems with the chemicals in your brain.
loved ones are also affected. this chemical imbalance affects how you feel, think, and act. so it’s wrong
They might worry that they’re to see depression as a weakness or character flaw. research has shown that it’s
somehow causing your moods. a medical illness just like diabetes or high blood pressure.
They may be angry with you
there’s a lot of variety in how people experience depression. It can be mild
for being down, or afraid of the
changes they see in you.
or severe. You might have it only once in your lifetime, have several episodes
over time, or have ongoing depression. Your symptoms may differ from those
community referrals.
Help your loved ones by sharing
of other people with depression.
the information in this booklet.
The more they understand the despite its various patterns, you should always take depression seriously.
disease of depression, the Untreated, depression can make it hard to be a good spouse, friend, or parent.
more they’ll be able to support It can hurt you at work and prevent you from taking care of yourself. It can
your recovery and ease their prompt you to pull back from the world — and may even lead to suicide.
own minds.
the good news? depression can be treated. most people Can recover and
lead full, productive lives.
Tobacco use
• Quitting Tobacco:
Patient Education
i n t e r m o u n t a i n h e a l t h c a re. o rg / p re v e n t i o n
diseases. Lung diseases decrease capacity for physical exercise, a necessary component
• Exercise top, bottom, front, and back muscle groups. Alternate muscle
groups each session to give muscles the chance to rest and rebuild.
• Perform 1-3 exercise sets per muscle group consisting of 8-12 repetitions per set at moderate
intensity. Begin with 1 set and progress to 3 sets.
Activity Prescription
• Rest for 30 seconds between sets.
Pad
• Moderate pace means you’re able to comfortably carry on a conversation while exercising
• Vigorous means you’re too winded or out of breath to carry on a conversation while exercising
intermountainhealthcare.org/weight
©2006 IHC Health Services, Inc. All rights reserved. ___________________________________ M.D.
Clinical Education Services. IHCEDHH007 – 1/06 physician signature
• Evidence-based recommendations:
–– Ask all adults about tobacco use and provide tobacco cessation interventions for those
who use tobacco products.USPS
–– Ask all pregnant women about tobacco use and provide augmented, pregnancy-
related counsing for those who smoke.USPS
• Resources and referral:
–– The Utah Tobacco Quit line (800-QUITNOW), a free, phone-based individual
counseling program, is available to all Utah teens, uninsured adults, and adults on
Medicare or Medicaid.
–– The Quit for Life program, a phone-based individual counseling program available to
Select Health members. (866-QUIT-4-LIFE)
–– The Intermountain booklet Quitting Tobacco: Your Journey to Freedom provides
additional help and resources.
• People experience a significant and disproportionate decline in energy • Consider other interventions,
expenditure after weight loss. After reaching and maintaining a 10% or greater such as special diets, pharmacological
weight loss over months or years, patients demonstrate a 300 to 400 kcal per day therapy, and/or surgery only in
reduction in energy expenditure compared to matched subjects at their usual weight.ROS carefully selected patients and only
This exacerbates the potential for weight regain. as an adjunct to intensive lifestyle
management.
• Lower energy expenditure is amplified if weight loss results mostly from
restricting calories. This is likely due to loss of lean tissue and lowered metabolic rate.
Increasing levels of physical activity may spare the loss of fat-free mass and help counter
the detrimental effects of caloric restriction.WAD1 The percent of weight lost as fat,
including abdominal and visceral fat, is greater with exercise than with diet.DGAC
• Other biological effects compound the difficulty of weight loss and weight
maintenance. Growing evidence shows that the decline in energy needs after weight
loss is amplified by biological factors that decrease satiation (thus increasing energy
intake) and conserve energy by keeping fat stores at a defined threshold. Much of this
may be mediated by the adipocyte-derived hormone leptin. More research is needed to
explore the implications for clinical practice.HAV,KIS,SUM
3. Agree on realistic weight-loss goals and success measures. THE RX TO LIVE WELL
• Assess and promote readiness. Assess the patient’s current readiness and attitude Use the Weight Management section
toward losing weight. Asking about previous weight loss attempts, successes, and of the Rx to LiVe Well to help
barriers may be helpful. patients set weight loss and tracking
• Reinforce the message of building lifelong, sustainable habits, including regular goals. Use other sections of the Rx
physical activity and ongoing dietary balance. Focus on helping patients find activities to help set 1 or 2 specific Rx to LiVe Well
and eating patterns they enjoy and are likely to continue throughout life.
MY KE Y RISK ARE A S AND POSSIBLE GOAL S
Physical Activity Nutrition
Moderate to vigorous aerobic physical activity: Eat a healthy breakfast times per week
Brisk walking or Eat or drink MORE of these:
Days/week x Minutes/day fruits: servings/day vegetables: servings/day
• Agree on a weight-loss goal and pace. For most patients, aim for initial weight loss
Reduce screen time (TV, video games, Internet) Keep a food journal for days
from hours a day to hours a day Reduce portion sizes by using a smaller plate or:
Other: Other:
of 5% to 10% of total body weight. This percent has been shown to significantly lower
Who: Record food intake every day for days
Reduce alcohol intake to less than drinks per week Target calories/day: Target carb gms/day:
Quit tobacco: Method: Quit date: Record daily physical activity for weeks
Reward myself for small changes and successes Target minutes/week: 250 300 Other:
health goals.
How:
Other:
Other:
the risk of diabetes and other weight-related health conditions. Aim for a loss of 1
Main goal my doctor and I agree on:
DPP
Patient education resources: Handouts given:
Referrals: Nutrition counseling: Dietitian Phone
Weigh to Health program: Location Phone
Other:
Tracking method: Report or follow up: In weeks / months with
Signed: (patient) (provider) (date)
*50280* Give the patient a copy of this Rx, and keep a copy in the patient’s chart.
• Arrange for more intensive therapy and more frequent follow-up if needed. If See the next page for a summary of
lifestyle changes are not improving outcomes after 6 months, consider more intensive these and other behaviors shown to be
diet therapies, weight-loss medications, or surgery (see pages 25 to 27). These options success factors for successful weight
might be considered earlier for patient with severe obesity-related risk. loss and weight-loss maintenance.
Key evidence-based lifestyle SUCCESS FACTORS ICSI, LAD, SCL, WING1, NWCR
INTENSIVE,
The tables below summarize lifestyle factors most highly correlated with initial and long-
MULTICOMPONENT term success. In general, the focus for weight loss is on problem solving — experimenting
BEHAVIORAL INTERVENTION with what works and identifying practices that can be sustained. For weight-loss
The U.S. Preventive Services Task Force maintenance, the focus shifts to sustaining successful practices by making them routine.
(USPSTF) found adequate evidence
that intensive, multicomponent TABLE 9. SUCCESS FACTORS for weight LOSS and weight-loss MAINTENANCE
behavioral interventions for obese
adults can lead to weight loss, as well Behavior (also see pages 8 to 11)
as improved glucose tolerance and other For weight LOSS For weight-loss MAINTENANCE
physiologic risk factors for cardiovascular
•• Identify triggers, such as stress, emotional eating, •• Stay accountable. Continue to keep a food and
disease.USPS boredom, or poor sleep.ICSI exercise journal, and weigh at least weekly.LAD
The most effective interventions were •• Set specific, measurable goals.ICSI •• Continue what works. Reinforce and continue
comprehensive and of high intensity — •• Track and report progress. Keep a daily food and successful behaviors and daily routines.SCI
12 to 26 sessions in a year — and exercise journal, weigh at least weekly, and record and •• Celebrate ongoing commitment. Find self-
report progress regularly.
incorporated the following components: rewards for sticking to a diet or exercise plan.SCI
•• Follow up frequently with the doctor, dietitian, or
weight-loss counselor. •• Don’t let setbacks become habits.
• Behavioral management
Recognize that it’s normal to get off track; make
activities, such as setting weight-loss •• Seek support from family and friends. a plan for catching “slips” before they turn into
goals •• Remember WHY: personal motivations, progress habits.
already made, etc.
• Improving diet or nutrition
• Increased physical activity Physical activity (also see pages 12 to 15)
• Addressing barriers to change For weight LOSS For weight-loss MAINTENANCE
• Self-monitoring • Get at least 250 to 300 minutes of moderate • Continue with high levels of physical
or vigorous aerobic exercise per week. (This is activity (similar to the amounts needed for
• Coming up with strategies to
equivalent to about an hour a day or 2,500 or more weight loss).
maintain lifestyle changes calories per week.)WNG1, LAD, ICSI
• Continue successful daily routines of
For obese patients with BMI >30, • Find enjoyable activities that can become enjoyable and sustainable activities.SCI
such intensive programs resulted in an sustainable habits.
• Continue an overall more active lifestyle with
average weight loss of 8.8 to 15.4 • Build up gradually and consistently by increasing
less sedentary time.
pounds, compared to little or no Frequency, Intensity, Time, and/or Type. Start by
increasing time by 10 minutes a day. • Add resistance exercises for all major
weight loss with controls. These
• Plan activity into every day. Make it routine, not muscle groups at least 2 days a week
interventions also improved glucose to help maintain lean body mass and
an afterthought.
tolerance and other physiologic risk metabolic rate.
factors for cardiovascular disease.USPS • Move more all day. Decrease overall sedentary
behaviors like watching TV.
For obese patients with elevated plasma
glucose levels, behavioral interventions Nutrition (also see pages 16 and 17)
have been shown to decrease diabetes
incidence by about 50% over 2 to 3 For weight LOSS For weight-loss MAINTENANCE
years (number needed to treat — • Be aware of calorie needs based on age, gender, • Continue to maintain appropriate calorie
only 7!).DPP and activity level. LinkUSDA2 balance throughout life. Evidence suggests
• Reduce calories by 500–1,000 per day for a that due to physiological changes that decrease
Although intensive interventions may energy needs, a patient needs to continue to
gradual weight loss of 1 to 2 pounds per week.
be impractical within many primary care eat about 300 to 400 fewer calories per
• Keep a food journal to increase awareness of
settings, patients may be referred from nutrition practices and to honestly evaluate portion day below pre-weight-loss practice to maintain
primary care to hospital- or community- sizes and overall food intake. new weight.ROS
based programs, such as Intermountain’s • Find what works individually. Evidence shows no • Continue to keep a food journal.
The Weigh to Health® program. For optimal proportion of nutrients for weight loss, as long • Eat breakfast regularly.NWCR
more information, see page 29. as patients stay within healthy ranges for calories from
fat (20%–35%), protein (10%–35%) and carbohydrates • Maintain routines. Maintain a consistent
(45%–65%). The key is to find what works for the eating pattern across weekdays and weekends.
WNG1
individual; for example, an insulin-resistant patient may
respond better to a lower-carb diet.
• Eat plenty of low-fat sources of protein.SCI
• Consider intensive diet therapies for
appropriate patients (see page 25) and referral for
individualized nutrition counseling.USPS
FDA EFFICACY BENCHMARKS: • FDA-approved weight loss medications. See Table 12 below for a summary of
• Meet this criteria:
FDA-approved weight loss medications. These medications meet the FDA weight-loss
–– More than a 5% difference in mean
requirements listed in the sidebar. Most patient will need to pay cash for weight loss
weight loss between the active- medications, as most insurers (including SelectHealth) do not cover them.
product group and the placebo- • Patient education and shared decision making. Educate patients about the risks and
treated group (and statistically
benefits of drug therapy — including realistic expectations, the importance of ongoing
significant)
intensive lifestyle therapies, and how and when to monitor and report side effects. A
OR
Weight Loss Medications patient fact sheet is available to guide this dicussion. Involve the
• Meet both these criteria:
–– More than 35% of active-product
patient in choice of drug and commitment to ongoing lifestyle changes.
subjects lost 5% or more of their • Monitoring and follow-up.
baseline body weight AND –– Follow up within 2 to 4 weeks of drug initiation to check for side effects and efficacy.
–– The percent of active-product
–– If the patient has severe side effects or has not lost at least 4 to 5 pounds within 4
subjects who lost more than 5%
of their baseline body weight is weeks, reevaluate the chosen medication and its dosing and/or consider discontinuing
approximately double the proportion the medication.
in the placebo group (and statistically –– For most patients, loss of 10% of body weight is a reasonable goal and good result;
significant) loss of >15% is excellent.
–– See Table 12 below for monitoring and follow-up recommendations for specific
medications.
TABLE 12. Medications FDA-approved for weight loss (link to dailymed.NHI.com for latest FDA information)
Orlistat Phentermine Diethylpropion Lorcaserin hydrochloride Phentermine/
(Xenical, Alli OTC) (Adipex-P) (Tenuate, Tepanil) (Belviq) topiramate (Qsymia)
Approval 1999 Prior to 1980 Prior to 1980 NEW June 2012 NEW July 2012
Category and Lipase inhibitor: Appetite suppressant: Appetite suppressant: Activates serotonin (5-HT) Sympathomimetic amine +
primary action reduces intestinal fat stimulates NE stimulates NE 2C receptors; decreases food antiepileptic: suppresses
absorption (norepinephrine) release (norepinephrine) release consumption and promotes appetite and promotes satiety
satiety
Max trial length 4 years 9 months 1 year 2 years 2 years
Avg weight loss -3.0 kg (6.6 lb) -3.5 kg (7.7 lb) -3.0 kg (6.6 lb) -3.3 kg (7.3 lbs) -7.8 kg (17.2 lb)
versus placebo at 1 year at 36 weeks at 1 year at 2 years at 1 year
Recommended Xenical 120 mg 3x/day; Alli 15 mg/day 75 mg/day 10 mg twice daily Once daily in a.m. Start at
dosing OTC 60 mg 3x/day with meals to 37.5 mg/day 3.75/23 mg/day x 2 weeks,
then 7.5/46 mg/day. Evaluate
at 14 weeks to d/c or titrate
up to max 15/92 mg/day if
sufficient (3%) weight loss is
not achieved.
Cost Xenical $475/month $30/month $30/month $200/month $180/month
Alli $65/month
Risks and Pregnancy category X. FDA Pregnancy category X. Pregnancy category B. Pregnancy category X. Potential Pregnancy category X. Potential
precautions revised label to include safety Potential for abuse and Potential for abuse and for abuse and dependence. for abuse and dependence.
information on rare liver injury. dependence. Contraindicated dependence. Contraindicated Risk with other serotonergic Contraindications: pregnancy,
with MAOIs, other central with MAOIs, other central drugs; risk for recreational use glaucoma, hyperthyroidism, and
appetite suppressants, appetite suppressants, (euphoria, altered mood, etc.); taking within 14 days of an
uncontrolled HTN, seizures, uncontrolled HTN, seizures, CHF, increased risk of hypoglycemia, MAOI; antiepileptic drugs may
CHF, stroke, arrhythmias, arrhythmias, stroke, agitation headache, back pain, cough, increase suicide ideation
agitation and fatigue in diabetic patients
Potential side Diarrhea, flatulence, bloating, Most common: Most common: hypertension, Fatigue and cognitive changes, Paraesthesia, dizziness,
effects abdominal pain, dyspepsia hypertension, dizziness, head- dizziness, headache, GI headache, dizziness, fatigue, dysgeusia, insomnia,
ache, GI symptoms, insomnia symptoms, insomnia nausea, dry mouth, constipation constipation, dry mouth
Monitoring and •• Balanced, reduced-calorie •• Check blood pressure •• Check blood pressure •• Caution use of heavy •• Obtain baseline blood
follow-up diet with about 30% of weekly. weekly. machinery when initiating chemistry profile; monitor
calories from fat. •• Consider cardiac evaluation •• Consider cardiac evaluation therapy. periodically.
•• Add fat-soluble vitamin and echocardiogram before, and echocardiogram •• If dyspnea or edema •• Monitor for elevation in
supplement. during, and after therapy. before, during, and after develops, evaluate for heart rate, suicidal thoughts,
•• Pregnancy test monthly. therapy. valvular heart disease. mood and sleep changes,
•• Recommended for short- •• Pregnancy test monthly. •• Discontinue if 5% weight cognitive impairment, and
term use (a few weeks) loss not achieved in 12 angle closure glaucoma.
weeks. •• Discontinue if 5% weight loss
•• Pregnancy test monthly. not achieved after 26 weeks.
•• Pregnancy test monthly.
Bariatric surgery
Candidates: Bariatric surgery used in addition to intensive lifestyle interventions is the REFERRAL, FOLLOW-UP, AND
most effective therapy available for morbid obesity. It can improve or completely resolve COMMUNICATION
obesity comorbidities.MBS Appropriate candidates include: Frequent follow-up is critical for successful
–– Patients with a BMI of 40 or higher (extremely obese). In addition, bariatric surgery weight loss. Follow-up doesn’t need to
is sometimes indicated for patients with a BMI of 30 to 39 and serious weight-related fall solely to the PCP clinic. Rather, PCPs
are encouraged to refer to hospital or
health problems, such as diabetes, severe GERD, or ventral hernia. Laparoscopic
community programs and specialists for
adjustable gastric banding (lap banding) is FDA approved for these patients.ICSI intensive multicomponent interventions.
–– Patients who have been unable to achieve or maintain a healthy weight through See the following pages for ideas
non-operative means, including nutritional counseling, diet, exercise, intensive and tools for follow-up, referral, and
multicomponent behavioral interventions, and/or pharmacological therapy. communication — both within your
clinic and between your clinic and other
Surgical options: Bariatric surgery works by limiting food intake and/or interfering with programs and specialists.
the body’s ability to absorb nutrients. Types of operative procedures have increased and
are continuously evolving; both open and laparoscopic bariatric techniques are effective
therapies.MBS Options include adjustable gastric band; gastric bypass (Roux-en-Y);
biliopancreatic diversion with a duodenal switch; and sleeve gastrectomy.
Clinical efficacy. Some patients lose as much as 50 percent of their body weight after
surgery, and nearly half keep the pounds off for up to 10 years.BUC A new study by LDS
Hospital researchers, published in JAMA, showed the following benefits for patients who
underwent gastric bypass (Roux-en-Y):ADM
WEIGHT MANAGEMENT
TOOLS
–– Effective maintenance of weight loss: Surgical patients lost an average of 34.9% of
their initial weight 2 years after surgery, and kept off 27.7% of the weight 6 years Patient Tool Kit
after surgery. Of these patients, 96% maintained more than 10% weight loss from
baseline, and 76% had maintained more than 20%. By contrast, patients in the • The Weigh to Health®
groups without surgery either lost no weight or gained weight over the next 6 years. Program brochure.
–– Remission of type 2 diabetes: 62% of patients who had diabetes before surgery were See page 29 for more
in remission after 6 years. That compares to only 8% and 6% for the nonsurgical information on this program.
groups. Gastric bypass patients who did not have diabetes before the surgery were 5
to 9 times less likely to develop diabetes than nonsurgical participants. • The Weigh to Health®
Cost effectiveness: Though more research is needed, a recent analysis of patient-level booklet Includes
cost data for 3,651 patients up to 5 years after surgery estimated that all costs of bariatric behavior, nutrition,
surgery were recouped within 2 years for laparoscopic surgery patients and within 4 years and activity advice
for open surgery patients.FIN for how to reach and
maintain a healthy
The bariatric surgery team: A multidisciplinary team should evaluate and care for body weight.
patients considering bariatric surgery. Once a patient and the PCP have decided bariatric
surgery is the best option to treat the patient’s obesity, the PCP should refer the patient for • The LiVe Well 1-Week LiVe Well 1-Week Habit Tracker
Breakfast Activity:
Breakfast Activity:
Minutes: (aim high)
Breakfast Activity:
Minutes: (aim high)
Lunch Intensity: Light
Fruits Moderate Vigorous
Dinner Hours sitting (aim low)
at work/school
Snacks outside work/school
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 HH016- 05/13
More health information is available at intermountainhealthcare.org/wellness.
Program certification: The American Society for Metabolic and Bariatric Surgery (ASMBS) • Weight Loss
and the American College of Surgeons (ACS) are joining together to become the new Medications patient FACT SHEET FOR PATIENTS AND FAMILIES
Weight-loss Medications
certifying body for bariatric surgery programs. Criteria for certification are still under review.
The first and most important steps are always to change
your eating habits and get more physical activity. For
some people, though, these steps don’t help enough. If
your weight is putting you at risk for other health
conditions, you may need more help. You may want to
discuss with your doctor whether a prescription weight-
loss medication would be a good choice for you.
For more information, visit the ASMBS website or the LDS Hospital Bariatric Surgery website.
• Body mass index (BMI) of 30 or higher
• BMI of 27 or higher AND an obesity-related condition
such as high blood pressure, type 2 diabetes, or
high cholesterol
Insurance coverage: Most commercial insurers don’t cover bariatric surgery, though
Some lose more weight than others. The average amount longer-term health effects of weight-loss medications.
of weight lost is about 8 pounds within 12 months. If you use them for a longer period, discuss your
Weight tends to level off for the remainder of treatment. personal situation and side effects with your doctor.
To be effective, weight-loss medications must be combined Talk about whether you have been able to make the
some either cover or have optional riders. Coverage is also available for Medicare patients to expect.
and other programs sponsored by the federal government. Coverage is limited to certain
procedures and program requirements. For example, Medicare requires patients to have All the above tools and more are
a BMI of 35 or higher with at least one obesity comorbidity, and the procedure must available at intermountainhealthcare.
be done at a certified program. See pages 30 and 31 for more information and links to org/weight
resources on coverage for obesity-related interventions.
Worksheet
MY KE Y RISK ARE A S AND POSSIBLE GOAL S
including topics such as intuitive eating, stress management, and menu planning.
Physical Activity Nutrition
Moderate to vigorous aerobic physical activity: Eat a healthy breakfast times per week
Brisk walking or Eat or drink MORE of these:
Days/week x Minutes/day fruits: servings/day vegetables: servings/day
= Total minutes per week: (build up to at least 150) other:
Strength training 2 or more days per week: Eat or drink LESS of these:
What: sweetened drinks - less than 12-oz servings/week
Reduce total sitting time other:
from hours a day to hours a day Eat meals together as a family times per week
Reduce screen time (TV, video games, Internet) Keep a food journal for days
from hours a day to hours a day Reduce portion sizes by using a smaller plate or:
Other: Other:
O t h e r I m p o r t a n t L i f e s t y l e Fa c t o r s Weight Management
Sleep hours per night nights per week Lose % of body weight or pounds
*50280* Give the patient a copy of this Rx, and keep a copy in the patient’s chart.
Pt Inst 50280 © 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM015f - 05/13
• Creating a
Weight Watchers and other programs may also help meet recommendations for intensive, Lifestyle
multicomponent behavior interventions. See page 32 for other resources. Management
Team (presentation
Referral and communication with other specialists for team meetings)
When the primary care physician partners with specialists, such as a registered dietitians
• Rx to LiVe Well: Use
Lifestyle and Disease Management
FACT SHEET FOR PATIENTS AND FAMILIES
Clinic Team Process Worksheet
or mental health specialists, patients feel that there is a team supporting their efforts.
1. Identify area of focus and supporting materials
Area of focus (diabetes, asthma, depression, lifestyle/weight, etc.):
Gather Intermountain care process models, guidelines, or other evidence-based materials to review:
to “prescribe” changes,
Gather Intermountain patient education materials (see www.i-printstore.com or www.intermountain.net/cp):
Communication between the primary care clinic and the specialist helps ensure
Clinic team
A team approach allows all staff members to participate effectively in chronic disease
management or weight management. The key is communication and coordination between the Patient
clinic team members, the patient and family, community resources, and specialists. Your & family
team may have set a goal related to the area of focus (an outcome goal, a process goal, or Resources Specialists
something else). If your team has set a goal, document it below.
encourage follow-up
Team goal for chronic condition management or weight/lifestyle management:
How and when we’ll measure results, and how we’ll know we’ve met the goal:
3. Identify clinic team roles; plan for provider and staff education
consistent messaging and shows patients that the team is coordinated — avoiding the
Below, identify who will oversee the process and communication, who will coach and educate patients, and make a plan for physician
and staff training. Also, consider using the table to note how the various roles on your team can assist in the process overall. Doing this
may spark ideas to help you create the process flow in Step 4.
Patient coach role (coaches and educates patients; several people may share this role):
T e a M M e M b e R Ro L eS P Ro C eSS n oT eS
Primary care provider/s (MD, DO, PA, NP)
Clinic manager
sense of navigating a “maze” of care. See the tips below for improving referrals and
Front office staff
referrals to programs
Nurse / MA
Other:
• HEDIS requirements: Physical activity assessment and counseling are HEDIS • How to code for a problem-focused
(E/M) service that arises during a
quality measures for older adults and for children and adolescents. CMS
preventive visit. You can prevent
reimbursement is in part tied to our ability to improve rates of physical activity bundling of services by adding
assessment and counseling. the appropriate E/M service
code, modifier 25, and separate
• Meaningful use of the electronic medical record (EMR): CMS provides extra benefits documentation. Inform the patient
(and eventually will impose penalties) based on whether the patient’s EMR includes that while there will be no copay
height, weight, and calculated BMI. or bill for the preventive visit, the
problem-focused services will be
• Personalized Primary Care: Personalized Primary Care (PPC) is Intermountain’s billed as usual.
medical home initiative. By focusing on illness prevention and effective chronic
• Suggestions for appropriate coding
condition management, PPC helps manage costs as Intermountain becomes an for visits that meet the full ACA
Accountable Care Organization (ACO). Intermountain’s PPC initiative is based on obesity counseling requirement
NCQA medical home standards, and requires clinics to focus on 3 chronic conditions, (described on page 30). Referral to
one of which must be behavioral. Lifestyle and weight management is an appropriate a program such as The Weigh to
choice for the behavioral focus. The PPC initiative also focuses on clinical quality Health® is a good way to meet this
measurement and improvement of measures for chronic illness and prevention. requirement.
Measurement of the Physical Activity Vital Sign (PAVS) and counseling for nutrition
and physical activity are good options to meet this requirement.
CODING & REIMBURSEMENT
TOOLS
2013 INTERMOUNTAIN LIFESTYLE METRICS Clinic Implementation Kit
Examples of metrics that Intermountain will be measuring and reporting:
The Lifestyle and
• BMI and change in weight Weight Management
• Percent of patients with the Physical Activity Vital Sign (PAVS) recorded in HELP2 Coding and
(including minutes per day, days per week, and intensity) Reimbursement Guide
provides effective coding
• Percent of patients who have been advised to start, maintain, or increase physical activity
combinations to bill for
— or advised to improve nutrition lifestyle management
Additional metrics — such as number of visits or patients referred — will be added as evaluation services. See other
and reporting evolve. resources on page 32.
Assessment & Behavior Modification Tools Health information and local Tools to help providers and the public
• LiVe Well Lifestyle and Health Risk Questionnaire resources for consumers, providers, increase physical activity, including a
and businesses Keys to Exercise video series
• R x to LiVe Well
• LiVe Well Readiness Worksheet www.ChooseMyPlate.gov www.weightwatchers.com
• LiVe Well Action Plan
• LiVe Well Food & Feelings 1-Day Journal
• Live Well 1-Week Habit Tracker
©2015 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. This CPM is based on best evidence at the time of publication. It is not
meant to be a prescription for every patient. Clinical judgment based on each patient’s unique situation remains vital. We welcome your feedback;
32 contact [email protected]. Patient and Provider Publications 801-442-2963 CPM015 - 5/20/15