Helping patients with weight loss

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SanDiegoSOD

Milk was a bad choice
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I shadowed a FP doc last year (I'm an MSIII) and was surprised to see him take the time to personally write out weight loss advice for a few patients. Though I respect that he did this, I didn't think it this was very efficient, b/c the advice was general and not really specific to the patients. There must be some literature or other tools that docs can give to patients to teach them about weight, and make future conversations about the subject more productive and efficient. Any ideas? I'd love to know of this before I do my official family medicine rotation. Thanks!

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There's plenty of solid information available online and I've known several physicians who just choose their favorite source and have the stuff printed out and ready to go in case a patient asks for it. Or, they type it up themselves and then have several copies of that on hand.
 
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Thanks for the resources. Follow up Q: Do docs bill for time specifically spent talking about weight loss, or assisting a patient through a weight loss plan? I would think that they couldn't as such advice should be part of a normal check-up, but perhaps they can as Medicare/insurers want more time time spent on the issue for preventative reasons. Clearly, I know nothing about billing :oops:
 
Thanks for the resources. Follow up Q: Do docs bill for time specifically spent talking about weight loss, or assisting a patient through a weight loss plan?

As long as you document it properly, you can bill based on time. That's usually how I do most weight-loss visits. For example, if you spend more than 50% of a 15-minute office visit counseling, you can bill a 99213 (level 3 established patient visit); if you spend at least half of a 30-minute visit counseling, it's a 99214.

It doesn't really matter if their insurance covers it or not. If it's a non-covered service, you can bill the patient directly.

This assumes, of course, that the visit is for weight-loss management only. If you counsel them as part of an annual physical, you're not going to get paid extra for discussing weight loss or anything else.
 
my current preceptor has a separate wellness clinic where his clients pay cash to spend an hour with him talking about their "wellness". My understanding is that its mostly counseling in a spa like atmosphere, and he may handle some of his clients meds (antidepressants, diet aids, etc). He does very well with this side business, even in a semirural area.
 
my current preceptor has a separate wellness clinic where his clients pay cash to spend an hour with him talking about their "wellness". My understanding is that its mostly counseling in a spa like atmosphere, and he may handle some of his clients meds (antidepressants, diet aids, etc). He does very well with this side business, even in a semirural area.

oh man.... weight loss advice -- and they all want Adderall or Ritalin, "what is wrong with my 94 year old husband, why is he tired?", "why does my 1 month old have constipation?", note on the chart -- "Fifth Disease getting worse and not getting better".
Lets admit what counseling is equivalent to, in today's health care system. Absolutely nothing.
 
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Lets admit what counseling is equivalent to, in today's health care system. Absolutely nothing.

Not necessarily. That's not to say that it always makes a difference, but that doesn't mean it's always worthless, either. Sometimes, it's just a matter of saying the same thing over and over again until it finally sinks in. If you don't, who will?
 
Not necessarily. That's not to say that it always makes a difference, but that doesn't mean it's always worthless, either. Sometimes, it's just a matter of saying the same thing over and over again until it finally sinks in. If you don't, who will?


yes definitely it is beneficial for the patients, and it definitely helps society. I am saying from a monetary standpoint, there is no value to our current health care system, for counseling. They just do not care about compensating counseling. It is truly sad.
Being a Hospitalist certainly pays much better, and is not nearly as difficult as running a practice.
Plus no hassles of EMR and office politics, and call. You work your shift, and then go home.
Not to say it is perfect, but certainly much better than clinic.
No disrespect to clinic, but our current Health Care system does not care about Preventive Medicine and Counseling. As physicians, we should do what is right for the patient, and there are so many valuables to patients being a Primary Care doctor.
However, the system is what it is, and it is quite disappointing.
 
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I am saying from a monetary standpoint, there is no value to our current health care system, for counseling.

There is if you know how to bill based on time. A 99214 pays the same whether it's for followup of depression or diabetes/hypertension/hyperlipidemia/hypothyroidism/obesity. The notes are a lot easier to write, too.
 
There is if you know how to bill based on time. A 99214 pays the same whether it's for followup of depression or diabetes/hypertension/hyperlipidemia/hypothyroidism/obesity. The notes are a lot easier to write, too.


awesome, you see this is exactly what nobody teaches you... only gain from experience..
 
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Lets admit what counseling is equivalent to, in today's health care system. Absolutely nothing.

I'll tell you what it's equivalent to, cold hard cash.

I think that's a brilliant idea. Paint a room a soothing color, add a waterfall statue and some Andean lute music, and sit there for an hour and listen. Much better than sitting in your clinic getting backed up while being paid whatever pittance Medicare deems worthy of your time to do the exact same thing.
 
Word.
Saw a kiddo last night who was 355#. Now she's a big kid, about 5'6"ish, but her BMI is around 58 (estimated height). And she is NINE YEARS OLD.
I looked at her mom.
I'm dumbfounded. I said, "She's gained 30 pounds since February. This can't go on."
Mom looks at me, unflappable. "Yeah, but she's LOST 8# since school started (literally, 8 days ago).
Me: "Why is that?"
Mom: "Well, she's not sitting around on her butt like she was all summer."
There is a serious problem here, and it's generational. Now, I know Mom a little, and she's fat too, well frankly, also morbidly obese, but her 9 y/o daughter has a hundred pounds on her. And this is a premenarchal girl.
I'm not privy to all the gory details here because I see this kid for an otitis in urgent care, but I guess she has a consult next week with an obesity specialist. 'Bout time. But really, it's just tragic.
And really, if I could lose 8# in 8 days just by getting up and going to work I think I would have stumbled onto a weight loss miracle. Sadly, I have to cut out the chocolate and step it up on the elliptical to effect that little change.
*sigh*

Sure, but...Mom's probably fat, too.
 
I'll tell you what it's equivalent to, cold hard cash.
Yeah, the guy charges something like $200 an hour.
I guess his clients all love him and while I find some things about his practice somewhat questionable(definitely a different topic)he seems to be making a rather large impact on his community. He's got nearly all of his overweight patients (clinic and wellness center) on a diet and most of the smokers in his clinic on chantix or have quit.
 
He's got nearly all of his overweight patients (clinic and wellness center) on a diet and most of the smokers in his clinic on chantix or have quit.

Cash-paying patients are something of a self-selected population, of course.
 
How to make your own weight losing breakfast meals?
It's a good natural way to help anyone lose weight.

1- FRUITED RICOTTA TAPIOCA

A pleasant change from cereal, this fruit topped breakfast pudding is a good low-fat source of calcium, potassium and vitamins A and C. Each serving provides 285 calories, and contains 70% carbohydrates, 13% protein, and 17% fat. It also supplies the body with 191 mg of calcium, 1 mg of iron, together with 116 mg of sodium.

Ingredients :

15 cl (1/4 pint) apple juice concentrate.
4 tablespoons quick-cooking tapioca.
250 g (8 oz) low-fat ricotta cheese.
2 large egg whites.
1 tablespoon brown sugar.
1 mango.
1 banana.
150 g (5 oz) fresh or frozen blueberries.
How to make :

Mix the apple juice, tapioca and 25 cl (8 fl oz) of water in a small pan and set aside for 5 min.
Bring the mixture to the boil, stirring occasionally, and cook for 1 minute.
Remove the pan from the heat and set aside for 30 minutes,, or until cool to the touch.
Meanwhile, in a medium sized bowl, whisk together the ricotta, egg whites and sugar until smooth.
Fold the ricotta mixture into the tapioca and spoon the mixture into four dessert bowls.
Cover the bowls with plastic film and refrigerate overnight.
Just before serving, stone the mango and cut it into 1 cm thick slices.
Peel the banana and cut it into 5 mm thick slices.
Garnish the tapioca with the mango, banana and blueberries.
Make 4 servings.


2- RASPBERRY-RICE SHAKE

This meal-in-a-glass gives you about the same amount of protein as two rashers of bacon and two eggs, but it has only about one fifth the fat. This shake also supplies 10 grams of fibre, while bacon and eggs have none. It provides 455 calories per serving, and contains 78% carbohydrate, 13% protein and 9% fat. It also provides 433 mg of calcium, 2 mg of iron and 153 mg of sodium.

Ingredients :

75 g cooked brown rice.
1 banana, pealed.
125 g (4 oz) frozen raspberries.
17.5 cl (6 fl oz) plain low-fat yogurt.
4 tablespoons skimmed milk.
2 teaspoons honey.
How to make :

Place the rice in a food processor or blender and process until pure'ed.
Scrape down the sides of the container with a rubber spatula as necessary.
Add the banana and process for another 30 seconds, or until the mixture is as smooth as possible.
Add the raspberries, yogurt, milk and honey.
Process for 15 seconds, or until blended.
Serve immediately ( Makes 1 serving ).
3- APPLE-RICE PANCAKE

Many people eat high-fat fast-food breakfasts for the sake of convenience, but this dense , crusty rice cake, which will keep for up to three days in the refrigerator, is just as convenient and much lower in fat.

Each serving provides 230 calories, and contains 69% carbohydrate, 10% protein, and 21% fat. It also supplies 30 mg of calcium, 2 mg of iron, and 48 mg of sodium.

Ingredients :

300 g (10 oz) cooked white rice.
2 large eggs plus 1 egg white.
2 tablespoons honey.
1 Granny Smith apple.
1/4 teaspoon ground cinnamon.
1/4 teaspoon pure vanilla extract.
1/4 teaspoon grated lemon rind.
2 teaspoons vegetable oil.
How to make :

In a medium-sized bowl, stir together the rice, eggs plus egg white and honey; set aside.
Wash and core but do not peel the apple, then grate it into a small bowl and squeeze it dry.
Add the apple, cinnamon, vanilla extract and lemon rind to the rice mixture and stir to combine.
Heat 1 teaspoon of the oil in a medium-sized frying pan over medium heat.
Add the rice mixture and pat it into an even layer.
Cover the pan and cook the mixture for 5 minutes, or until the bottom of the pancake is golden and the top is dry.
To turn over the pancake, slide it on to a plate, cover with another plate and invert.
Heat the remaining oil in the pan.
Slide in the pancake cooked side up and reduce the heat.
Cook the pancake, uncovered, for about 5 minutes, or until golden and cooked through.
Cut into quarters and serve warm, or cool the pancake, refrigerate it and serve cool.
Makes 4 servings.
4- PEACH MUFFINS

Although made with little fat, these muffins are so moist they can be eaten without butter or jam, which could add 50 to 100 calories. Each muffin provides 140 calories, and contains 70% carbohydrate, 10% protein, and 20% fat. Each muffin also supplies the body with 50 mg of calcium, 2 mg of iron, and 153 mg of sodium.

Ingredients :

30 g (1 oz) bran cereal.
175 g (6 oz) plain flour.
60 g (2 oz) wholemeal flour.
1 teaspoon baking powder.
1 teaspoon bicarbonate of soda.
1/4 teaspoon ground cinnamon.
35 cl (12 fl oz) buttermilk.
3 tablespoons vegetable oil.
4 tablespoons honey.
2 large eggs, lightly beaten.
275 g (9 oz) dried peaches, coarsely diced.
How to make :

Preheat the oven to 190*C (375*F or Mark 5).
Line an 18-hole bun tin with paper liners.
In a large bowl, stir together the cereal, the flours, baking powder, bicarbonate of soda and cinnamon, and make a well in the centre.
In a medium-sized bowl, beat together the buttermilk, oil, honey and eggs.
Pour the buttermilk mixture into the dry ingredients, add the peaches and stir just to combine.
Divide the batter among the bun tin cups and bake for 20 to 25 minutes, or until the muffins are lightly browned. ( Makes 18 muffins ).
5- BLUEBERRY-ORANGE MILK SHAKE

Skimmed milk and fruit make this recipe an excellent low-fat source of the minerals calcium and potassium. Each serving provides 105 calories, and contains 77% carbohydrate, 18% protein, and 5% fat. It also supplies the body with 190 mg of calcium, traces of iron, and 64 mg of sodium.

Ingredients :

1 navel orange.
100 g frozen blueberries.
25 cl (8 fl oz) skimmed milk.
How to make :

Grate 2 teaspoons of rind from the orange, being careful not to include any of the white pith; set aside.
Peel and segment the orange; remove and discard the membranes.
Place the segments in a polythene bag and freeze them for 3 to 4 hours, or until frozen solid.
Place the blueberries, the orange segments and rind in a food processor or blender, and process until pure'ed, scraping down the sides of the container with a rubber spatula.
Add the milk and process for 1 minute, or until well blended.
Pour the shake into two tall glasses and serve. ( Makes 2 servings ).
6- QUICK BROWN RICE PUDDING

Instead of cereal and milk, try this breakfast " pudding ". It is a better source of protein and fibre than most packaged cereals. You can cook rice especially for this recipe, or use leftover rice. Each serving provides 205 calories, and contains 82% carbohydrate, 11% protein, and 7% fat. It also supplies the body with 158 mg of calcium, 2 mg of iron, and 46 mg of sodium.

Ingredients :

12.5 cl (4 fl oz) plain low-fat yogurt.
1 and 1/2 teaspoons molasses.
1 teaspoon honey.
1/2 teaspoon pure vanilla extract.
150 g (5 oz) cooked brown rice.
2 tablespoons currants.
How to make :

In a small bowl, mix the yogurt, molasses, honey and vanilla extract.
Stir in the rice and currants.
Chill before serving, if desired. ( Makes 2 servings ).
 
Some exercise and diet advice can be helpful to lose the unnecessary body weight.
Raw vegetables diet along with some protein diet work effectively to burn the fat maintain the weight at the healthy level. There should also be a regular exercise plan specially cardio exercises i.e jogging, running, swimming, and cycling etc. to lose the weight.

adamprowse fitness
 
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I think we're grossly untaught nutrition in medical school. A lot of doctors give out half @$$ed advice, and I don't blame a patient for not wanting to go to the doctor to hear "Eat less sugar, eat more raw vegatables, do some cardio."

On my outpatient psych--the doctor was trying to provide dietary counseling, and there was no mention of the word calories. Just, eat less fat, eat less sugar blah blah.

I struggled with my weight up until a few years ago, I spent a great deal of time on the bodybuilding.com forums reading about nutrition/dieting. I think there's a wealth of information there, and I think pa fundamental understanding of how weight loss/gain works as opposed to eat less sugar would help a lot of frustrated patients.

The one pause I would have is that IIFYM has a strong following there, and I'm sure a lot of patients aren't going to do so great with the "IF" part.
 
"I think we're grossly untaught nutrition in medical school."

I'm so glad that someone else thinks so, too. While shadowing a family doc, I heard the mini-lecture about eating a Mediterranean diet a couple times a day. Several patients had more extensive questions about their diets, including the opportunity cost of red wine and resveratrol, etc.

What I am wondering is this: would it benefit a practice to hire a dietician to consult with patients? Or would it be too much effort by a doctor to provide a fitness/diet plan that's tailored to each patient, maybe one that they could keep up with online? And maybe most importantly, can most family physicians competently come up with a diet and exercise plan with their level of training?

My friend is an intern now, and he learned almost everything he knows about nutrition from research outside medical school. He will have the power to choose each of his hospitalized patients' diets, so why isn't he taught the fundamentals of today's diet options?

When I brought it up, he said that the closest thing he got was biochemistry, but it was still an inadequate substitute given the demands that are placed upon physicians' shoulders.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430660/
 
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Typically, I agree. We docs often don't do a great job with nutrition because there is and was so much else for us to do and learn. However, if argue that a little time on nutrition is time well spent.

Here's a good online resource that we used in med school:

http://www.nutritioninmedicine.net

That being said, I would also argue that most patients know what they need to eat. They know the basics of nutrition, which is often what doctors tell them anyway. The trick is to get our patients to want to make the choices and changes they know they should make. This can take a long time and several visits. As part of our clinic rotations as interns, residents in my program have to do some modules on "Motivational Interviewing," which is basically spending your time figuring out what is holding patients back from making healthful changes rather than lecturing them on what they likely already know what they need to do. Just a thought; sorry if similar things have already been said.
 
you sure what you're being told is based on truth? check this out (the talk below is very interesting and well worth your time).

http://eatingacademy.com/nutrition/...-saturated-fat-and-cholesterol-are-bad-for-us



Yeah, there's a lot of really good stuff in there. I'm in the same boat as the one guy's friend. I had a summer research project where I wasn't really utilized, just sat at a desk all day so I could put it on my resume.

Most of my knowlledge base comes from pub med articles and the bodybuilding.com forums--which will surprise you at the amount of research and evidence based data they post.

I actually don't think most patients understand enough of the dietary picture to be successful. Eat less, eat better. To a lot of people, that means eat baked chicken or talapia and broccoli all day.

Part of my research project involved biweekly seminars on endocrinology, and there were a few on diabetes and obesity. Fat free foods actually create a lot of problems--because, "hey, there's no fat in it, so I can eat all I want." And then you send the message that fat contributes to you being fat because it's called fat. Not because it's calorically dense. When in actuality, dietary fats are a vital part of our diet. I think before we can teach someone how to eat better, we have to teach them how to eat. A lot of people get calories in vs calories out, but for a long time, I thought dietary fat played some secondary role in the equation. I thought all diets involved eating a lot of boring bland food. And food is such a big, pleasurable part of life. People don't want to full on give that up.
 
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I start with asking the patient what they typically eat in a day and what they have had the last few days. You cannot change someone's diet in one visit. Usually the first step is cutting out soda/sweet tea/iced starbucks drinks. If they are a soda junky, I calculate the total calories they are getting in a day just from soda. It surprises a lot of them when they realize they are consuming 1500 calories a day in just soda.
Usually they have other health problems that you can quickly evaluate (HTN) as well. If they are diabetic, ask how their sugars are doing (just evaluated their DM). I will bring they back for follow up to discuss weight. I have had a lot of patients that just want lap band or gastric bypass. however, most insurances require 6 months of monthly weigh in at the pcp office to demonstrate weight loss first. I have never had a patient be compliant with this. I don't promote this either. quick fixes are not the answer.
I had one patient that we changed their diet little by little and in 1 year she went from 270 to 210 lbs and is off all insulin and diabetic meds (last a1c was 5.4%). Telling patients they need to exercise or need to go on a diet will do nothing. Most know this and just need a help. Those I know that are trying I praise them for every pound they have lost. Even if it has been 2lbs in 1 month. I had one patient who was 450+ lbs 1 year ago. They were educated and worked. They would get so mad at other residents in the hospital because they would come in and say, well you need to lose weight, it is affecting your health. The pt told me I was the first one who did not tell her that and instead starting asking her about what her diet was and asked her what she thinks is the reason she has not been able to lose weight. Most morbidly obese people know they need to lose weight, they just really don't know where to start. And simply telling them the obvious is not the same as counseling. Pt is now down to 270 lbs (70lbs was necrotic tissues removed) and a1c is <7.0.

The big thing is telling them it is not a diet. They have to change the way they are eating for good.

I recently read the book Eat To Live. Has some really good information. Even though it says vegan is the best, you can alter it to include meat and dairy still.
 
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