CMs can take role in fighting obesity epidemic

Education should target the entire family

Pick up any newspaper or magazine or turn on the news, and you're likely to hear somebody talking about this country's obesity epidemic.

There's a lot of emphasis these days on obesity and helping people keep their weight down and avoid chronic disease. Health care workers have always known that obesity contributes to and exacerbates chronic conditions. With today's sedentary lifestyles and dependence on fast food, obesity is become a bigger and bigger concern, says Connie Commander, RN-BC, BS, CCM, ABDA, CPUR, president of Commander's Premier Consulting Corp.

Consider these recent reports:

Obesity-related medical costs reached $147 billion in 2008, or about 10% of U.S. medical spending, according to a report by the Centers for Disease Control and Prevention (CDC). As of 2006, the number of obese adults had more than doubled in 25 years to 72 million people, or 35% of adults, the CDC reports.

A study released in Nov. 2009, shows that rising obesity rates will be an increasing burden on the health care system over the next decade, and if current trends continue, 43% of Americans will be obese and obesity spending will quadruple to reach $344 billion by 2018.

The study, "The Future Cost of Obesity: National and State Estimates of the Impact of Obesity on Direct Health Care Expenses," was based on research by Emory University health care economist Ken Thorpe, PhD, executive director of the Partnership to Fight Chronic Disease. The study was commissioned by UnitedHealth Foundation, Partnership for Prevention, and American Public Health Association.

As she worked with a hospital in California late last year, Commander drove nine miles to work each day and passed literally dozens of outpatient dialysis centers.

"There is a huge population of people with end-stage renal disease, and we know that obesity is one factor in contributing to such chronic conditions for certain individuals," she says.

"When people are overweight, they are subject to diabetes and cardiac issues, which are very expensive to treat. Obesity is the No. 1 driver of our future medical costs," says Laurie Gondek, vice president of health advocacy products, who oversees CIGNA's lifestyle coaching and disease management programs.

Society frowns on people who are overweight, and since many people reach for food when they feel uncomfortable or unhappy, it creates a vicious cycle, adds Cathy Campbell, BSN, MBA, CHC, FACHE, director of case management at Mesquite Specialty Hospital in Dallas.

"As a registered nurse, I know that many diseases are attributable to obesity. People's bodies are in a compromised condition when they are obese. The reality is that obesity is an illness, and people often need psychological treatment to overcome it," Campbell says.

Many obese people suffer from depression, which drives them to eat more in an attempt to feel happier, she points out.

Weight loss is important to any person in the continuum of care, whether it's a member with risk factors, someone with a chronic disease, or a relatively healthy person who has a few pounds to lose, says Linley Thomson-Siag, MPH, MPA, health educator in health promotion and wellness department at CDPHP, an Albany, NY-based health plan.

"Research says that if people lose just 5% to 7% of their body weight, they can prevent chronic diseases. Just that 5% can be critical to an overall health goal," she says.

Health care professionals tend to tip-toe around weight problems, even though they know that being overweight is a comorbid factor in every disease, Commander says.

"We in the health care field need to be accountable at different levels to the population we serve. Case managers need to look beyond the person right in front of their face. We have an opportunity to encourage everybody we touch to live a more healthy lifestyle," she says.

Case managers need to do their part in preventing obesity and helping people lose weight, Commander adds.

"We know that obesity leads to diabetes and potentially to other conditions such as coronary vascular disease and renal insufficiency. Obese people are likely to have higher rates of hypertension and cardiovascular disease. Chances are that an obese person is going to develop one or more of these conditions. We need to encourage people to do healthy things before they develop a chronic disease," Commander says.

Commander recommends that case managers do everything they can to help clients live a healthy lifestyle, regardless of the condition or episode of care you are helping them learn to manage.

"Weight, diet, and an exercise regimen should be included as part of the plan of care as we work with our individual clients in managing their chronic conditions and staying healthy. Even if obesity is not the primary reason someone was hospitalized or has a chronic condition, it is a comorbid factor," she says.

Build weight management, healthy eating, and exercise into the care plan for all of your patients and work with them to identify little things they can do in their daily life to stay healthy, Commander suggests.

"Hospital case managers can include tips about eating healthier or taking the stairs instead of the elevator in their education for patients, even if the hospitalization isn't related to obesity," she says.

As you work with your clients on managing their chronic conditions, include family members and caregivers in the mix, Commander says. Encourage family members to set an example and entice them to get healthier as they support the patient, she adds.

People have to want to lose weight and exercise, and they need support to do so, she says.

"The Case Management Adherence Guidelines speak of knowledge, self-motivation, and willingness to change, and we know that people are not going to change unless we set up support for them. That's why it's always a good idea to have others in the family participate in healthy lifestyle changes," she suggests.

The guidelines developed by the Case Management Society of America (CMSA) are designed specifically to help case managers work with their patients on medication adherence and behavioral changes, Commander says.

"It's important for case managers to work with the individual patients, but they also should follow up with a program that makes sense to the family so they want to participate," she says.

For instance, if the patient needs to follow a low-fat or low-salt diet, encourage the family members to follow the diet and become healthier as well. This gives the cook in the family an opportunity to learn new methods of cooking or experiment with seasonings to provide food that tastes good and is healthy as well, she says.

"Don't just tell people they need to exercise or lose weight. Encourage them to diet or exercise in an effort to support the patient in maintaining a healthy lifestyle. Build around what the patient needs to do and include family members and friends who can support the patient," she says.

For instance, if grandfather needs to start a walking program, suggest that he walk with the grandchildren, which will get them on an exercise program.

Tell family members that their dad needs to exercise but it's hard for one person to do it himself. Suggest that they come up with a buddy system.

Mention that it's hard for one person to follow a diet when other people are eating other things.

A critical intervention is to provide resources for the family and caregiver, she says.

"Healthy eating and weight loss is part of the patient education that case managers are responsible for. Sometimes we let it slip a little because we have such busy schedules, but teaching preventive care is as important as helping people learning about their medication," Campbell says.

Approach weight loss gingerly, Campbell recommends.

"We don't want to offend anyone, but it's very important to be open and honest in letting patients know that they are endangering their lives," she says.

Campbell advocates bariatric surgery for patients who are obese as long as they receive an extensive psychological work-up and understand that the surgery isn't a cure but a tool.

"I have a gastric band and I know several people who have had gastric bypass. I have been able to reach out to people because I have been there," she says.

Campbell advocates therapeutic communication with your patients.

"One technique might be to approach someone and comment that they seem unhappy. This can elicit a conversation and provide them with an outlet. So many times, we are busy and just keep moving along," she says.

When you visit patients in the hospital, sit in a chair so you will be on their level and try to get them to talk, Campbell suggests.

"If you keep standing, they'll think you are in a hurry. Allow them to vent their feelings and frustrations and get around to what is making them unhappy, which may very well be that they don't feel good about themselves because of their weight. Just one visit may not do it, but if people know you really care, you can help them," she says.

Health plans are taking a proactive approach to helping members lose weight and stay healthier.

CDPHP's Weigh 2 Be program is a six-week classroom program offered at various locations in the community. The classes are open to any member who is interested. Topics include interactive sessions taught by experts on healthy eating, physical activity, and stress management.

The health plan is piloting the program at the offices of large physician groups.

"We've found out through the case management program that the best referrals come from physicians who know the issues of individual members," says Melissa Marcelli, health educator in the insurer's health promotion and wellness department.

In addition to the physician-centered approach, the health plan is offering the program to employer groups during lunch time.

"The unique feature is that people don't need to have to lose weight to be in the program. We focus on proper nutrition and healthy eating. Many of the people who participate just want to learn to eat healthier," adds Thomson-Siag.

For instance, the program includes a session on sodium and how reducing sodium in the diet can help people lose weight and keep blood pressure under control, Marcelli says.

Other components include sessions on how stress can affect eating habits and weight and ways to manage it as well as exercises that people can do at home or at their desks.

CIGNA's Healthy Steps to Weight Loss weight management program offers people a non-diet approach to weight loss and long-term lifestyle changes. The program is available online and telephonically. The program has received an overall satisfaction rating of 96.3%.

In additional to helping people with weight management, the program includes a lifestyle assessment that helps individuals and disease management nurses work together to create a personalized program.

The tool takes a practical approach to weight management. For instance, if the individual reports that he doesn't like to cook for himself, the nurse suggests healthier choices for fast-food meals. If the person eats when stressed, the program offers stress management techniques.

"We look at the person holistically and assess his readiness to change. We focus on behavior, not diet. The purpose is to motivate people to make the behavioral changes they need to stay healthy," Gondek says.

The program is open to anyone who wants to enroll through employers who have purchased the suite of lifestyle management programs.

The program meets CIGNA's requirements for preparing patients for gastric surgery.

People can go to CIGNA's web site, fill out the profile information, and take a personal lifestyle assessment. They can follow the program at their own pace and receive content by e-mail depending on their personal preferences.

The telephonic program includes 12 modules that many participants complete in six weeks while working with an individual coach.

"The secret to the success of the program is meeting the person where they are. The coaches spend a lot of time listening to the people and finding what motivates them, then empowering them to set goals that they think are attainable," she says.