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Obesity From Head to Toe

SIU providers help patients understand obesity's role inside and out

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Written by Rebecca Budde • Photography by James Hawker

Obesity“I was going to have to pick out my coffin if I didn’t do something drastic,” says Pat Arnold, age 65, of Quincy. At her heaviest, Arnold weighed 285 pounds. Cancer, diabetes, liver disease, a heart attack, stroke –– all were possibilities for Arnold and the more than 72 million Americans who are obese, according to the Centers for Disease Control and Prevention (CDC). Arnold says that all her doctors over the years had told her to lose weight. “I even was diagnosed as morbidly obese, and wouldn’t you think it would cause me to do something?” she muses.

Across the SIU School of Medicine campus, clinicians in numerous divisions are cross-talking and collaborating on ways to help obese patients like Arnold “do something” and maintain a healthy balance. Primary care physicians, surgeons, dietitians, psychologists and other specialists –– nearly every kind of health care provider is dealing with problems stemming from obesity. Working together will lead to answers to combat the nation’s ever-growing epidemic.

According to the CDC, only 15 percent of Americans were obese in 1980 compared to 35.7 percent in 2010. Predictions show that by 2030, 42 percent of the American population will be obese. If the number of obese Americans remained at the 2010 level, the United States would save $549.5 billion in medical expenditures over the following twenty years. In 2010, no individual state had a obesity prevalence less than 20 percent; and collectively, the Southern states rank the highest at 29.4 percent, closely followed by the Midwestern states at 28.7 percent. “No one becomes obese because they want to, our lifestyle just makes it very easy,” says David Steward, M.D. professor and chair of internal medicine. “We’re catching the disease.”

As a physician, Dr. Steward encounters many patients whose health problems can be attributed to obesity. As a person who has struggled with his own weight loss, he also knows first-hand the issues obesity causes. After a minor biking accident and subsequent trouble with his knees, “I knew the best thing I could do to avoid surgery was get a little less heavy than I was,” Dr. Steward says. Through diet and exercise, he lost approximately 60 pounds and gained valuable insight to the plight of losing weight. “It’s hard work and takes commitment to battle against all the climates in the social world,” he says. His insight, however, allows him to be a better physician and address the issue of weight with his patients.

Kwesi Grant-Acquah, M.D., third-year resident in the department of internal medicine, presented “Obesity in Ambulatory Care Settings” at a recent Grand Rounds. He indicated that too few primary care physicians advise their patients on losing weight or even diagnose their patients as obese. Dr. Steward agrees that physicians need to be more consistent in their approach toward patients who need to lose weight.

From cataracts to gout, obesity affects every inch of the body. Added fat clogs the arteries; damages the liver, gallbladder and kidneys; encourages digestive upsets; makes the lungs work harder; disrupts sleep and adds stress to the joints. Obesity is also linked to some of the leading causes of death: various cancers, heart disease, stroke and Type 2 diabetes.

RAISING BLOOD SUGAR

Type 2 diabetes is probably the most talked-about condition related to obesity, with more than 40 million people affected in the United States alone. Michael G. Jakoby, IV, M.D., associate professor of internal medicine in the division of endocrinology, says that the division treats many obese patients with diabetes. “Eighty percent or more of the diabetic patients we see with comorbidities are obese, but their conditions are treatable with diet,” he says.

The division runs an integrated, in-patient diabetes management service to educate and treat patients with the disease. Their guided endocrine care includes Registered Dietitian Sara Lopinski, LDN, and Certified Diabetes Nurse Educator Caren K. Bryant, RN, BSN. Point-of-care testing decreases the wait-time for results and allows physicians to make immediate clinical decisions.

“I encourage patients to maintain a healthy balance by focusing less on the numbers on the scale and more on healthy eating and moving more,” Lopinski says. She holds Healthy U and Diabetes U classes that teach patients to keep food diaries. By counting fat calories, or carbohydrates in the case of a diabetic, patients can choose healthier options, thus allowing them to lose weight and reap clinical benefits over time. Dr. Jakoby and other providers can refer patients to Lopinski’s classes or even for one-on-one nutrition counseling for optimal results.

By losing just 5-10 percent of their body weight, patients obtain clear, measurable clinical benefits from weight loss. Blood sugar regulates, sleep improves and high blood pressure can drop. “Our division is in a tough position because we are selling health in a way that we want to mitigate the risk of serious health complications,” Dr. Jakoby explains. “But our interventions are not likely to produce significant, immediate cosmetic changes.”

CAUSING INFERTILITY

Lopinski and Bryant may also work with pregnant patients who have developed gestational diabetes or need to lose some weight before becoming pregnant. Obesity is surpassing sexually transmitted diseases as the number one cause of infertility in the United States, according to J. Ricardo Loret de Mola, M.D., director of the SIU Fertility and IVF Center and professor and chair of obstetrics and gynecology.

A person of healthy weight has a Body Mass Index (BMI) of 19-24.9; having a BMI of over 35 reduces pregnancy rates by about 50 percent. Patients must have a BMI under 35 before starting fertility treatments at the Center, according to Dr. Loret de Mola. And for those who have tried to become pregnant for years, it’s heartbreaking to be told they have to wait until they lose weight. But Dr. Loret de Mola stresses that weight management must be a component of fertility treatment. “Too much weight makes our bodies shut down: in women, it stops ovulation, causing significant disruption in the menstrual cycle,” he says.

However, many patients don’t believe or have never been told that their added pounds compromise their fertility. That was the case for Roxanne Fraire, age 31, who was confronted about her 294-pound weight when she sought fertility treatment after trying to get pregnant for two years. “Until I was educated how my diet and my weight affected my hormones and fertility, I was not aware, nor had I thought it was a possible cause of infertility,” she says. “I was told that changing my diet and losing weight would help me become pregnant, maintain a healthy pregnancy, and have a healthy baby. At first I was surprised and angry. When you are trying to have a baby, you always notice everyone around you with babies. I often saw very heavy women who had babies; some I knew personally. It made me upset that I had spent all this time trying to get pregnant without being told to lose weight.”

Like the division of endocrinology, the IVF Center has options for patients who need help managing their weight. “At the Center, we bring awareness to the problem, diagnose a lot of undiagnosed diseases and treat them, and we also give them the resources right here to reach the goal,” says Dr. Loret de Mola. “It’s not uncommon for a patient to lose 50-100 pounds before starting pregnancy treatments.” After reaching the weight-loss goal, patients “graduate” and move on to traditional fertility treatments.

After losing more than 50 pounds, Fraire got pregnant with no clinical interventions. Dr. Loret de Mola says that, like Fraire, about 50 percent of patients get pregnant after losing the weight and need no other fertility treatments.

Those who happen to get pregnant without losing the weight, however, put themselves and their future child at risk. Overweight or obese women are at risk for preeclampsia, gestational diabetes, C-sections, surgical complications and increased healing time, all of which can lead to additional stress on the mother and the baby.

Men are not excluded in the obesity and infertility link. Added fat creates a hormonal imbalance in the male system, causing decreased sperm production and problems with erections and ejaculation. Excess weight also causes decreased libido.

It takes two healthy people to make a child, so providers at the Fertility Center feel it’s important to treat the couple. Providers encourage couples to support each other in healthy nutrition and physical activity. “The benefit of being a medical school is that we have many resources that a private clinic might not have,” says Dr. Loret de Mola. One of those beneficial resources is the knowledge of male fertility specialist Tobias Köhler, M.D., assistant professor of surgery, who can help couples understand and pursue treatment for male infertility.

SOLUTIONS

Obese patients who have been unsuccessful losing weight with diet and exercise and whose BMI qualifies them as morbidly obese may have other options. “For patients with a BMI over 40, we put bariatric surgery on the table upfront,” says Dr. Loret de Mola. About half of the patients who qualify pursue this surgery, but it’s not a “quick fix.”

Dr. Sajida Ahad and Dr. Russell Yang

Dr. Sajida Ahad and Dr. Russell Yang are two SIU providers helping patients with obesity.

According to Sajida Ahad, M.D., assistant professor of surgery and medical director of St. John’s Bariatric Services Program, the biggest struggle for many people is keeping the weight off. “I tell my patients that obesity is a risk to their health and their longevity,” she says. “The role of the primary physician is crucial in this case. When they see patients struggling, they can refer them to a bariatric program.” However, she states that only about 1 percent of the 15 million people who would have qualified for bariatric surgery in 2007 actually received it.

Surgery proved to be the best option to “do something” for Pat Arnold, after many years of carrying around what she calls “another person’s worth of weight.” Her primary care physician, James M. Daniels II, M.D., professor of family and community medicine at SIU’s Quincy Family Medicine residency, referred Arnold to Dr. Ahad and the bariatric surgery program at SIU in Springfield.

Patients who qualify for bariatric surgery must comply with a pre-surgery program, which includes appointments with multiple providers. In addition to Dr. Ahad, patients receive care from a nutritionist or dietician, a counselor and may also be referred to an endocrinologist, pulmonologist and cardiologist. “We all collaborate to get the patient optimized for bariatric surgery,” says Dr. Ahad.

Even after the program of keeping a food diary, undergoing psychological evaluation and attending support group meetings, Arnold still had some reservations. However, her husband, a retired family physician, put the situation into perspective for her saying, “Pat, if there was something I could do to turn my health around, I would do it.” She proceeded with the surgery, and after an approximate 100 pound weight loss, her health has, indeed, turned around: she no longer needs to take medication for diabetes, she sleeps better and has reduced her need for blood pressure medicine. “Dr. Ahad gave me my life back,” says Arnold. “I feel 500 percent better than before the surgery!”    Learn more about research regarding the diabetes­­-bariatric surgery >

However, not all people who wish to lose weight qualify for surgery, and surgery also poses some risks. SIU’s Division of Gastroenterology is working to perfect non-surgical, endoscopic sewing technique that show great promise, according to Russell D. Yang, M.D., Ph.D., professor of internal medicine, division chief for gastroenterology (GI) and medical director for diagnostic gastroenterology services at St. John’s Hospital. The reversible techniques involve manipulating muscle and tissue layers of the GI tract as well as installing devices that bypass normal digestive processes. The technique is not considered surgery. “It’s faster, safer and less invasive than surgery, which might make it more cost effective for patients,” says Dr. Yang. “The techniques are potentially reversible so patients can have better control over their health.”

Though the procedures are not yet FDA-approved, Dr. Yang believes the timing is imminent. “We are preparing for the future. When these techniques are approved, we will be ready to go.”

The future for the millions of obese Americans is uncertain. Fraire and Arnold, like many others, say healthy eating and exercising to keep weight off is still “a battle.” But providers at SIU School of Medicine continue to find the best ways to treat patients like them. Integrated care provides patients with the best resources in the region to prevent the pitfalls of weight gain and help those currently burdened by obesity.

“Obesity affects everything,” Dr. Loret de Mola says. “If we can prevent or reverse obesity, people will be healthier and we wouldn’t need as much health care.”

Obesity Prevention

In 2007, The National Survey of Children’s Health showed that 34.9 percent of Illinois children ages 10 to 17 were overweight or obese, surpassing the national average of 31.6 percent. Some physicians at SIU School of Medicine have received phone calls from mothers who are concerned about their teen-aged children who weigh more than 300 pounds. Melissa Jones, project coordinator for the Springfield Collaborative for Active Child Health says that the Collaborative is using all of the School’s resources in education, patient care, research and service to fight and prevent this serious national health problem in our own community.

Based at the School of Medicine and funded by Blue Cross Blue Shield of Illinois, the Collaborative is an active group of academic, community, school and government entities and primary care providers working together to improve healthy lifestyle behaviors in the community. “The Collaborative is a place where everyone in the School can come together to see that we have a consistent message rather than each division doing their own thing. We’re stronger in groups –– more funding, resources and opportunities,” says Tracey Smith, medical student educator in the Department of Family and Community Medicine.

LEARNING ABOUT NUTRITION

“We’re hearing the message over and over that a nutrition curriculum is lacking in medical schools across the nation,” says Smith. A few years ago, the Department of Family and Community Medicine developed electives for third- and fourth-year medical students focusing on nutrition and physical activity in response to student and community requests. Those electives are now a part of the Collaborative’s outreach efforts.

The nutrition elective has two components, which makes it unique from many other medical school’s elective programs. It contains not only a section about nutrition education, but requires the students to complete a community nutrition outreach activity. The class gives the students the tools to be more comfortable talking about nutrition and shows them specific obstacles that hinder a healthy diet. “Many students don’t realize how hard good nutrition is for some people,” says Smith. Experiential activities for the students range from food budgeting for a family with limited resources, smart grocery shopping, fast food awareness and reflective writings.

Then the medical students take the message of healthy eating and nutrition into the Springfield District 186 mandated programs, Coordinated Approach To Child Health (CATCH) in the elementary schools and Choosy Kids: I Am Moving, I Am Learning in the Springfield Urban League Head Start Programs. “This elective will help make the medical students better physicians,” says Smith. “They’ll be better prepared to help their patients control their weight before it gets out of hand.”

ACTIVE IN THE COMMUNITY

The group works with the Springfield Head Start programs and several District #186 elementary schools to supplement nutrition lessons and enhance physical education for students. “Support of the Collaborative in the schools has been great,” says Jones, who holds a degree in nutrition sciences.

Visits from the medical students and Jones help reinforce the focus on improving nutrition and physical activity. The medical students visit the schools approximately three times a year, and Jones visits each school at least twice a year for a few days to measure progress and work with the administration and faculty. The face-to-face reminders are producing positive results for students –– and teachers. “A couple of teachers have said that they, too, have lost weight since the program started,” says Jones. The Collaborative also holds special events throughout the school year to educate the parents and caregivers, using the same information the students receive at school.

Support from  Schools

DATA DEVELOPMENT

To evaluate the effects of their efforts, the Collaborative is tracking the BMI’s of the Head Start children beginning at age 3, an innovative endeavor, according to Smith. “The Collaborative is doing this with very little money, and other groups with millions in funding haven’t figured out how to do it yet,” she says. Joint efforts between the Center for Clinical Research at SIU and the schools’ information technology departments resulted in a uniform coding system for the collected data. Jones and Smith hope this data could be linked to the children’s medical records in the future to help physicians and schools improve communication in handling the growing obesity epidemic.

PRESCRIPTIONS FOR HEALTH

Although the data collected isn’t linked to medical records at this time, SIU’s Department of Pediatrics supports the Collaborative’s efforts to improve patient care. Mock “healthy prescription pads” offer the pediatric providers a tool to remind parents and children of the importance of healthy eating, physical activity and an adequate sleep schedule. The indications on the prescription offer a message consistent with those that the child receives in school. “It’s important to have consistency so that when kids hear what foods they should eat or how much to exercise, it will always be the same message,” says David E. Steward, M.D., professor and chair of internal medicine. “There’s evidence that if kids are active, they are more likely to score well on tests, so the schools want this to work ."