I have been working with a program that is funded by the Fairbanks Foundation, operating out of Wishard Health Services. And we are also working in conjunction with the Regenstrief Institute and IU Medical Group, whose facilities we are hosted by. And then the IU-CAR, which is the IU Center on Aging Research, who has also been trying to help put some data together for us.

So, I’m just glad to be here today, and I think you for being patient with me as we are passing out handouts. I’m sorry that you didn’t get those sooner. So, thank you.

Just a few things about lifestyle changes. I found in a study that was just actually completed last year, but it was done in 2005 by the Marion County Health Department, and it was also a Richard Fairbanks Foundation-funded grant and study, that was an adult obesity needs assessment.

And it was interesting, because it was just about Marion County residents. They actually surveyed by telephone about 5000 of the adult, ages 18 and over, residents of Marion County. And about 60% of them were either overweight or obese, which is pretty close to the same guidelines along the lines of the whole nation and of Indiana as a whole.

They also found that people reported over the telephone that they had a chronic disease—which, you know, could be anything, not just diabetes, but diabetes was one of the things that was listed—that it was double in obese patients. And obese, of course, is defined as their BMI being 30 plus. So, 69% reported having a chronic disease compared to 38% who were normal, underweight patients, reported chronic disease.

Most obese adults were actually planning to adopt healthier eating habits. And that was interesting to me. That’s put a little bit of a new spin on it for us, because as a lot of you are familiar with the stages of change, that’s what they were actually asking as the questions were presented to them in terms of, have you ever thought about trying to change your eating habits?

And it was interesting that—and let me see if I have that percentage here—about 57% of the obese patients and 46% of the overweight, BMI 25 to 29.5, patients were actually planning to adopt healthier eating habits within the next six months. So, people are already thinking about it. It doesn’t mean that they were just planning on staying that way, they were already thinking about it.

And obese adults were the most likely to actually report intentions to increase their physical activity, as well. So, again, they were already in that stage of preparation. They had passed their not-precontemplation, their not-contemplation, they were actually thinking about doing this, and some of them, maybe, had already taken some steps to increase it, but hadn’t been doing it for very long yet.

Same study reported that 30% of the obese adults and 68% of the overweight adults actually reported that the doctor had not told them that they were overweight. Which is interesting to me, but I know it’s difficult; and that’s something we’re going to talk about, too. Over 40% of the obese adults had not received any nutritional or physical activity advice from their doctors. Now, that’s looking at the negative side of it. The positive side is, about 60% had received that. So, it’s really good. And same thing, you can look at the flip side on all the rest of these, that 70% of the obese adults actually had been told that they were overweight by their doctor, and so on.

The studies also show, and actually you guys already saw this in some of the other presentations, that people with a BMI of 35 and greater are at 20-times more likely to develop diabetes than those of a normal BMI. And I think some of you may have heard Dr. Marrero speak earlier today, and I found the results of the diabetes prevention program also showed that intensive counseling on an effective diet, exercise, and behavior modification reduced the risk of developing type 2 diabetes by 58%. And actually, it was even greater for those who were older, which is amazing.

And the National Institutes of Health does recommend that providers are discussing weight loss with their patients, as well as U.S. Preventive Services Task Force. And studies actually show that the majority of the patients actually do want their providers to tell them that they are overweight. They’re frustrated when people aren’t actually telling them.

So, I had to include a little bit of humor here, today, too. It’s a little bit different than the videos you got to watch. They were a little bit more exciting, I’d have to say. But it’s sometimes not that easy. Lots of unique ways that we can actually present lifestyle change information to people. Maybe we need commercials on TV that tell people to go for a walk.

There are a lot of challenges, of course, as we just mentioned. The challenges for the providers are time. I mean, if they have such a brief period of time when they’re interacting with their patient, how much of that can be put toward healthy lifestyle counseling? I’m sure it’s very minimal and very quick when the doctor is with them. But it should be a priority, in my opinion.

And the relationship with the patient can also be difficult. If you have a patient, it’s their first visit with you, that may be one of the indicators for not actually going forward. If you haven’t developed that relationship, you may not feel comfortable actually talking to the patient about their weight at that time. And also, studies show that the more frequent your contact is with a patient, the more you’re actually have a better relationship and you’re able to approach the more difficult subjects with them, such as their weight.

And actually having the belief and confidence that patients will make these lifestyle changes is important, too. So, there actually has to be some sort of confidence there. Of course, it’s not the most comfortable subject for people to bring up. So, there is the issue of just that discomfort in discussing weight. And how serious really is this in the scheme of the rest of their diagnoses? Sometimes, they may have other things that the provider feels are more important than that issue, even though a lot of them can tend to be tied in with obesity. Certainly, it may not come up as the first thing that people want to discuss.

And then sometimes, there’s a lack of resources. Sometimes the providers are thinking it’s difficult to bring it up, because then they don’t know where to send them or what to tell them or what to do once they have talked about obesity and talked about healthy lifestyle changes, such as physical activity and nutrition.

This is some unpublished data right now. But some information from Dr. Keith, Anthony Perkins, and Dr. Clark, talking about the rates and correlates of prescriptions to a primary care weight management program, the Take Charge-like program that we are currently running.

As you can see, I’ve highlighted a few of them. This study was actually done with seven providers over at the West Side Clinic, which is one of the Wishard outpatient clinics on the West Side. So, seven providers were interviewed and asked these 21 questions. And as you can see right here, they were asked, do you have time to discuss the weight with the patients? And actually, they felt—on a scale of one-to-three, so one is strongly agree, they felt that it was difficult—they disagreed, and actually said that, no, we actually do have time to discuss it with the patients. So, they felt like, yes, there is time. It is important.

Do they feel comfortable with bringing up weight? Out of these seven providers, it was an absolute yes. Yes, absolutely, they felt that it was important and that they were comfortable with bringing it up with their patients when necessary. The obese patients have a lot of problems and not enough time for looking at weight. There was a little bit of disagreement on that. You can see that people are kind of middle of the road here, some agreed, and some disagreed that there is time to deal with the weight issues based on the other issues that they have.

Obese patients are likely to reject lifestyle changes. Again, it was middle of the road. Some agreed; some disagreed. Obese patients do not want the primary care provider bringing up their weight. You can see, there’s strong disagreement there. They actually do. The providers feel that the patients do want them to bring up their weight. Then, I do not know how to tell a patient they are obese. Out of these seven providers, again, they feel comfortable with actually being able to tell patients.

So, I don’t know if this is a good look. This is just a very small sample, but according to this, these providers actually do feel comfortable bringing it up and feel that it is important and necessary to address that with their patients.

So, counseling is something that is very important for these patients. One possible thought and strategy is that we could have the providers make sure that they are calculating a BMI on all their patients prior to the visit. So, as they come in the door, if they haven an encounter form, that they’d have a BMI that is just calculated off their height and weight right there. And it becomes just another clinical indicator that the providers can discuss with their patients, such as they’re discussing their blood pressure, they’re discussing their cholesterol levels, they’re discussing their BMI.

And that is an opportunity, so it is not just looking at weight, but it provides an education opportunity for the patient, as well. Not only is this important when talking to the patients that already have a high BMI or are already obese, but it’s also important for those who are just overweight in the 25 to 30 category, as well. It’s important any time to talk to the patients about that.

Maintaining frequent contact is also important. The more contact you have with a patient, the more likely they are to feel comfortable and have that rapport and that relationship built up, that trust, that you can discuss these issues with them. Of course, it’s difficult when it’s a new patient or someone that you haven’t had a lot of contact with. But the more contact, the more likely you are to be able to bring up these issues.

Using motivational interviewing techniques can also be beneficial. Motivational interviewing is something that we are actually using in our program, our project, right now. And I’ll give you some ideas of what that entails in one of the next slides. Also, being able to refer to community resources, as I mentioned before, is also important. Knowing what those resources are and being able to make it more practical for the patient to know what to do once they leave the office.

With motivational interviewing, some good questions: What concerns you about diabetes? That way, it allows the patient to have a small dialogue. Again, time can be an issue here. But just a series of questions that can be presented to the patient over time, not necessarily all in one single session, but as they return for future visits. And they move, possibly, from the preparation to the action stage.

Another question is, What’s so good about the way things are right now? Gets them to start thinking a little bit about, you know, what’s my life like right now? What’s so good? And what’s not so good? And again, this first question up here about what concerns about diabetes, that can be: What concerns you about starting a physical activity program? Or, What concerns you about your nutrition habits?

And then, What would be the worst-case scenario if you didn’t make any changes? Again, it just gets people thinking a little bit about, what really would happen. Or you can even have them think about their visions. So, think down the road five years. How do you see yourself in five years, especially if you were to think about making some of these changes?

Acknowledging the challenges is very important. People want to know that you’re listening to them, too, but also knowing that you’ve heard that this isn’t easy, that it’s difficult. It is something that is going to be new and possibly frustrating and challenging for them. Emphasizing that it is a personal choice, so helping them to have some ownership and feel confident that, you can try this or you can’t, it’s up to you. It’s your choice. Building their confidence, especially based on past successes. So, if someone has, say, stopped smoking before, they may now be able to see the correlation between that and the possibility of exercising.

Then maybe another question: If you were going to set a goal, what would it be? Again, it’s a different approach to not just us telling them, this is what you should do. This is saying, what would you like to do? What do you think? Because we find that a lot of people are fairly educated, and they know what they need to change. It’s just a matter of letting them come up with the idea and process it, and actually put some action to it.

There are a lot of different ways that you can approach trying to fit things into your day. Again, our approach is not to actually tell people, but we let them come up and be as creative as they want to be about how they’re going to fit physical activity or good nutrition habits, or any other things into their life. We’ll give them a pedometer, and they can count their steps, too.

So, what are some of the resources that are available? There are dietitians that are available at a lot of the clinical sites. We have dietitians that we partner with, and we refer an awful lot of our patients to the dietitians. And the majority of them are patients with a chronic condition. But that would be the majority of the patients that we see do actually have some kind of chronic condition.

Social workers are also available in a lot of the clinical areas, and they are able to connect the people with resources. And sometimes, it’s a matter of stress. It’s not even something that’s related to diet or exercise. Maybe it’s that money is tight and they need another resource. Transportation is difficult; they need transportation to be able to get somewhere. So, having some connections and knowing the social workers is a good resource.

And then also, different community programs that are available in an area. In Marion County here, we actually now have this 2-1-1 number that people can call, and they can get connected with what the resources are. Also, there’s a program, Indy in Motion. That’s a partnership with the Marion County Health Department and the Indianapolis Mayor’s Initiatives, and NIFS, I believe, are the people that are running these free exercise classes out at the Indy Parks and Rec areas. So, free classes are out in the communities and available to people. And a lot of them are right in their communities and they’re more affordable.

Then Take Charge Lite is another program. And I’ll tell you a little bit about Take Charge Lite right now that’s available at Wishard. We call it TCL, not TLC, but TCL. It’s just a free, healthy lifestyle program, and it’s available to those that are ages 18 and above. It is right now, we have two bilingual coaches, so it is available for English- and Spanish-speaking patients. And we’re currently in six of the clinics in the surrounding Indianapolis area, one of them being right there at Wishard Health Services in the Regenstrief Building.

It is a grant-funded program by the Richard Fairbanks Foundation. So, we are very grateful for the funding for the program.

And I had to throw in a lot of pictures, as you probably see in your handouts, but I’m just really proud of the staff that actually work daily with the patients and are changing lives right now, because they really build a relationship.

Right here you can see she’s looking at a newsletter. That’s one of the things that we keep as part of our program. The coaches all collaborate to put together newsletters for their patients. On the back of that, you can see there’s an incentive program, too. I’ll tell you a little bit more about that.

With our program right now, it is actually doctor referred. The physicians, the providers are able to screen the patients through an electronic system, and they’re screening for someone who has a BMI of 25 to 30 and two cardiovascular risk factors, or a BMI of 30 and above.

Then they order the program, and it’s just through a one-touch key through the Gopher. It’s a medical records system. They just touch and it orders the program for them. It actually prints out a script. It prints out a handout for them. It gives them a phone number that they can call to order the program. Then when they get an appointment, they actually call to the Wishard Services; they get an appointment with a coach at their clinic. Then the coach is there to meet with them one-on-one right now to give them education support and then opportunity to get into other programs that are involved with Take Charge Lite.

This, in turn, then builds their confidence. It builds their motivation, which is one of the key things of motivational interviewing techniques. And then it also builds their competence. There is some self-monitoring. So, the patients are encouraged to keep food records. They’re encouraged to keep physical activity logs. Some of them wear their pedometers, so they’re encouraged to keep any time of recording that’s going to help them become more aware of their habits. And they’re primarily looking at nutrition and physical activity. Although, in the newsletters especially and in the support groups, we do talk about other issues, such as stress. Then ultimately, we’re looking at, are they losing weight, too?

This is one of the groups that we have over at the West Side Clinic. It’s a support group, so they’re there to support each other. You can see, they look very happy.

And so, some of the tools that we use, we do use an assessment in the initial interview with a patient. We are gathering some of the information and data about them. Then we use some behavioral counseling techniques along with the motivational interviewing I talked about. They are doing some self-monitoring. We provide newsletters with calendars of the activities.

There are support groups, and in these support groups, again, there are different topics that they talk about. They get to meet with each other and actually feel like they belong and are part of something.

There are educational classes. They talk about a lot of different topics that we’ve discussed already. And there are even exercise sessions. The coaches will lead them in chair exercise, or they’ll lead them in some sort of yoga class, or they put in a video and let them go through the video.

We also partner, as I mentioned earlier, with dietitians to refer them on for further nutritional information. And then we have an incentive program where they, right now, are doing a passport to wellness. So, they get a passport, and for every activity that they do, even recording in their food logs, they get stamps in their passport, and they get prizes once they’ve reached different countries in their passports.

We also have community partners, people that we are collaborating with in order to refer them out into the communities so they can continue on their own, as well. And again, more of our patients.

Some of our successes so far. In the physical realm, we’ve so far shown an average of four-pound weight loss. Again, not staggering, especially compared to the gastric bypass surgery presentation we just had earlier. But it does mean that they are progressively and slowly keeping it off, as well, which is very important. They’ve also seen some mental, social, and emotional benefits. So, they’re getting to learn more about physical activity, nutrition, and just behavior change in general.

They are getting to socialize with each other. And a lot of these people do have conditions, sometimes depression and other psychological conditions, so it allows them to be part of something and to get together with other people who are very similar to them. And emotionally, of course.

We are collaborating with another program that is a grant-funded program. It’s called Fit for Life, that actually runs with IU exercise, the Physical Education Department here. Actually, I think I might have a picture. I’ll show that to you later. There is a workout center over at George Washington Community School, and that is free and open to the patients of our program, as well as anyone living in the West Side Community. It has two bicycles and three ellipticals, I think, and whole set of weight machines. And it’s totally free and open to the community.

We have had great provider support, so that providers are referring to our program. Over at the one clinic, over about a year’s period, they’ve showed about a 38% referral rate of all the people that were eligible for our program.

We are continuing to expand. We’ve just started working with the Wishard Employee Wellness program. So, now we are working with the employees of Wishard, which has been fantastic. There it is. That’s some of the bikes that are over there at the George Washington Community School, and some of our patients that are taking part in our program. And just some of our patients, just some of their testimonials. They actually have been very pleased.

One of these is also an employee over at Wishard, and she’s had people coming up to her. I just saw her before I came over here today, and she said, people are coming up and saying, wow, I knew you before when you were really heavy. And she said, boy, they have a strange way of telling me that, you know, they think that I look good now, because they’re telling me that I was pretty heavy before. But she said it’s amazing, because they’re inspired by her. And they’re ready to actually try it, too.

Again, just some more of our patients. You can see, they’re very diverse. We have quite a good group of people over there.

And this is just some of the people who have helped work on the program. So, Dr. Clark, Dr. Harris are principal investigators. Dr. Keith is helping to do some of the investigational research in the program. And our coaches, down here, they’re in the program.

We actually took part in the American Heart Walk a few weeks ago. And these were a lot of our patients who had completed three miles, which was amazing. We were very proud of them. And they all have on their Take Charge Lite T-shirts, which you can see. You could find them in a crowd anywhere. And that’s it.

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