Yusuf Khoury

Issues that should be addressed first: 

1. Diabetes control as his Hgb A1C is 9.0 and his glucose is usually between 180-200 
2. Overweight BMI through diet and exercise 
3. Depression as it is only somewhat controlled 
4. Arm and shoulder concerns 

Immunizations:

• Influenza as it is November 
• Td booster if he has not had it within the last ten years
• Zoster recombinant if not given yet

Screening: 

• Alcohol misuse 
• Obesity
• Tobacco use 
• HIV
• Hepatitis C as he was born in 1962
• Colonoscopy screening if he did not have one starting at age 50. 
• Cardiovascular disease with a lipid panel as well as fasting blood glucose. 
• If the patient disclosed that he smokes and/or was a prior smoker and meets the criteria, I would screen for lung cancer with a low dose CT. 
• I would also discuss the benefits and harms of prostate cancer to the patient, especially with his family history and that he is over 55 and allow the patient to decide if he wants to be screened.
• Does notneed to be screened for hypertension, depression or abnormal glucose since he already has these medical problems. 

Injury Prevention: The subway is close to the patient’s home and office, but I would counsel the patient on pedestrian/traffic safety when walking across the street.

Diet: Mr. Khoury does have some dietary issues that should be addressed. His current diets are loaded with carbohydrates, including a buttered roll, sandwiches and cookies. The chips and soup he sometimes gets for lunch can potentially have excessive sodium and saturated and trans-fat. The excess sodium, saturated fats, also from his half and half in his coffee, and carbohydrates are not beneficial for his diabetes and hypertension. The carbohydrates will breakdown into sugar, which can be contributing to his elevated blood glucose levels as he is not within normal limits right now at consistent 180-200 glucometer readings. However, I would commend Mr. Khoury for using Equal instead of sugar in his coffee! While the amount of carbohydrates a patient should eat is highly individualized, the American Diabetes Association recommends a low-carb diet for diabetic patients trying to reduce their blood sugar. The carbohydrates he does eat should be rich in fiber and vitamins and be low in sugars and added sugars. 

 Instead of a buttered roll every morning, he can eat an omelet with non-starchy vegetables such as broccoli and peppers.  For lunch, Mr. Khoury can try to find a local restaurant near work that has a salad with non-starchy vegetables such as onions, cauliflower, tomatoes and cucumbers. Of course, his diet should be in moderation, so he can eat a sandwich or soup and chips every once in a while, such as once a week instead of five times a week. With this meal, he could order a side of vegetables, which he could eat or save for dinner. Mr. Khoury did not provide his typical dinner, but he can include lean meats, cold water fish such as salmon with legumes such as lentils or beans and a small portion of fruits for dessert. I would advise him to reduce the number of cookies and sweets he eats at work as there may be a large amount of sugar in these sweets. Instead, he could eat fruits such as strawberries or apples or sugar-free cookies if the office has them available, or he could bring them himself! 

Ideally, the meals and snacks he eats should be high in dietary fiber, vitamins and minerals. Specifically, a low-carb diet could help reduce his hemoglobin A1C, which is elevated in Mr. Khoury at 9.0. Ideally, I would like his Hgb A1C to be below 7.0. Another option for Mr. Khoury is a Mediterranean diet, which could help with both his Hgb A1C and reduce his risk for cardiovascular disease. A Mediterranean diet could include fruits, vegetables such as carrots and celery, whole grains and using monounsaturated fats to cook with such as olive oil. I would tell Mr. Khoury that he does not need to change his entire diet all at once, but I would advise that he slowly change his diet to more plant-based foods and gradually modify the amount of sweets and carbohydrates he eats. He could consider working on these changes through meal prepping on the weekends with his wife, so he knows what he will be eating during the week and so he can potentially reduce the amount of food he eats from restaurants during the week, which may also make it difficult to know the exact nutrition of the meal. All of these changes can be beneficial for his diabetes, hypertension and weight. It is important to let him know that changing a diet does take time and can be done in small steps! 

Exercise: Mr. Khoury is not getting adequate exercise per current CDC guidelines of at least 150 minutes of moderate intensity a week and he states he does not particularly enjoy exercising. In addition to this, Mr. Khoury is largely sedentary on the weekends, apart from walking his dog, and has a sedentary desk job during the week. Since he is not accustomed to exercising, it is important to start him off slowly and gradually increase his exercise regimen. First, I would make sure that he is not short of breath when walking in the office and assess whether he is willing to change his physical inactivity. I would suggest that he start by getting off an earlier subway stop if possible so he can walk longer from the subway to his apartment. Adding just a short 10-minute walk, along with taking the stairs in his apartment instead of the elevator, will start him on the journey of increasing his physical activity. Along with this, if he does not want to join his wife at the local mosque on the weekends, he and his wife can at least walk together to the mosque, which will add more physical and social activity for him. Other activities he can participate in include taking a short walk during the day while at work or going to a breakfast or lunch location for lunch that is a further distance.  As his activity increases to the recommended 150 minutes a week, he and his wife can take longer and brisker paced walks. Additionally, I would recommend that he add light stretching or muscle strengthening, by possibly ordering some small dumbbells for home, two times a week. However, I would not recommend him adding dumbbells if his shoulder and wrist pains are not resolved yet and would not recommend adding longer walks with his dog until we treat his two concerns at this visit. There are many benefits I would share with Mr. Khoury in regard to exercise, including losing weight and reducing his depression, and I would advise he work towards getting adequate exercise per week.

Harm Reduction: No significant harm reduction for this patient. He could drink decaf coffee instead of regular coffee. In addition, Mr. Khoury could also choose healthier options at the local restaurants he eats at during the week. 

Brief Intervention for Obesity: Mr. Khoury has a BMI of 26.1, which is overweight, and a waist circumference of 43. With these results. I would have a brief intervention regarding obesity with him as he is at further risk for cardiovascular disease and it can also be adding to his hypertension and diabetes. In order to counsel this patient, I would use the 5As for obesity management as outlined below: 

Ask:I would first seek permission to have a nonjudgmental conversation about weight with him by asking “Would you be okay with us discussing your weight during today’s visit?” If he said yes, I would continue to ask questions to the patient to ultimately assess whether he is ready or wants to manage his weight, asking “Do you feel you are ready to work on your weight at this time?” 

Assess: During assessment, I would further evaluate the patient’s BMI and waist circumference, which is noted above. I would assess what other factors are contributing to the patient’s obesity, such as his mental health, mechanical factors, metabolic and monetary factors. For Mr. Khoury, I would specifically assess whether the patient thinks his depression his affecting his weight, such as “Do you think that your depression is negatively impacting your weight or lack of desire to exercise?” I would also ask questions such as “Can you tell me about any weight loss or weight gain you have experienced in the past?” and “Do you have family members who are overweight or obese?” 

Advise: After asking and assessing his obesity, I would ask him if I have permission to offer a plan to manage his obesity by saying, “Would it be okay if I recommended a plan to help with your weight?” I would then give the patient advice on how to modify his lifestyle, through the diet and exercise portions listed above. In addition, I would also provide him with further treatment options for his depression, including additional medication, if I was treating his depression, as he says it is somewhat controlled and advise he follow up with a counselor. If he also expresses concern that he does not want to be active due to his shoulder and wrist pain, I would address these appropriately – such as placing a referral to a hand specialist for his wrist pain since it may be carpal tunnel. I would also advise the patient on the health risks associated with obesity by asking “What do you know about the health risks of obesity and the benefits of losing weight?”

Agree: Next, I would obtain an agreement from him about the plans I proposed. I would ask “Do you feel the treatment plan above is appropriate for you?” If he feels that some of the diet or exercise plan is not obtainable at this time or does not feel he needs further management for some of his conditions, I would modify the plan/recommendations to a plan he feels he is comfortable following. Although, it is extremely beneficial for Mr. Khoury to lose weight, I would focus on improving both his physical and mental habits and changing his everyday habits rather than the amount of weight he should lose. However, achievable goal setting can be extremely beneficial for Mr. Khoury, so I may ask him “How much weight would you like to lose and what activities do you think will be most beneficial in creating healthy habits?”

Assist: The last part of the intervention will identify what will both help and hinder Mr. Khoury’s management plan, by asking him “Are there any factors in your life you think will positively or negatively affect your treatment plan?” By reviewing these factors, such as his shoulder and wrist pain, I will be able to again refer him to the correct specialties. In addition, I may refer him to a weight-management provider, specifically one who specializes in weight management in diabetics, in order to further assist him. I may ask Mr. Khoury “Would you like me to refer you to a nutritionist or a mental health specialist?” 

References:

Obesity PowerPoint

Writing an Exercise Prescription PowerPoint 

Nutrition PowerPoint 

https://care.diabetesjournals.org/content/42/5/731

https://www.diabetes.org/nutrition/healthy-food-choices-made-easy/non-starchy-vegetables

https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=55

Vallis, Michael et al. “Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care.” Canadian family physician Medecin de famille canadien vol. 59,1 (2013): 27-31.