This activity is supported by an educational grant from Takeda Pharmaceuticals International, Inc., US Region and Orexigen Therapeutics, Inc, and jointly sponsored by Medical Education Resources (MER), Nurse Practitioner Associates for Continuing Education (NPACE), and Haymarket Medical Education (HME).
Caroline Apovian, MD
Director, Nutrition and Weight Management
Boston Medical Center
Release Date: September 10, 2014
Expiration Date: September 9, 2015
Estimated time to complete the educational activity: 30 minutes
Statement of Need: Primary-care clinicians in the United States see the majority of overweight or obese patients in their practices, yet studies find significant barriers to the diagnosis and management of obesity in primary care. Bias against obese patients, limited time and reimbursement, and lack of knowledge all contribute to under-diagnosis in professional practice. Thus, healthcare providers in primary care need to address the problem of obesity head on and offer strategies for weight-management in an effort to promote overall public health.
Target Audience: This activity has been designed to meet the educational needs of primary-care physicians, physician assistants, nurse practitioners, and other clinicians with an interest in obesity prevention and management.
Learning Objectives: After completing the activity, the participant should be better able to:
- Utilize evidence-based measurements in conjunction with BMI to accurately screen patients for overweight and obesity
- Counsel overweight/obese patients on evidence-based lifestyle modifications for weight reduction
Physician Credit: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of MER and HME. MER is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation:MER designates this enduring material for amaximum of 0.5 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity
Nursing Credit: Nurse Practitioner Associates for Continuing Education (NPACE) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC).
Credit Designation: NPACE designates this enduring material for amaximum of 0.5 contact hours of credit. Participants should only claimcredit commensurate with the extent of their participation in the activity.
American Academy of Physician Assistants (AAPA)
The AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hour of Category I credit for completing this program.
MER ensures balance, independence, objectivity, and scientific rigor in all oureducational programs. In accordance with this policy, MER identifies conflicts of interest with its instructors, content managers, and other individuals who are in a position to control the content of an activity. Conflicts are resolved by MER to ensure that all scientific research referred to, reported, or used in a CME activity conforms to the generally accepted standards of experimental design, data collection, and analysis. MER is committed to providing its learners with high-quality CME activities that promote improvements or quality in health care and not the business interest of a commercial interest.
It is the policy of Nurse Practitioner Associates for Continuing Education to ensure balance, independence, objectivity, and scientific rigor in all of its educational activities. All faculty participating in our programs are expected to disclose any relationships they may have with commercial companies whose products or services may be mentioned so that the participants may evaluate the objectivity of the presentations. In addition, any discussion of off-label, experimental, or investigational use of drugs or devices will be disclosed by faculty.The faculty reported the following financial relationships withcommercial interests whose products or services may be mentioned inthis CME/CE activity:
Caroline Apovian, MD, has participated on advisory boards for Amylin, Arena, EnteroMedics, Johnson and Johnson, Merck, Nutrisystem, Orexigen, Sanofi-Aventis, and Zafgen. She has received research funding from Amylin, Aspire Bariatrics, Eli Lilly, GI Dynamics, MetaProteomics, Orexigen, Pfizer, Sanofi-Aventis, and the Dr. Robert C. and Veronica Atkins Foundation.
Susan Basilico, Debra Gordon, MS, Krista Sierra, and Sarah Taegder, all of HME, have no financial relationships to disclose.
MER Content Manager has no financial relationships to disclose.
NPACE Planning Committee has no financial relationships to disclose.
Disclosure of Unlabeled Use: This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. HME and MER do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Method of Participation:There are no fees for participating in and receiving CME/CE credit for this activity. During the period of September 10, 2014 through September 9, 2015, participants must:
- Read the learning objectives and faculty disclosures;
- Study the educational activity;
- Submit the post-test online (clinicians may register at www.mycme.com);
- Complete the evaluation form online
A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better.
Disclaimer: The content and views presented in this educational activity are those of the authors and do not necessarily reflect those of MER, NPACE, or HME. The authors have disclosed if there is any discussion of published and/or investigational uses of agents that are not indicated by the FDA in their presentations. The opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of MER, NPACE, or HME. Before prescribing any medicine, primary references and full prescribing information should be consulted. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. The information presented in this activity is not meant to serve as a guideline for patient management.
Jennifer M. is a 37-year-old Latina patient who presents to her primary-care clinician for a routine physical. She has no health complaints other than fatigue that has persisted since the birth of her first child 9 months prior. She is surprised to hear that her blood pressure (BP) today is 120/82 mm Hg, indicating prehypertension.1
Jennifer wonders if her elevated BP is related to the fact that she is still “carrying some baby weight.” She admits she hasn’t weighed herself in “about 6 months.” She is shocked when she steps on the scale today and discovers that she is 192 lb, significantly more than this 5’5” patient has ever weighed.
According to estimates from the 2011–2012 National Health and Nutrition Examination Survey (NHANES), 68.5% of American adults are overweight—with a body mass index (BMI) between 25 kg/m2and 29.9 kg/m2—or obese (BMI ≥30 kg/m2) (Table 1).2
Table 1. Overweight and obesity in U.S. children and adults, 2011–20122
|Population||Overweight or obese %||Obese %|
|Persons aged 2–19 years||31.8||16.9|
|Adults aged 20 years and older
If current trends continue, nearly 90% of U.S. adults will be overweight or obese by 2030.3Obesity and its related consequences now account for an estimated 10% of all medical spending in the United States.4Societal costs include job discrimination related to the stigma of obesity, poor physical functioning, and limitations in activities of daily living.5
Health risks of obesity
The increasing prevalence of obesity and its correlation with numerous health effects and risks has led to the reclassification of the condition to a medical issue.6As early as 1998, the National Institutes of Health (NIH) declared obesity to be a disease and issued guidelines for the identification, evaluation, and treatment of overweight and obese adults.7
In 2011, the Centers for Medicare and Medicaid Services announced it would reimburse clinicians for providing intensive behavioral therapy for weight loss to appropriate Medicare beneficiaries.8Two years later, the American Medical Association officially declared obesity a disease.9
The numerous health-related consequences of obesity can be divided into two categories: those resulting from the excess weight itself and those associated with the increased metabolic activity of excess stored fat cells.10
The former group includes the behavioral and mental health effects of obesity resulting from the stigma associated with the disease; osteoarthritis from increased pressure and trauma on ligaments, joints, and bone; and sleep apnea.10
The second category encompasses metabolic diseases such as type 2 diabetes mellitus (T2DM), insulin resistance, and metabolic syndrome. Observational studies have found a 40- to 60-fold increased risk of diabetes in individuals who have a BMI ≥35 kg/m2.11,12
Even a 20-kg weight gain in a normal-weight or overweight individual increases the risk of diabetes 15-fold, while the same amount of weight loss eliminates that increased risk.10
Obesity is also a significant risk factor for hypertension and dyslipidemia, which—along with diabetes and metabolic syndrome—substantially increase the risk of heart disease and stroke. Indeed, individuals with a BMI >29 kg/m2have a 3.3-fold increased risk of coronary artery disease.10
Obesity, diabetes, and hypertension are also risk factors for chronic kidney disease (CKD).13One study found that individuals who are overweight at age 26 years through age 36 years are twice as likely to develop CKD by age 60 years to age 64 years compared with those who never become overweight or those who do not become overweight until age 60 years to age 64 years.
The researchers found that concomitant diabetes and/or hypertension could not fully explain the link, and estimated that 36% of all CKD cases among individuals aged 60 to 64 years would be avoided if no one became overweight until that age.14
Nonalcoholic fatty liver disease (NAFLD), the most common cause of chronic and advanced liver disease in adults and children and a common reason for liver transplantation, is also strongly associated with obesity.15,16NAFLD affects about 30% of the general population,15,17between 60% and 80% of persons with diabetes and obesity, and nearly 100% of morbidly obese individuals.
Persons who are overweight have significantly increased risks of certain malignancies, including reproductive cancers and cancer of the gallbladder in women, and cancers of the colon, rectum, and prostate in men.10
Recent research has found that obese adults die 3.7 years earlier from all causes and 1.6 years earlier from cardiovascular disease (CVD)-specific causes than do normal-weight adults.
Those most at risk are obese adults aged 45 years to 64 years, who die up to 12.8 years earlier than those who are at normal weight. Most, if not all, of these sequelae in obese individuals could be reduced with a relatively moderate weight loss of just 5% to 10%.18-20
Current estimates of overweight and obese children and adults in the United States are based on BMI, which assesses body weight relative to height. This simple-to-use tool has been validated in numerous epidemiologic studies.20However, while the BMI has a high specificity for detecting obesity in men and women, it has a low sensitivity.21
Other limitations of the BMI include the inability to account for differences in body fat distribution based on age, race, or sex, and the inability to distinguish between lean and fat mass. Thus, individuals with a normal weight but excess body fat might not be diagnosed as overweight or obese, suggesting that the prevalence of obesity is actually underestimated.22,23
Furthermore, BMI alone does not completely capture obesity-related health risks. It is recommended nonetheless as the primary tool for assessing body fat in clinical practice.2,22
Other options for diagnosing obesity that more accurately evaluate obesity-associated health risks include waist measurement, dual-energy x-ray absorptiometry, the use of fat calipers to assess body fat percentage, and measurement of fasting leptin levels.23
Evidence-based recommendations for assessing obesity and related health risks
In 2013, the American Heart Association (AHA), the American College of Cardiology (ACC), and The Obesity Society (TOS) released updated guidelines for the assessment and management of obesity in adults.24
These joint recommendations for the assessment of obesity and related health risks call for clinicians to do the following:
Measure each patient’s height and weight and calculate BMI at least annually; results should be noted in the chart.
Use the current cutoff points for overweight (BMI >25.9 kg/m2– 29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk for CVD.
Use the current cutoff points for obesity to identify adults who may be at elevated risk of all-cause mortality.
Advise overweight and obese adults that the greater their BMI, the greater their risk of CVD, T2DM, and all-cause mortality.
Measure waist circumference at annual visits or more frequently in patients with BMI >25.
Use the current cutoff from either NIH/National Heart, Lung, and Blood Institute (NHLBI) or the World Health Organization (WHO)/International Diabetes Federation (IDF) to identify patients who may be at increased risk until further evidence becomes available.
The NIH/NHLBI cutoffs are 102 cm for men and 88 cm for women;7the WHO/IDF definition is ≥94 cm for European men and ≥80 cm for European women, with ethnicity-specific values for other groups.25
Advise adults that the greater their waist circumference, the greater the risk of CVD, T2DM, and all-cause mortality.
Although waist circumference and BMI are interrelated, waist circumference provides an independent prediction of risk over and above that indicated by BMI. Waist circumference measurement is particularly useful in patients who are categorized as normal or overweight on the BMI scale.
At a BMI ≥35, waist circumference has little added predictive power of disease risk beyond that of BMI. It is therefore not necessary to measure waist circumference in individuals with a BMI ≥35 (Table 2.)
Table 2. Classification of overweight and obesity by BMI, waist circumference, and associated disease risks24
|BMI (kg/m2)||Obesity class||Men =102 cm (40 in) Women =88 cm (35 in)||Men >102 cm Women >88 cm|
|Extreme obesity||40.0+||III||Extremely high||Extremely high|
The role of primary-care clinicians in the management of obesity
The high—and steadily increasing—prevalence of overweight and obesity coupled with the substantial morbidity and mortality associated with the disease put primary-care clinicians at the forefront of the epidemic. These health-care providers have significant potential to influence patient lifestyle choices and encourage weight loss.
Indeed, studies find that clinician involvement in obesity management improves the likelihood that patients will make lifestyle changes for weight loss and maintenance.26-30Even clinician acknowledgment that a patient is overweight can increase the patient’s motivation to lose weight.30
Numerous studies have found, however, that clinicians consistently underdiagnose obesity.31-37
Continuation of case study
Jennifer’s clinician determines that her BMI is 31 and explains that she now meets the criteria for obesity. The health-care provider takes the patient’s waist measurement, which is 35 inches. The clinician explains that waist size is correlated with obesity-related health risks and recommends additional testing to better assess her risk of cardiometabolic disease.
Jennifer’s test results show an A1C of 6.2 and a fasting blood glucose level of 110 mg/dL. The patient is shocked that in addition to borderline hypertension, she also meets the criteria for prediabetes.
Assessing and addressing obesity-related risk factors and comorbidities
According to the AHA/ACC/TOS guidelines for obesity management,24clinicians should assess the risk of CVD and/or the presence of obesity-related comorbidities in patients who are overweight or obese per BMI. This assessment should include a thorough history, physical examination, and clinical and laboratory assessments of BP, fasting blood glucose, and fasting lipid panel.
Individuals with a BMI <35 kg/m2should undergo a waist-circumference measurement to provide additional risk information. In patients with a BMI >35, waist circumference measurement is unnecessary as it is presumed that it will be elevated and thus will provide no additional risk information.
Intensive management of CVD risk factors (hypertension, dyslipidemia, prediabetes, or diabetes) and/or other obesity-related medical conditions (e.g., sleep apnea) should be implemented if they are found, regardless of weight-loss interventions.
Continuation of patient case study
Jennifer is highly motivated to embark on a weight-loss program. She tells her clinician that 10 years earlier, she had been able to lose the 30 lb she gained after college by using a commercial diet with meal replacements. She managed to keep the weight off over time by running five times a week and “cutting back on junk” whenever her clothes began to feel snug.
However, Jennifer notes that with an infant, she does not have much free time to go to the gym or to cook healthy meals.
Lifestyle interventions for obesity
As a first step in helping patients implement lifestyle changes for weight loss, clinicians should assess the person’s lifestyle history and determine other potential factors that are contributing to weight gain.
Patients should be asked about history of weight gain and loss over time, details of previous weight-loss attempts, dietary habits, physical activity, family history of obesity, and other medical conditions or medications that may affect weight.
Such information can guide the clinician in making the proper adjustments to a patient’s medical regimen that may help with weight-management efforts and in providing appropriate advice on lifestyle change. It may also impact treatment recommendations.24
The clinician and the patient who is ready to begin a weight-loss plan should work together to set appropriate health goals and develop a comprehensive lifestyle treatment strategy to achieve those goals.
Although sustained weight loss of as little as 3% to 5% of body weight may lead to clinically meaningful reductions in some CVD risk factors, larger weight losses produce greater benefits. The AHA/ACC/TOS guidelines recommend that patients lose 5% to 10% of baseline weight within 6 months.24
Patients who are ready to embark on a weight-loss program should be advised that to be successful, they will need to create an energy deficit through caloric restriction, physical activity, or—ideally—both. An energy deficit of ≥500 kcal/day typically can be achieved with dietary intake of 1,200 to 1,500 kcal/d for women and 1,500 to 1,800 kcal/d for men.24
Choice of diet should be based on the patient’s preferences, needs, and health status. Very-low-calorie diets (<800 kcal/d) should be used only in limited circumstances and under medical supervision. If a specialized diet for CVD risk reduction, diabetes, or another medical condition is warranted, the patient should be referred to a nutrition specialist.24
Data show that the most effective behavioral weight-loss strategy is an in-person, high-intensity comprehensive weight-loss intervention provided individually or in group sessions by a trained interventionist.24
The principal components of such an intervention include: 1) prescription of a moderately reduced-calorie diet; 2) a program of increased physical activity; and 3) the use of behavioral strategies to facilitate adherence to diet and activity recommendations.
Ideally, patients should complete 14 or more sessions within a 6-month period. In general, patients can expect to see a weight loss of approximately 8 kg during this time. After 6 months, most patients will require an adjustment of energy balance if they wish to lose additional weight.24
In primary-care offices in which frequent, in-person individual or group sessions led by a trained interventionist are not possible and not available by referral, alternative delivery modes may be considered. Emerging evidence supports the efficacy of weight-loss interventions delivered by telephone or the Internet (including some commercial programs).24
If a high-intensity comprehensive lifestyle intervention program is not available or feasible, another option is referral to a nutrition professional for dietary counseling.24
In addition to caloric restriction, comprehensive lifestyle intervention programs usually advocate increased aerobic physical activity (such as brisk walking) for >150 min/wk (equal to >30 min/d, most days of the week). Higher levels of physical activity, approximately 200 to 300 min/wk, are recommended to maintain weight loss or minimize weight regain over the long term (>1 year).24
During weight-loss treatment, the clinician should manage hypertension, dyslipidemia, and other obesity-related conditions present in the patient. This includes monitoring a person’s requirements for medication change as weight loss progresses, particularly for antihypertensive medications and diabetes medications that can cause hypoglycemia.
Adjunctive strategies for weight loss
In recent years, there has been increased recognition of the need for adjuncts to diet and physical activity. Patients with a BMI ≥30 or of ≥27 with a comorbidity, who are unable to achieve or maintain sufficient weight loss to improve health risks, may benefit from bariatric surgery evaluation and/or treatment with anti-obesity medications.24
Such medications may help patients better adhere to a lower-calorie diet to achieve sufficient weight loss and related health improvements when combined with increased physical activity. These agents work by decreasing appetite or reducing fat absorption. It is recommended that they be used as directed in appropriate patients as an addition to—rather than instead of—lifestyle modifications.
Evidence-based practices to improve obesity-related counseling
The chronic-care model, developed in 1998, provides a framework around which to initiate and provide the type of discussions and long-term management required with a chronic condition such as obesity.38
The model assumes that improving care for chronic conditions requires a team approach involving the clinician, the patient, and the health-care system. It calls for interventions that address psychosocial and lifestyle issues as well as medical problems.39
Engaging obese individuals in behavioral changes designed to address weight loss requires engagement and a patient-centered approach. The first step is to assess the patient’s readiness to change, which can be accomplished through motivational interviewing.
This is a patient-centered method of identifying and enhancing an individual’s internal desires to change by exploring and resolving any ambivalence and/or resistance he or she may have to change while focusing on the three key components of motivation: importance, confidence, and readiness.40
For example, instead of chastising patients about their weight and highlighting the negative aspects of diet and exercise interventions, clinicians can try to explore patients’ feelings about their weight through a series of open-ended questions, then work with the patient to set specific goals, identify the steps required to reach those goals, and track progress (Table 3).
Table 3. Motivational interviewing in obesity counseling 48
|Agenda setting||“Would you mind if I talked with you about your weight?”||Asking permission emphasizes patient autonomy|
| “Are you interested in being more active?”
“Would you be able to walk for 30 minutes each day?”
“You mentioned that you’re now more open to adding
exercise to your routine. What makes you open to it now?”
“How important is it that you get more fit?”
| Assesses value of changing
Assesses patient self-efficacy
Assesses current sources of motivation
Assesses degree of motivation
|Providing information||“Obesity has been linked to a greater risk of diabetes and heart disease. Losing even a modest amount of weight can lower your risk. There are several options available to help you lose weight.”||Conveys hope; relates risk behavior to long-term health outcomes; indicates that there are treatment options|
|Listening and summarizing||“What do you think about that idea?”
“It sounds like you’re interested in seeing a dietitian for nutrition advice but are worried about finding the right one.”
|Elicits view of personal health risk and acceptable interventions; identifies sources of ambivalence|
|Generating options and contracting||It sounds like you have several good ideas about how to reduce your calorie intake. Which one do you think would work best? I look forward to hearing about it at our next appointment.”||Patient selects specific plan, to be reevaluated at an agreed-upon time|
Patients may be more receptive to conversations that are framed in such a positive manner and less likely to become defensive about their weight. Indeed, greater weight loss has been observed in patients who received motivational interviewing counseling than in those who received standard counseling.41-44
The chronic-care model and motivational interviewing fit well with the 5As counseling approach: Assess risk, current behavior, and readiness to change; Advise change of specific behaviors; Agree and collaboratively set goals; Assist in addressing barriers and securing support; and Arrange for follow-up.
This method was developed as a tool for smoking cessation and other preventive behaviors. However, it is also associated with better outcomes in weight management.45-49
More than two-thirds of the adult population in the United States is overweight or obese, a figure that has shown little improvement in the past decade. The excessive morbidity and mortality associated with obesity now account for at least 10% of all health-care spending in the nation.
Primary-care clinicians see the majority of overweight or obese patients in their practices; thus, they are on the front lines of this epidemic. However, studies find significant barriers to the diagnosis and management of obesity in primary care, including bias against obese patients, limited time and reimbursement, and lack of knowledge.
Recent clinical guidelines for assessing obesity call for measuring weight and height at every visit, calculating BMI, and measuring waist circumference, all of which could be performed and documented before the clinician sees the patient.
If the patient is diagnosed as overweight or obese based on these criteria, the guidelines recommend weight-loss counseling. This requires that clinicians partner with their patients to identify and implement a plan driven by the patient’s own goals, not those of the clinician.
Integrating motivational interviewing, using the 5As approach, and addressing the problem of obesity through a chronic-care model offer the potential for significant improvement in primary-care-centered weight-management efforts.
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- American Medical Association. AMA adopts new policies on second day of voting at annual meeting. June 18, 2013. News release. Available at: www.ama-assn.org/ama/pub/news/news/2013/2013-06-18-new-ama-policies-annual-meeting.page.
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- Hall ME, do Carmo JM, da Silva AA, et al. Obesity, hypertension, and chronic kidney disease. Int J Nephrol Renovasc Dis . 2014;7:75-88. Available at www.dovepress.com/obesity-hypertension-and-chronic-kidney-disease-peer-reviewed-article-IJNRD.
- Silverwood RJ, Pierce M, Thomas C, et al. Association between younger age when first overweight and increased risk for CKD. J Am Soc Nephrol . 2013;24(5):813-821. Available at jasn.asnjournals.org/cgi/pmidlookup?view=long&pmid=23559581.
- Karlas T, Wiegand J, Berg T. Gastrointestinal complications of obesity: non-alcoholic fatty liver disease (NAFLD) and its sequelae. Best Pract Res Clin Endocrinol Metab . 2013;27(2):195-208.
- National Institute of Diabetes and Digestive and Kidney Disease. Liver Transplantation. 2012. Available at digestive.niddk.nih.gov/ddiseases/Pubs/livertransplant/index.aspx.
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- Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA . 2005;293(15):1861-1867. Available at jama.jamanetwork.com/article.aspx?articleid=209359.
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- Logue E, Sutton K, Jarjoura D, et al. Obesity management in primary care: assessment of readiness to change among 284 family practice patients. J Am Board Fam Pract . 2000;13(3):164-171.
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- Post RE, Mainous AG III, Gregorie SH, et al. The influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity in the United States. Arch Intern Med . 2011;171(4):316-321. Available at archinte.jamanetwork.com/article.aspx?articleid=226670.
- Stafford RS, Farhat JH, Misra B, et al. National patterns of physician activities related to obesity management. Arch Fam Med . 2000;9(7):631-638.
- Lemay CA, Cashman S, Savageau J, et al. Underdiagnosis of obesity at a community health center. J Am Board Fam Pract. 2003;16(1):14-21.
- Bardia A, Holtan SG, Slezak JM, et al. Diagnosis of obesity by primary care physicians and impact on obesity management. Mayo Clin Proc . 2007;82(8):927-932.
- Block JP, DeSalvo KB, Fisher WP. Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents. Prev Med . 2003;36(6):669-675.
- Diaz VA, Mainous AG III, Koopman RJ, et al. Undiagnosed obesity: implications for undiagnosed hypertension, diabetes, and hypercholesterolemia. Fam Med . 2004;36(9):639-644. Available at stfm.org/fmhub/fm2004/October/Vanessa639.pdf.
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