Imagine this: At the end of a busy office visit during which you have addressed acute and chronic health issues, health maintenance, and comorbid psychiatric concerns, your patient turns to you and says, “What I really came in for today is help losing weight.”
You've just completed a complicated visit. You're out of time. Other patients are waiting. What should you do?
You could offer the patient another appointment in the near future to ensure adequate time to discuss the multiple, complex dimensions of healthy diet, exercise, and weight loss. You could refer the patient to an available dietitian, a personal trainer, or another provider. Or, given that the patient has just expressed a desire to change, you could conduct a brief lifestyle consult using one of the following tools:
5–2–1–0. The “5–2-1–0” rule, which comes from the pediatric obesity literature1 but can be adapted for use with adult patients, recommends “5” servings daily of fruits and vegetables. I suggest three servings of vegetables and two servings of fruits with disease-specific modifications for the case of diabetes, irritable bowel syndrome, and other conditions.
The “2” refers to limiting recreational screen time to no more than two hours per day. For my patients who are parents, I encourage them to self-reflect by asking how they are modeling this behavior to their kids.
The “1” represents a recommendation that kids engage in at least one hour daily of moderately vigorous physical activity. Most of my adult patients cannot set aside that amount of time for exercise, so I ask them to consider a more realistic activity level, perhaps 20 to 30 minutes every other day if they are not yet physically active.
Finally, the “0” is a reminder to consume no sugar-sweetened beverages – zero! I am continually astonished to learn how much soda and sweetened tea my patients ingest without regard to the long-term additive effect on their weight. Many will say, “I only drink one soda a day.” One 12-ounce can of soda has 140 calories. Multiplied over 30 days, this adds up to 4,200 calories, a deficit of which could contribute to a 1.2–pound weight loss in a month's time or 14.4 pounds in a year.
MyPlate. Promoted by the USDA, “MyPlate” uses a graphic of a dinner plate to illustrate how much fruit, vegetables, grains, protein, and dairy individuals should consume. We keep handouts of the plate readily available for patient education. Many patients' daily diets consist of nearly 50 percent starch and 50 percent protein and fat, with only the occasional serving of vegetables or fruit. They are often shocked to learn that half the plate should consist of fruits and vegetables, and the other half should be protein and grains, preferably whole grains. The graphic quickly helps patients realize that a plateful of starch and fried foods will not facilitate weight loss or optimal nutrition.
Of course, some patients will need more assistance, but for many patients, these tools are a good starting point. If your counseling turns out to be significant and you provide it as part of a separate problem-oriented encounter, you can bill for it using a preventive counseling code along with modifier 25, or possibly a time-based code. In most cases, though, it doesn't rise to that level.
I have used these tools for several years, and time and again patients have come back and thanked me for helping them learn to make healthier choices. Armed with the 5–2–1–0 and MyPlate concepts, and a couple minutes, you too might start some life-changing discussions.