Overcoming Obstacles to Obesity Care—Is Your Practice Current?

Given the continuing rise in obesity and associated chronic conditions, having the tools to help patients will matter little if there is no patient-provider acknowledgement of the problem. Retool your practice for better weight control outcomes in your patients.

With Wendy Scinta, MD, Harold Bays, MD, and reviewed by  J. Michael  Gonzalez-Campoy MD, PhD

While prescribing pills and recommending bariatric surgery may represent the best treatment strategies to support weight control, a lot of groundwork must first be laid so that the patient may consider any such medical approaches. How well would your clinical practice rate in addressing the most common barriers to sustained weight management in your patients?

If practitioners are ever to reverse the obesity epidemic, both patient and practitioner must move away from the “just eat less and move more” mindset. The current clinical climate affords limited time with each patient, and the lack of reimbursement for proper obesity management presents significant barriers,1 according to the Strategies to Overcome and Prevent (Stop) Obesity Alliance led by William H. Dietz, MD, PhD, and Scott Kahan, MD, MPH, at the George Washington University Milken School of Public Health in Washington,  DC.

Knowing how to speak with your patient about their obesity is critical to their success.Most people want to lose weight but need empathy and guidance to get them beyond their self-blame and shame.

Start by Recognizing the Barriers to Long-Term Weight Control

Having a familiarity with the significant barriers to care that are often cited by patients offers an invaluable perspective were revealed in a report of results from the National Action Study.2 How familiar are you with these common perceptions, attitudes, and behaviors that are holding back your patients with overweight and obesity from finally achieving the weight loss they truly desire?

See How Many of the Following Statements Get a “Yes” from You3

  • We use a large adult blood pressure cuff for thigh cuff on patients with an upper arm circumference is > 34 cm.
  • Use extra long needles to draw blood.
  • Our chairs can accommodate patients with weight over 250 pounds.
  • We have a scale with the capacity to accurately gauge body weight over  400 lbs in a private area.
  • Your staff reframes from commenting on weights when recording in a chart.
  • Does your nurse or you ask if the patient wants to discuss their weight?
  • You Do Not use the term Obese or obesity, using instead  BMI or weight in patient discussions.
  • You have some understanding of the patient’s prior efforts at weight loss, and recognized the health behaviors that are most likely impeding behavior change.

So, the more “Yeses” to the above questions, the closer you and your team may be in providing the most effective treatment to your patients who have obesity. However, there are simple fixes for every "no" response.

And the Nos have it. Despite the move by leading professional organizations including the American Association of Clinical Endocrinologists, the Endocrine Society, and the American Medical Association to recognize obesity as a “complex, chronic disease, requiring treatment,” five years ago, favorable conditions supportive of effective strategies have not evolved fast enough nor has public acceptance grown sufficiently to see an impact in patient care.4,5

This failed responsiveness leaves patients exposed to 236 obesity-related comorbidities that may be eliminated with effective management.6The valid, oft-repeated mantra that just a 5-10% loss of weight may lessen the risks of conditions, has had no impact on the rates of cardiovascular disease, type 2 diabetes, sleep apnea, and hypercholesterolemia, or the increased risk of morbidity and mortality associated to numerous types of cancer.7

Anticipate the Sensitivities that Have Prevented Readiness to Change 

One of the harshest realities with regard to obesity management is the difficulty that people have in achieving weight maintenance following weight reduction. The focus has for too long been on weight loss, rather than management of lost weight.

Consider the perceptions that most patients have about their weight, based on responses of some 3,008 individuals who completed a survey about obesity:2

  • Less than half of the individuals with a body mass index (BMI) over 30 kg/m2 consider themselves as having obesity.
  • The feeling of shame may be the primary obstacle preventing most patients from speaking with their physician about weight loss
  • More than 80% of those surveyed indicated feeling completely responsible for their weight loss, a common misperception
  • Despite several attempts at weight loss, only 23% of respondents reported losing even 10% of their body weight over the last three years even as this amount is considered sufficient to reduce chronic disease risks.
  • Obesity is perceived as a personal failure rather a treatable disease
  • Being given a formal diagnosis is the exception rather than the rule

Nearly three out of four patients who enter a physician’s office will have overweight or obesity;9 as such, clinicians must step up efforts to more actively engage patients in their obesity management plan.

Incorporate Resources to Improve Your Obesity Management Practices

A variety of digitally accessible resources have been developed by the Obesity Medicine Association to foster effective, evidence-based clinical interventions that lead to optimal care for patients.

“Application of these resources is simple and can take many forms, from downloadable obesity treatment guidelines that can be used in any office to in-person and online continuing education covering the latest research and technologies,” says Wendy Scinta, MD, MA, FOMA, clinical assistant professor of family medicine at SUNY Upstate Medical University in Syracuse, New York, and, president of the Obesity Medicine Association.

“Whether looking for quick tips to treat obesity more effectively in primary care or looking to specialize in obesity medicine full-time, these resources extend across the continuum of clinical needs,” Dr. Scinta told EndocrineWeb. One of the greatest hurdles to effective weight management is talking about it. While many patients want, even expect, guidance on what do to, the conversation rarely happens beyond—yes; you should lose weight.

That led the OMA to develop and provide a variety of evidence-based tools aimed to support clinicians overcoming the obstacles that have been impeding patients from sustained weight loss,10 she said. Among the resources are an obesity algorithm and communications tools to sensitively initiate the conversation of weight with patients.

“The intent of the obesity algorithm is to provide clinicians with an overview of principles important to the care of patients with increased and/or dysfunctional body fat, based upon scientific evidence, supported by medical literature, and derived from the clinical experiences of members of the Obesity Medicine Association,” said Harold Bays, MD, FOMA, FTOS, FACC, FACE, FNLA, president and medical director of the Louisiana Metabolic and Atherosclerosis Research Center in Louisville Kentucky, and author of the obesity algorithm.

“Since its beginning in 2013, [obesity algorithm] has undergone yearly updates,” Dr. Bays told EndocrineWeb. “The latest update, set to be released in April 2019, is very “disease state” oriented. It explores exactly how obesity causes the most common conditions evaluated and treated by clinicians (eg, cardiovascular disease, diabetes mellitus, high blood pressure, dyslipidemia, fatty liver, and cancer), and outlines what both patients and clinicians can do.”

Start by Opening the Dialogue and Creating a Safe Space to Talk

Why Weight? Developed by the STOP Obesity Alliance is a tool to guide more productive discussions about obesity with your patients.

The best starting point, according to Dr. Scinta, is to open the conversation with a personalized statement demonstrating empathy (ie, do you find it difficult to carry out activities of daily living? Or you mentioned that your back hurts, a condition that may be worsened by excess weight), then ask for permission to discuss their weight. Once you receive the green light to proceed, it’s advisable to begin the discussion by acknowledging that obesity is a complex disease, and like any condition will require multiple strategies, evolving over time and addressed as a team in order to help the patient succeed.

From there, you’ll want to employ a motivational interviewing style of discussion, which fosters a collaborative approach. The OMA recommends the FRAMES model to promote an open style of communication:6

  • F – Feedback: Present feedback to the patient in a way that is respectful and has an impact. Feedback can include information about how unhealthy behaviors are harming the individual and should be based on information gathered in patient interviews, reports, and objective measures. Ensure that your communication reflects the patient’s statements of concern. 
  • R – Responsibility: Emphasize that the patient has the responsibility and freedom to change or not.
  • A – Advice: Provide clear and direct advice about the importance of making lifestyle changes and suggest different ways that this can be accomplished. Advice should recognize that the patient makes the ultimate choice. 
  • M – Menu: Offer different alternatives for the patient to choose. For example, “There are different ways that people successfully change their lifestyle behaviors. Perhaps we can spend a few moments talking about this so that I can share some of these strategies with you. You can tell me which of these might make the most sense for you.” 
  • E – Empathy: It is important to listen to and reflect on the patient’s statements and feelings. This approach ensures that you understand the patient and that the patient feels understood by you, both of which foster productive communication. Expressing empathy involves communication that is warm and supportive and demonstrates that you are paying attention to the patient’s verbal and nonverbal communication.

Just as it typically takes years for obesity to develop, so will the process of undoing the clinical repercussions will take a long time. By opening the conversation, and establishing a collaborative relationship with your patients, the process of reversing obesity and its comorbidities will at long last be possible. 

Continue Reading:
Sustained Weight Loss Viable with Diet/Drug Combination Therapy
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