Rise in extreme obesity creates new level of treatment complexity

More than one-third of U.S. adults are obese. If current trends continue, no state will have an obesity rate lower than 44% by 2030, according to September estimates by the Robert Wood Johnson Foundation and Trust for America’s Health.

As clinically challenging as it is for primary doctors to treat obese patients — defined as those with a body mass index of 30 or higher — the problem is compounded when caring for patients with morbid obesity. These are patients with a BMI greater than 40, and their numbers are growing rapidly.

In 2000, 3.9% of U.S. adults had a BMI of 40 or greater. By 2010, the figure grew to 6.55%, said a study published Sept. 18 in the International Journal of Obesity.

“That’s a scary increase,” said Roland Sturm, PhD, the study’s lead author. “We’re not talking about a few pounds too heavy; we’re talking about an average-height male being 100 pounds overweight. This is a very serious medical issue for them.”

Severely obese patients are complex for physicians to treat, health experts say. They often have tried and failed many diet programs, such as WeightWatchers, on their own. And weight-related complications such as joint and back pain make adhering to an exercise regimen difficult.

While moderately obese patients are 25% costlier to treat than normal-weight patients, morbidly obese patients are twice as expensive to care for, said Sturm, senior economist and professor of policy analysis at the nonprofit RAND Corp. in Santa Monica, Calif.

“This is a disaster,” said Jaime Ponce, MD, president of the American Society for Metabolic and Bariatric Surgery. “Unfortunately, 95% of them will fail on weight-loss methods that are not surgery. So, if you let that patient continue to go on those terms, they are going to continue to be overweight, and these numbers are going to increase.”

Bariatric surgery can result in weight loss of 30% to 60%, studies show. A randomized trial published March 26 in The New England Journal of Medicine found that 75% of patients with diabetes who underwent bariatric surgery achieved glycemic control within two years. None of the patients in the medical treatment comparison group achieved glycemic control, said the study of 72 patients. Yet fewer than 1% of patients deemed eligible for some kind of bariatric or weight-loss surgery — those with a BMI of 40 or more, or above 35 with serious weight-related illnesses — have undergone the procedure, Dr. Ponce said.

“Physicians find it very frustrating to deal with this group of individuals, because there’s not universal access to bariatric surgery,” said Michael F. Noe, MD, MPH, associate dean of community relations and clinical affairs at the University at Buffalo School of Public Health and Health Professions in New York. “The surgery may not be available in their community, and also there may not be coverage of the procedure by insurance companies.”

The number of bariatric surgeries grew rapidly starting in 2000, rising from 36,700 that year to 220,000 in 2008, according to the bariatric surgery society. But growth has slowed due to the sluggish economy and other factors.

Bariatric surgery tied to substance use

Even with insurance coverage, bariatric surgery involves out-of-pocket expense, recovery time and a major adjustment to a new lifestyle that involves much smaller food portions. Many patients find the change difficult, as shown by an October Archives of Surgery study of 155 patients who underwent weight-loss surgery. Patients’ use of alcohol, recreational drugs and cigarettes grew by 44% within two years of the procedure.

For these and other reasons, many severely obese patients are loath to try surgery, Dr. Noe said. “There is among a lot of people a general wariness of taking that drastic step,” he said.

Dr. Noe led a project studying intensive medical interventions among patients whose BMI ranged from 40 to 60. In the most aggressively managed group — patients who received weekly cognitive behavioral therapy, weight-loss medication, walked 10,000 steps a day and kept a low-calorie diet — 17% of patients were able to lose 20% or more of their body weight and keep it off after two years, he said. The research group is waiting to analyze further data for submission to peer-reviewed journals, Dr. Noe said.

Most primary care clinics “are not well-suited” for such an intensive weight-loss intervention, he acknowledged. But he encouraged doctors to seek out specialist resources available in their communities.

“There are registered dietitians and other types of professionals who are trained in cognitive behavioral therapy, who may be running group programs and who could help to enhance an individual’s motivation and self-efficacy,” he said. “It would be worth referring a person to one of those.”