Obesity care: When the problems outpace the solutions
■ Physicians on the front lines talk tactics in getting their adult patients to lose weight but face substantial obstacles that frustrate them and their patients.
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Every day, family physician Andrew Pasternak, MD, sees an overweight or obese patient.
Many have weight-related medical conditions, including type 2 diabetes and joint pain. Most want to shed some pounds. But it’s often difficult for Dr. Pasternak and other primary care physicians to help such people reach a healthy weight — and even more challenging to help them maintain it.
“A lot of times [your efforts] don’t take,” said Dr. Pasternak, who is part of a two-physician practice in Reno, Nev.
The nation’s obesity epidemic has ballooned to epic proportions with more than a third of adults and 17% of children age 2 to 19 considered obese, according to the Centers for Disease Control and Prevention.
Researchers are projecting a dramatic increase in adult obesity and related health care costs by 2030 if the trend continues. As a result, public health experts are urging primary care doctors, who are on the front lines of the epidemic, to step up efforts to turn the crisis around.
Physicians want to help reduce obesity, but they face substantial obstacles in getting patients to lose weight and keep it off, medical experts say. They say some health professionals are overwhelmed by the magnitude of the problem and lack adequate training to deal with it.
Addressing obesity is “challenging in terms of the time required to do it right and the lack of coverage” by most insurers, said Yul David Ejnes, MD, a Cranston, R.I., internist and past chair of the Board of Regents of the American College of Physicians.
Although Medicare covers a series of primary care visits for obesity counseling among patients with a body mass index of 30 kg/m2 or greater, such appointments are not covered by most other insurance companies, said Scott Kahan, MD, MPH, director of the National Center for Weight and Wellness. The multidisciplinary obesity treatment center is based in Washington. As a result, physicians often must squeeze complicated discussions on improving diet, boosting physical activity and changing eating behaviors into short appointments that are scheduled for a separate health problem.
“It’s frustrating, because we have very good surgeons in town who will do gastric bypass and get paid really well for it,” Dr. Pasternak said. “But if we want to spend 20 or 30 minutes with a patient discussing their dietary habits and exercise … a lot of times it doesn’t get reimbursed.”
Complicating matters is that adult obesity often is related to poor behaviors that people have had for decades, said Norristown, Pa., internist Charles Cutler, MD. Changing such deeply rooted behaviors takes more than a few 15-minute visits a year, he said.
Dr. Kahan said doctors should not give up despite such hurdles. He teaches obesity and public health-related courses at George Washington University School of Medicine in Washington and Johns Hopkins Bloomberg School of Public Health in Baltimore.
DID YOU KNOW:
Although childhood obesity rates have dropped in some areas of the country, adult obesity rates have stayed the same.
“When you delve into the literature, there are dozens of effective clinical treatments for patients … and a number of experts we can refer patients to,” he said. Treatments include medication and prescribing a structured meal plan.
Dr. Kahan recommends that physicians stay up on advancements in obesity management by reading studies on the topic that are published in journals. He also encourages doctors to attend sessions on nutrition and obesity that are offered at annual meetings of their specialty societies.
Working weight into the conversation
At Dr. Cutler’s practice in Pennsylvania, as many as half of the patients are overweight or obese. To keep from getting overwhelmed by the problem, he sets modest goals.
For instance, rather than trying to help a patient lose 50 pounds, he encourages the individual to lose five or 10 pounds over a few months. Reaching that attainable target inspires the patient to continue losing weight.
Before creating a weight-management plan, however, Dr. Cutler addresses the health problem that brought the individual to his office. In the common scenario of an obese patient with back pain, he often mentions the likelihood that the person’s unhealthy weight is contributing to back trouble.
“Your back wasn’t built to carry this much weight,” he tells the patient. “Once we get the pain taken care of, the next thing I want to do is talk about strategies to lose weight.”
Beyond setting reasonable goals, physicians need to understand the causes of the epidemic to address it effectively, public health experts say. Those include increased availability of processed foods; more stress, which can lead to overeating; and the development of communities with no sidewalks or trails where people can be physically active.
Obesity increases the risk of a variety of potentially fatal health conditions, including breast cancer, coronary heart disease, type 2 diabetes and stroke. It also leads to rising health care costs. About $147 billion was spent on medical care costs related to obesity for U.S. adults in 2008, according to the latest available data from the CDC.
Recent data show there have been some improvements in reducing obesity in children. Declines in the childhood obesity rate have been seen in states such as Mississippi (13.3% decrease), said a September 2012 report published by the Robert Wood Johnson Foundation.
But declining rates have not been seen for adults.
“The adult problem is harder to cure, because it’s been more long-standing in each person,” said Joseph J. Colella, MD, a bariatric surgeon at the University of Pittsburgh Medical Center.
Dr. Colella encourages physicians to refrain from telling obese adult patients to “exercise more” during their first few weight-related conversations.
“People who are struggling with their weight have heard [that advice] ad nauseam,” he said. “The minute they hear it from another person, they zone out and stop listening.”
Exercise boosts people’s appetite, and that could prompt obese patients to make poor food decisions, Dr. Colella said. He recommends that physicians focus on reducing an individual’s sugar consumption.
Physicians should inform patients that excess sugar doesn’t come from just soda and baked goods. It also can be found in sweetened coffee creamer, cheese, milk and yogurt, Dr. Colella said.
He said once patients have a dietary plan, doctors should recommend a gradual increase in physical activity.
Learning from failure
Primary care physicians can benefit from the trusting relationships they have developed with patients over the years. Dr. Ejnes uses that bond to establish individualized obesity treatment plans, rather than simply telling all patients to stop eating white starchy foods and move more.
He also asks patients to take a more active role in their weight management by reading the nutrition book Eat This, Not That! and downloading weight loss apps to smartphones. The apps he typically recommends are Lose It! and MyFitnessPal.
Those apps “help you see that little snacks add up to real calories,” said Dr. Ejnes, who tried MyFitnessPal for several weeks. “It makes you think about budgeting your day’s [caloric] intake.”
He said the adoption of a patient-centered medical home model at his practice significantly improved his ability to help patients lose weight and keep off the pounds. Now he can refer overweight and obese patients to a nurse care manager or a medical assistant for additional nutrition and fitness information.
Those staff members regularly schedule follow-up appointments or phone calls to offer patients support and guidance. That frees up Dr. Ejnes to see other patients.
Despite such efforts, “sometimes it becomes clear that one approach isn’t going to work, no matter how hard you try,” Dr. Ejnes said. In those cases, he often refers patients to a dietitian, medically supervised weight loss center or bariatric surgeon. Dr. Ejnes said he feels bad when he can’t help patients lose weight, but he tries to identify why the person struggled and what he could do differently.
“My approach is to get them back on the wagon,” he said. “You learn from the failure.”
Education tools for doctors
Some public health experts say physicians need better training on nutrition and obesity.
Dr. Kahan developed an obesity management class for medical students at George Washington University. He and his colleagues are developing resources for practicing doctors on how to address obesity with patients on Medicare, which covers such visits. The free tools will include a tutorial on how to approach visits with obese patients, a script to follow and an agenda to guide the content covered during follow-up visits.
The resources are expected to be available online by the end of 2013 and in a small handbook that physicians can carry in a pocket of a white coat.
A new tool that is ready to use includes a free guidebook and DVD, which address the impact of overweight and obesity on health and offer doctors tips on how to introduce the topic of weight into their practice. The resource, “Excess Weight and Your Health — A Guide to Effective, Healthy Weight Loss,” was launched on April 15 by the American College of Physicians and the Obesity Action Coalition. The coalition is a Tampa, Fla.-based nonprofit that represents individuals affected by obesity. Physicians can request a copy of the guidebook and DVD by visiting the group’s website.
“The opportunities [to learn about obesity management] are out there,” Dr. Cutler said. “If physicians are interested in doing a better job, they can do it.”