Rodney Chin, 60, is the executive director of a YMCA branch in San Francisco, California. As the YMCA’s national organization rolled out a diabetes prevention program to local branches last year, Chin decided to take the online survey to learn more about it. To his surprise, he qualified for the program, which is designed to prevent prediabetics, who already have some insulin resistance, from developing type 2 diabetes.
“I’ve always been average to heavy, I’ve never been overly thin, but not to the point where I thought that I was at risk of being diabetic,” Chin said. “I never had issues with high blood sugar; even my eating habits were not overly eating sugar. After taking the survey, I go, ‘Wow, I do qualify!’”
Chin is not alone in misunderstanding the risks associated with excess body fat. What he called “average to heavy” was actually obese according to the standard medical estimate of body fat, called body mass index (BMI). Yet, in comparison to the world around him, Chin was just average to heavy at 5 foot 6 inches and 195 pounds. Nearly 70 percent of American adults are overweight, and 1 in 3 are obese, according to the most recent national data.
Obesity and related metabolic problems raise a person’s risk of very serious diseases, including cancer, high blood pressure, heart disease, respiratory problems, and diabetes. One study found that an obese man at age 25 would have 12 years shaved off his life expectancy. A quarter of all Americans are prediabetic, but only about 10 percent know their risk.
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There’s been a sustained public policy debate about obesity, and individuals have been flooded with information about how to avoid the pitfalls of fast food and a sedentary lifestyle. But, two decades into what’s widely called an obesity epidemic, doctors have done almost nothing to help their overweight and obese patients lose pounds and roll back their health risks, even in the face of growing evidence that individuals can’t do it alone.
Chin’s doctor set a weight loss goal and advised him to “watch portion size.” But many general practice doctors avoid the issue altogether, their peers who specialize in obesity medicine told Healthline.
“There is lots of data showing that there is relatively little intervention by primary care doctors. In general, they don’t inquire about patients’ weight and weight-related health problems. In general, they don’t measure body mass index. In general, they don’t bring up the issue, and in general they don’t have much assistance to give,” said Dr. Scott Kahan, director of the National Center for Weight and Wellness.
Less than one third of obese adults get a diagnosis of obesity from their doctor. Slightly more patients than that are offered weight-related counseling. Bariatric surgery, though widely talked about, is a last-ditch option that still requires patients to make major lifestyle changes.
“If we were to treat obesity as any other disease, we’d start with the least invasive therapy, and then escalate to the next one, then escalate to the next one,” said Dr. Lee Kaplan, director of the Massachusetts General Hospital Weight Center. “There’s no question that one of the key barriers to solving the problem is the lack of engagement.”
There are a number of reasons why doctors don’t treat weight and related risks systematically or well. Some are hardwired into the U.S. healthcare system. Others are rooted in social bias.
But new insight into what causes obesity and what it takes to lose weight and keep it off is merging with incentives for preventative care offered under the Affordable Care Act. We may finally be reaching the point where excess weight and related medical conditions can be treated, rather than just reproached.
Why the Gap?
Last month, Drs. Christopher Ochner, a pediatrician at Mount Sinai Hospital, and Adam Tsai, a Denver internist and obesity specialist, published an article in The Lancet making the case that doctors should start treating excess weight before patients develop diseases linked to obesity. People whose BMI is categorized as overweight but not obese are at high risk of moving into the more dangerous weight classifications.
The article argued that the science is settled: Obesity isn’t only or primarily caused by bad eating habits, and once set, it’s nearly impossible to undo with diet and exercise alone. Ochner and Tsai laid out some recommendations for how doctors could move progressively from noninvasive care like nutrition education up through medication and on to recommending bariatric surgery.
The response from other doctors was mixed, but included remarks like, “You’re just giving people excuses to be lazy,” and, “You’re taking personal responsibility out of it,” Ochner told Healthline.
Doctors’ hostility reflects changing scientific views of weight. It was just two years ago that the American Medical Association recognized obesity as a disease. Most doctors have had only minimal training in nutrition, most frequently tucked in as a subunit in a course on biochemistry or gastroenterology, according to the Association of American Medical Colleges (AAMC).
In 2007, the AAMC released a white paper calling on medical schools to do more to train doctors to address obesity sensitively with patients, but the organization doesn’t formally track their progress.
With little to offer, doctors often send patients away with simplistic advice, such as avoiding soda, exercising more, or watching portion size, studies have shown. The medical literature shows that these tips rarely work.
The body fights weight loss, causing those who have lost weight to be hungrier and at the same time require fewer calories than their counterparts at the same weight, new studies have shown. That, not laziness, accounts for the fact that about 70 percent of dieters regain the weight they lose.
“What we’re doing is appropriate for prevention, but we’re not using it for prevention. Sustained obesity is in large part a biologically mediated disease, so if we give a treatment that is insufficient and it doesn’t work, we have to stop blaming the patients,” Ochner said.
The newer scientific findings will have to take hold among general practitioners before treatment for obesity and related diseases improves. Doctors still often see weight regain as an issue of willpower.
“Most people think it’s caused by the voluntary behavior of the person with the disease, if he or she could just control their behavior. … Anybody can lose weight in the short term, but short-term weight loss has no predictive value for long-term weight loss. The equivalent is you can hold your breath for a minute — almost anybody can — but you can’t hold it for longer,” Kaplan said.
After advising patients this way and seeing them fail to lose weight, many doctors grow frustrated and stop talking to patients about obesity and related metabolic conditions.
“I think they’re discouraged by the low response rate, and that’s understandable because as internists what we’re used to doing is prescribing blood pressure medication and seeing blood pressure go down. It’s much harder to deal with lifestyle changes,” said Tsai, the co-author of the Lancet paper who’s also a spokesperson for the professional group the Obesity Society.
So What Does Work?
There’s a growing consensus about how best to help patients lose weight and lower their risk of obesity-related diseases. Efforts are under way to make those approaches work in our current healthcare delivery system.
It takes intensive, long-term behavior modification programs to help people change the way they’ve learned to eat.
The YMCA’s program evolved out of a long-term research study to explore whether it was possible to halt the march toward diabetes in patients who were prediabetic. What researchers found was that behavior modification was twice as effective as medication, specifically metformin (Glumetza, Glucophage). The researchers also found that patients who reduced their body weight by just 7 to 10 percent cut their chance of developing diabetes by more than half.
What began as research has become the YMCA diabetes prevention program that Rodney Chin participated in. Participants meet once a week for 16 weeks and once a month for the remainder of the year to weigh in and learn about nutrition, exercise, and stress management from trained experts. Participants also talk to peers about how they can avoid poor lifestyle choices, even in an environment that makes overindulging the norm.
Chin lost 10 to 15 pounds and was able to stop taking the blood pressure medication he’d been taking on and off since he was 14 years old.
The YMCA offers the program in 173 cities, and the group aims to offer it in 300 cities by the end of 2017. It costs $450, but at least two major insurance companies have begun to cover it.
General practitioners can certainly get better at treating weight loss, but referring patients to community programs may offer some additional benefits.
“I think doctors should be assessing people for their weight, but offloading weight loss to groups who have the most time to address that. If you say, ‘That costs money,’ yes it does. I don’t have a perfect solution, but we’d get farther that way,” said David Marrero, Ph.D., president of health care and education at the American Diabetes Association.
The YMCA’s program has been met with more enthusiasm from participants than Medicare’s move in 2013 to cover nutritional counseling with primary care doctors. Few Medicare patients have taken advantage of that benefit, which dieticians have argued they are more qualified to provide. YMCA officials are now in the process of trying to persuade Medicare to cover their program, according to Heather Hodge, director of chronic disease prevention programs at YMCA USA.
Rather than setting goals based on BMI numbers or cosmetics, the program targets the 7 to 10 percent weight loss range with proven health benefits. Patients find this much more manageable.
Hodge thinks the group bonding that takes place in the program, which assigns no more than 15 people to a cohort, is its “secret sauce.”
Weight Watchers and Jenny Craig programs also offer some of the same benefits, and have been shown to help patients lose weight over the long term.
Offering the program in community locations, away from the doctors who may have alienated overweight and obese patients, may also draw people who might not otherwise show up.
“There are a lot of people who don’t go to doctors’ appointments because they don’t want to get on the scale and get that weight loss lecture,” said Linda Bacon, Ph.D., author of the 2007 book, “Health at Every Size: The Surprising Truth About Your Weight.”
Bacon wants to see people and their doctors focus on health rather than weight. She would like to see medical providers give people a clearer message about choosing foods that help them feel better, have healthy bowel movements, and not feel overstuffed. “Instead of telling them to eat fruits and veggies, you can help them make the connection between choosing foods that help them feel good, which is a very different message.”
Patients who have tried weight loss programs before often go into nutritional counseling feeling defeated, said Sonya Angelone, RDN, a spokesperson for the Academy of Nutrition and Dietetics.
“If you’re at 250 pounds and you can really focus on losing 25 — first you’ve changed their mindset, they’ll get those medical benefits, and then they have momentum,” Angelone said.
New Medical Models Can Speed Weight Loss
Medical institutions have also responded to evidence that intensive behavior modification programs work. They meet the need with multidisciplinary centers, where a primary care doctor is joined by dieticians, psychologists, personal trainers, and bariatric surgeons who all provide coordinated care.
These centers are like the comprehensive cancer centers of the obesity epidemic, Kaplan said. Kahan, Kaplan, and Tsai all work in such centers in Washington, D.C., Boston, and Denver, respectively.
Insurance companies reliably cover only appointments with primary care doctors and surgeons. Even so, a doctor who is trained and willing can schedule repeated visits to help guide a patient through healthy weight loss and can make progress, the specialists said.
Doctors who specialize in obesity medicine, which first became a board-certifiable specialty in 2012, are much more likely to prescribe drugs to help patients improve their metabolic health. In the past two and a half years, the Food and Drug Administration has approved four new weight loss drugs.
“Just like you wouldn’t jump to medication for high cholesterol, but, on the flip side, you wouldn’t take the meds off the table just because it sounds silly to do something with drugs that could be done with diet and exercise,” Kahan said.
Obesity specialists and professional groups like the Obesity Society are hoping that the Affordable Care Act’s (ACA) focus on preventative medicine and accountable care will bring more support to the multidisciplinary model. Under the ACA, preventative care is covered with no patient copay out of pocket.
The U.S. Preventive Services Task Force recently added intensive behavior modification programs as a recommended preventative measure for obesity, so they will be covered beginning next year. The task force is also considering adding blood sugar screenings for overweight and obese patients.
Accountable care means that payments for medical providers are tied to patient health outcomes, not to the amount of care they provide. In the current model, most doctors can’t bill for providing nutritional counseling to patients, and many dieticians receive very low rates of compensation for their work.
But under the new model, a medical practice might get paid the same amount if a patient’s metabolic lab tests improved after a behavior modification program or after bariatric surgery. The surgery would cost the practice much more, incentivizing doctors to try behavior modification first with providers trained to do it. (The details of accountable care are still being hashed out.)
Many were disappointed that the ACA didn’t specifically identify obesity as it did mental illness as an area of care in which the current system has failed patients.
In 2012, a group including the Academy of Nutrition and Dietetics and the Obesity Society sent a lobbying letter to then Secretary of Health and Human Services Kathleen Sebelius. The groups made their case in language that says a lot about why treatments for obesity have lagged so far behind the disease.
“Unfortunately, those affected by obesity find themselves where the mental health community stood 20 years ago. It took years, decades if you will, of tireless lobbying by the mental health community to educate not only policymakers but more importantly their peers in the medical community — some of which still scoff at those who struggle with mental illness or addiction as weak or defective,” the letter said.