Certification Board for Obesity Educators

OBESITY EDUCATOR

Needs Assessment

The dramatic increase in obesity in the United States is well documented. In 2009, only Colorado and the District of Columbia had a prevalence of obesity less than 20%. Thirty-three states had a prevalence equal to or greater than 25%; nine of these states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia) had a prevalence of obesity equal to or greater than 30%.1

Obese patients are at an increased risk for developing many medical problems, including insulin resistance and type 2 diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, stroke, sleep apnea, gallbladder disease, hyperuricemia and gout, and osteoarthritis. Certain cancers are also associated with obesity, including colorectal and prostate cancer in men and endometrial, breast, and gallbladder cancer in women. Excess body weight is also associated with substantial increases in mortality from all causes, in particular, cardiovascular disease. More than 5% of the national health expenditure in the United States is directed at medical costs associated with obesity.2 The medical care costs of obesity in the United States are staggering. In 2008 dollars, these costs totaled about $147 billion.13

Basic treatment of overweight and obese patients requires a comprehensive approach involving diet and nutrition, regular physical activity, and behavioral change, with an emphasis on long-term weight management rather than short-term extreme weight reduction.1

In 1998, the NHLBI, in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases, released the first federal guidelines for the management of overweight and obese adults. In 2003, the United States Preventive Services Task Force published its recommendation (grade B) that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.3 Recently, on November 29, 2011, the Centers for Medicare and Medicaid Services, after reviewing various preventive services given a grade A or B recommendation by the USPSTF, decided to reimburse for intensive behavioral therapy for obesity when carried out in the primary care setting.4

Considering the public health implications of obesity, the numbers of individuals affected, and its multi-factorial complexity, it is essential that all qualified health professionals regard obesity as a complex disease and increase their knowledge of obesity and related co-morbidities. Furthermore, it is essential that primary care professionals lead and coordinate treatment in the context of a system that is improvable. Presently, there exists no such system.

Clinical Gaps

Weight loss programs are ubiquitous; weight control programs are not. One reason for this is economic. Since any diet that produces a caloric deficit will result in weight loss, a diet product or service is easy to produce and deliver. And since demand is strong, especially in America, it is also easy to sell. Consequently, commercial diets proliferate and profits are good even in a recession. Physicians have fallen into the trap; advising their patients to lose weight, they point them toward a commercial diet. This unintended cooperation with the commercial diet industry reinforces the diet as a reasonable solution, obscuring, even interfering with the true goal: weight control.

This gap between weight loss (a commercial opportunity) and weigh control (a clinical goal) is a catastrophic abyss that can be bridged only by a nationwide clinical solution that enables a system based on standards of care and an evolving body of knowledge, coordination of care, relevant metrics, and enhanced research that translates into increasingly effective treatment.

Gap One

Healthcare professionals in a variety of disciplines (e.g. physician, nurse, dietitian, etc.) treat overweight and obese patients, yet they do not follow a generally accepted set of scientific or clinical principles.

Indeed, there exist no such resource, no recognized custodian of research in the field of obesity, no custodian of best practices to which we may turn. This gap is egregeous as it stands in the way of continuous improvement and slows the translation of science into clinical practice. Because clinicians have no place to turn for authoritative guidance, many clinicians have low expectations concerning the availability of effective treatment for obesity and elect to focus in areas of medicine where treatment methods and resources are well documented.

Gap Two

Primary care providers cannot manage the treatment of overweight or obese patients effectively without a team of professionals trained to address the complexities of this evolving disease. Such coordination requires new professional skills and clinical processes. Traditional hand-offs must be improved and new handoffs enabled to provide care that cannot presently be delivered effectively by the physician or which must extend beyond office hours or the four walls of the clinic.

To progress toward effective, lasting behavior change, physicians need to be empowered by effective clinical and operational processes, and all health team professionals must acquire new skills to treat the overweight or obese patient effectively. The obese patient requires persistent follow-up between office visits, and may require treatment of co-morbidities by specialists. To function as an effective team, the PCP and all health professionals involved in treatment of the overweight or obese patient should share a common understanding of the science and the rationale for, and approach to, treatment. A team member may be a physician or a physical therapist, psychologist, exercise scientist or even a cardiologist or bariatric surgeon. Or, the team member may be a professional on the PCP’s staff trained to serve as the patient’s coach, ensuring the persistent follow-up necessary to advance lasting behavior change.

Gap Three

Translation of research into effective clinical treatment is impeded by a lack of clinical activity. Organizations like The Obesity Society sponsor significant and important research. But this research is used primarily by bariatric specialists and other researchers because the channel for clinical application is disturbingly narrow.

Growth in the number of primary care clinicians that coordinate and deliver obesity treatment, according to an improving standard of care, will accelerate the identification of both effective and ineffective treatment tools, protocols and therapies. It will increase the appetite for positive patient outcomes, exciting researchers to engage clinicians in the process of discovery and increasing the product of obesity research in terms of patient health outcomes.

Clinical Barriers

With 66 percent of Americans overweight or obese, primary care physicians are overwhelmed at the prospect that they may be the de facto quarterback with primary responsibility to treat obesity as a disease.10 With a projected shortfall of 40,000 primary care physicians by 2025, unless other health professionals participate as team members in the battle against obesity, no path to victory is in view. Complicating matters, while obesity manifests physically, treatment is largely behavioral. PCPs' assessment and behavioral management of overweight and obesity in adults is low relative to the magnitude of the problem in the US.15 Physicians by and large lack the skill or training necessary to feel confident providing behavioral care to obese patients. In reality, the best they can hope to do is lead and coordinate a team of health professionals that include psychologists, dietitians, nurse practitioners, registered nurses, exercise scientists and more. But, each of these professionals view obesity from vastly different perspectives and often based on anectodal information rather than current evidence-based science.

Key barriers to treatment of overweight or obese patients involve not only basic knowledge of the principles of obesity, but also behavior change which demands skill to motivate and encourage new behaviors, and systems to monitor patient progress between office visits or during temporary professional handoffs. Such barriers include:

Lack of understanding of obesity as an independent medical condition. Some physicians believe weight loss to be futile and dieting cycles dangerous for obese patients without co-morbidities.11 Patients with co-morbid conditions linked to obesity tend to receive counseling more often than their equal weight counterparts, indicating that primary care physicians do not manage obesity as an independent medical condition. Even for patients with documented obesity, physicians only discuss weight 65 percent of the time, recommend exercise 62 percent of the time, and refer patients for nutritional counseling 25 percent of the time.5 These low levels of counseling and referral indicate that there are barriers preventing physicians and patients from successfully initiating discussions about weight.

• Lack of a clear pathway to reimbursement. Reimbursement is available, but while some physicians have been reimbursed for weight counselling services, the vast majority lack confidence in reimbursement.8 Unless physicians understand the pathway to reimbursement, for obesity treatment, there will be little or no progress toward PCP engagement. This understanding of reimbursement pathways must extend from the PCP to other health professionals on the team as well. If a physician refers an obese patient for physical therapy, for example, in order to help advance recovery from obesity, it must be done in a way and at such time as may facilitate reimbursement to the PT, or the patient may not continue.

• Lack of confidence in available treatment methods. Physicians cite lack of effective treatment methods, and the belief that patients will not succeed, as well as opinions about the origin and responsibility for obesity as factors influencing their decision not to begin a discussion with the patient.7, 9 This problem is fundamental. If the healthcare provider, whether PCP or other team-member, does not respect the patient or does not feel competent to treat obesity, confidence will not be communicated. Without confidence, motivation and encouragement cannot be conveyed to the patient.

• Insufficient supply of primary care physicians. A spike in demand for primary care services, stemming from an aging baby boomer population, as well as from changes outlined in health reform legislation is expected to exacerbate the PCP shortage. Also, integration and care coordination are intended to link physicians to a variety of health care providers, including nurses, dietitians, physical therapists, specialists, and sometimes community resources. Additionally, many obese patients have co-morbid conditions requiring treatment by primary care physicians or specialists. The complexity of the issue and the treatment make coordination of care and integration across providers essential.14

• Insufficient training in behavioral care and lack of behavioral counseling experience. Physicians tend to give low ratings to their ability to treat obesity because they lack confidence in their weight counseling skills. As much as 44 percent of physicians in one study did not feel qualified to treat obesity.10

All of these factors contribute to “clinical inertia,” a situation in which physicians do not counsel for weight because they feel there is nothing they can do to address the problem or that available treatments are ineffective.12, 14

The introduction of a professional obesity educator, certified to an ever-improving standard of care is long overdue.  

Notes
1 http://www.cdc.gov/obesity/data/trends.html
2 Khaodhiar L, McCowen KC, Blackburn GL, 1999
3 http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm
4 Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N)
5 Waring, M.E., Robert, M.B., Parker, D.R., Eaton, C.B. Documentation and management of overweight and obesity in primary care. JABFM. 2009;22(5):544-552. Available at: http://www.jabfm.org/cgi/content/abstract/22/5/544
6 Kreuter, M.W., Chheda, S.G., Bull, F.C. How does physician advice influence patient behavior? Evidence for a priming effect. Arch Fam Med. 2000;9(5):426-433.
7 Sussman, A.L., Williams, R.L., Leverence, R., Gloyd, P.W., Crabtree, B.F. The art and complexity of primary care clinicians’ preventive counseling decisions: obesity as a case study. Ann Fam Med. 2006;4(4):327-333.
8 Foster, G.D., Wadden, T.A., Makris, A.P., et al. Primary care physicians' attitudes about obesity and its treatment.
Obes Res. 2003;11:1168-1177.
9 Rippe, J.M., McInnis, K.J., Melanson, K.J. Physician involvement in the management of obesity as a primary medical condition. Obesity, 2001;9:s302-s311. Available at:
http://www.nature.com/oby/journal/v9/n11s/full/oby2001135a.html
10 Jay, M., Kalet, A., Ark., T., McMacken, M., Messito, M.J., Richter, R. Physicians’ attitudes about obesity and their associations with competency and specialty: A cross-sectional study. BMC Health Services Research. 2009;9(106).
Available at: http://www.biomedcentral.com/1472-6963/9/106
11 Kassirer, J.P., Angell, M. Losing weight – an ill-fated New Year’s resolution. N Engl J Med. 1998;338:52-54.
Available at: http://content.nejm.org/cgi/content/full/338/1/52
12 Phillips, L.S., Branch, W.T., Cook, C.B., Doyle, J.P., El-Kebbi, I.M., Barnes C.S. Clinical inertia. Ann Intern Med.
2001;135(9):825-834. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11694107
13 Finkelstein, 2009
14 Improving Obesity Management in Adult Primary Care, STOP Obesity Alliance, 2010
15 Ashley Wilder Smith, et al., U.S. Primary Care Physicians' Diet, Physical Activity, and Weight-Related Care of Adult Patients, 2011