Understanding the Obese Patient

MAY 26, 2015
Douglas Rothrock, MD
The obesity epidemic in the US is well documented and discussed both in and out of the health care industry. Obesity rates have climbed nearly 50 percent since 1997, with as much as 30 percent of the population classified as obese.1 Clinically, the American Medical Association defines a patient as obese if they have a BMI (body mass index) of 30 or higher. Obesity has been linked with almost every chronic disease in some way, and effective treatment of the disease can have life-changing positive effects for patients; reducing cardiovascular risk factors and comorbidities such as hypertension, diabetes, sleep apnea, and dyslipidemia.2
There is strong belief within the health care industry that obesity should be treated as a primary medical condition, with physicians playing a major role. Evidence suggests that patients are more likely to lose weight when they are advised by their primary care physicians to do so. 3 However, the numbers tell us that we are not yet having a significant impact on the long-term health of the general population. Let’s look at some of the reasons this might be, and what we can do to change the situation. 
Barriers to treatment
Unfortunately, obesity stigma is common within our society, and, worryingly, research shows that obese patients aren’t even free from stigmatization within the supposedly safe confines of their doctor’s office. A study in the Journal of General Internal Medicine found that higher patient BMI was associated with lower physician respect, while others have found that some physicians characterize obese patients as lazy and lacking in willpower and self-control.4
Physicians often cite frustration when dealing with obesity and weight loss, due to feeling their patients lack the discipline to lose weight, don’t have time to exercise, or deny having poor eating habits.4 Some don’t even believe that obesity treatment can be successful – a mere 22 percent of physicians in a recent study felt that maintaining weight loss in the long term is possible.5 The obesity epidemic is growing, after all.
It would seem, then, that a lack of empathy towards obese patients can be extremely damaging. Losing weight is difficult. I have personally struggled to lose weight. Weight loss is a journey that requires a trusting and collaborative relationship between patient and practitioner, and long-term commitment from both.
Thus, there is hesitancy among some physicians to pursue treatment for obese patients because busy schedules do not accommodate for the time necessary to devote to this commitment, for which they feel they are not adequately reimbursed.4 While the introduction of the Accountable Care Act (ACA) and pay-for-performance measures might help overcome this financial roadblock, there are a number of questions physicians can ask to help understand their obese patients, and ultimately help them lose weight.
Is your patient ready?
No relationship works if it is one-sided. Weight loss is an extremely personal and often life-changing journey, and one that the patient should be ready to embark upon. If you have a patient you think would benefit from losing weight, talk to them. One-third of patients who are obese report that they have not been told by their physician that they are overweight,6 let alone provided with any weight loss guidance.
If they are ready, you should be too -- physician counseling and management of obesity treatment is proven to be effective in helping obese patients undertake and sustain weight management programs.2 Read up on current weight management programs to help provide the best support. A study in Obesity Journal found that physicians with knowledge of weight loss strategies had less reluctance to discuss weight loss. Further, the study found that increasing knowledge on weight loss treatments may also diffuse negative attitudes in physicians.4
Is their weight loss goal achievable?
If your patient has expressed a desire to lose weight, together, determine realistic and achievable weight loss targets. Weight loss goals should be discussed in-depth with your patient at the beginning, as well as throughout the entire treatment process. When goals are not reached, or progress towards them is not satisfactory, patients often abandon their attempt to achieve the goals.7
How are they coping with the weight loss journey?
According to a study in the American Journal of Preventive Medicine, using motivational interviewing techniques throughout the weight loss journey helps patients to succeed.8 Physician counseling and management of obesity treatment is effective in helping obese patients undertake and sustain weight management programs,2 but most obese patients don’t receive weight loss counseling in their physician’s office.3
New practice models and programs to help obese patients
Under the ACA, patients who are clinically obese may enroll in Medicaid and become eligible for intensive behavioral counseling for obesity, for which primary care physicians will be reimbursed from the Centers for Medicare and Medicaid Services (CMS). This could have a huge impact as historically Medicare has set the standard for commercial insurers. Already, most insurance plans are now required to cover weight loss and maintenance efforts for obese patients.
The biggest opportunity to address the obesity epidemic may come with the shift in health care away from the fee-for service model and towards pay-for-performance. Under the pay-for-performance model, reimbursement is based on quality metrics, adherence to certain care processes, scores on patient satisfaction surveys and patient outcomes. This model will support and encourage physicians to incorporate structured weight loss and long-term weight management programs that have measurable, repeatable and sustainable results in reducing obesity and its associated chronic illnesses. Structured programs help motivate patients along the way, and seeing tangible results in measurements, lab results or decreased medications will help ease frustration with weight loss and help your patient remain committed to the journey.
Five years ago I introduced one such weight-management program to my cardiology practice. The program provides tools such as one-on-one nutrition counseling and education to support patients along their weight loss journey, and perhaps most importantly, motivates patients throughout with measurable results. I lost 100 pounds on the program personally, and almost 6,000 of my patients have lost more than 96 tons of weight so far.
With the help of these industry changes, if we remain empathetic towards obese patients and fulfil our commitment to supporting them along the weight loss journey, structured weight loss programs that help patients fulfil their side of the commitment can help us tackle the obesity epidemic in ways we haven’t been able to before.
About the author
Douglas Rothrock, M.D., is a Board Certified cardiologist practicing in Prescott, AZ, and is the Senior Medical Advisor for Ideal Protein®, a physician-developed weight loss method now offered in more than 3,000 practices in North America.
1. Weight-control information network. Overweight and obesity statistics. 2012. http://www.niddk.nih.gov/health-information/health-statistics/Pages/overweight-obesity-statistics.aspx
2. Rippe J, McInnis K, Meanson K. 2001. Physician Involvement in the Management of Obesity as a Primary Medical Condition. Obesity Research, 9 (S4), 302S-311S.
3. Plourde G, Prud’homme D. 2012. Managing Obesity in Adults in Primary Care. Canadian Medical Association Journal, 184 (9), 1039-1044.
4. Ferrante JM, et al. 2009. Family Physicians’ Practices and Attitudes Regarding Care of Extremely Obese Patients. Obesity Journal, 17 (9), 1710-1716.
5. Foster G, et al. 2003. Primary Care Physicians’ Attitudes about Obesity and Its Treatment. Obesity Research, 11 (10), 1168-1177.
6. Breitkopf C, et al. 2012. Who Is Counseled to Lose Weight? Survey Results and Anthropometric Data from 3149 Lower Socioeconomic Women. Journal of  Community Health, 37 (1), 202-207.  
7. Dalle Grave R, et al. 2005. Weight Loss Expectations in Obese Patients and Treatment Attrition: An Observational Multicenter Study. Obesity Research, 13 (11), 1961-1969.
8. Pollak, K., et al. 2010. Physician Communication Techniques and Weight Loss in Adults: Project CHAT. American Journal of Preventive Medicine, 39 (4), 321-328.

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