New obesity guidelines help physicians and patients with weight loss treatments

Few health problems pose a greater threat to patients than obesity and its related ailments. Primary care physicians are on the front lines of the battle against obesity. That’s why, experts say, it’s critical for doctors to find ways of instituting health and behavioral modification programs into their practices to help patients make meaningful lifestyle changes.

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In 2010, more than 78 million U.S. adults and roughly 12.5 million children and adolescents were obese, according to the Centers for Disease Control and Prevention. And the rate is rising.

According to a recent analysis by Gallup Healthways, the adult obesity rate in 2013 was 27.2%, up from 26.2% in 2012, and it is on pace to surpass all annual average obesity rates since Gallup-Healthways began tracking it in 2008.

As our waistlines expand, so too do the number of medical problems caused by excess body weight. A 2012 report by the Robert Wood Johnson Foundation, “F as in Fat, How Obesity Threatens America’s Future,” found that if obesity rates continue on their current trajectories, the number of new cases of type 2 diabetes, coronary heart disease and stroke, hypertension, and arthritis could increase 10-fold between 2010 and 2020-and double again by 2030. All this comes with a current annual price tag of $190 billion.

 “As evidence unfolds, everyone is beginning to appreciate that obesity and excess body weight are driving medical conditions and costs. You cannot get medical costs under control as long as we have these rising rates of obesity,” says Donna Ryan, MD, professor emeritus at Pennington Biomedical Research Center at Louisiana State University Health System, and previous past president of The Obesity Society.

New obesity guidelines

New obesity treatment guidelines will give doctors a helping hand.The American Heart Association, American College of Cardiology and Obesity Society recently developed a set of guidelines to help healthcare providers tailor weight loss treatments to adult patients affected by overweight or obesity. The guidelines are the result of a systematic review of the latest scientific evidence from 133 research studies on the risks of obesity and the benefits of weight loss. The goal of the guidelines was to provide recommendations as to who needs to lose weight and  give physicians the weight loss techniques that have been proven to work to help patients lose weight, Ryan says.

The guidelines recommend screening for body mass index at each annual visit, or more often if appropriate, and using the screening results to engage patients in a discussion about their weight and its impact on their overall health.

Many doctors find that having the conversation with patients about their need to drop pounds can be difficult. But with the right approach most people are willing to listen, says Adam Tsai, MD, MSCE, a practicing physician with Kaiser Permanente Colorado and chair of The Obesity Society’s public affairs committee.

“One thing doctors can do is mention the topic in a way that doesn’t offend the patient. That’s a really important thing. Some patients don’t want to talk about it but most are interested in advice from their physician,” Tsai says.

Ryan agrees that talking with patients about their weight can be touchy. “The conversation is still not an easy one. If patients aren’t ready to hear what you have to say they’re going to turn you off.”

She suggests a three-step approach:

• Ask: Can I talk to you about your weight and what you do you think about losing weight?

• Advise: Let patients know they don’t need to lose 100 pounds to feel better. Even a modest drop in body weight will help.

• Refer: Have a list of commercial or hospital-based programs you can send patients to.

One of the most effective messages physicians can convey, obesity experts say, is the second item on Ryan’s list-that they don’t need to lose a significant amount of weight to make a substantial difference in their health. In fact, a sustained loss of just 3% to 5% of one’s body weight can “produce clinically meaningful health benefits,” reducing the risk of type 2 diabetes and limiting the need for medications to control high blood pressure and diabetes, the guidelines state.

Making lifestyle changes

The new obesity guidelines also recommend that doctors work with patients to develop a weight loss plan. According to Tsai, a good weight loss program has three components:

• specific recommendations for limiting calorie intake,

• a plan to increase physical activity, and

• a behavior modification plan that helps patients change their behavior around eating and exercise

His recommendations are in line with the new obesity guidelines, and with a study just published in the journal Obesity. It found that diet and exercise alone enabled half of participants with type 2 diabetes to maintain a 5% loss of body weight over an eight-year period through intensive lifestyle intervention for weight management that included diet and exercise. Called the Look AHEAD trial, it is the largest and longest randomized controlled trial of behavioral intervention for weight loss.

There’s no shortage of diets to choose from, yet no one diet program is better than another when it comes to losing weight, Ryan says. “We looked at 17 different diets and in terms of weight loss, didn’t see superiority among any of them,” she says.

Finding the right diet

Ultimately, a successful diet has to be consistent with the patient’s preferences. There is no magic formula, experts say.  “We usually say the best diet is the diet you can stick to,” Tsai says. Still, for people looking both to lose weight and manage particular health conditions, some diets may be better than others. In fact, U.S. News & World Report recently named the DASH diet as the best overall diet, and the top choice for people with high blood pressure, an assessment both Tsai and Ryan agree with.

For heart health, the Ornish diet took the top spot. The Mediterranean diet was named the best plant-based diet. And Weight Watchers was named the best commercial diet plan. “Of all the organized pay-for programs out there I think Weight Watchers has been the most effective for my patients,” says Rebecca Jaffe, MD, MPH, FAAFP, a director of the American Academy of Family Physicians. Medications can also play a role in helping patients lose weight. “When we put people on meds they may need it long-term to avoid weight gain,” Tsai says.

The U.S. Food and Drug Administration has approved two drugs for long-term treatment of overweight and obesity. They are phentermine and topiramate extended-release (brand name Qsymia), and lorcaserin HCI, marketed under the brand name Belviq. Some insurers have not covered these medications in the past,  but recently  Aetna, CVS Caremark, and a few other payers have placed included one or both among their formularies. Eisai, one of the manufacturers of Belviq, reports that 50% of insured commercial lives can now have access to its drug.

Making lasting change, as the Look AHEAD trial demonstrated, depends on patients engaging in a comprehensive lifestyle program that helps them both drop weight and maintain that weight loss. The guidelines recommend in-person meetings-two to three per month for at least six months-as the most effective method of helping patients achieve their weight-loss goals. “That can be done by going to Weight Watchers. You don’t have to be in a dietician-based program, though research shows dietician programs are more successful,” Tsai says.

In fact, the new obesity guidelines recommend patients work with trained healthcare professionals, such as a registered dietitian, behavioral psychologist or other trained weight loss counselor.

Shifting practice and payment to better manage obesity

Effective treatment of  obese patients means addressing a wide array of clinical, cultural, and psychological issues as well as lifestyle modifications such as  diet and exercise. Adding to the challenges associated with treating obesity is the environment in which most independent physicians practice today. A 15-minute office visit hardly leaves enough time for the range of medical issues with which patients present, and few physicians have the training to address the full spectrum of patient needs.

Although it has no obesity-specific program, the National Commission on Quality Assurance (NCQA) offers guidelines for physicians practicing in the Patient-Centered Medical Home model that support the care the obesity guidelines indicate are required for patients who are overweight or obese. NCQA’s PCMH standards include six areas of evaluation on the extent to which practices:

• enhance access and continuity by accommodating patients’ needs during and after hours, provide medical home information, and offer team-based care;

• identify and manage patient populations by collecting and using data for population management;

• plan and manage care with the use of evidence-based guidelines for preventive, acute, and chronic care management;

• provide self-care support and community resources by giving patients and families information, tools, and resources;

• track and coordinate care, such as tests, referrals, and care transitions; and

• use data to measure and improve performance for continuous improvement

“The program is structured to focus on a few conditions so that the practice can give us concrete examples of how they manage care for patients. The majority of practices report obesity and a large number of pediatric obesity cases,” says Mina Hawkins, assistant vice president of NCQA’s physician recognition programs.

These standards help guide physicians in developing or enhancing a medical practice infrastructure that can help patients with chronic disease, including those who are obese. In many respects, they also complement the new obesity treatment guidelines.

For example, prioritizing the identification of patient populations, including those in need of weight counseling, is a goal of both the obesity guidelines and NCQA’s PCMH standards, and one that can be achieved in part with the effective use of electronic health records.

“We expect practices to show they are using the data they are collecting on patients,” Hawkins says.

Providing tools for lifestyle modification is also something NCQA evaluates in its reviews. Hawkins says the organization looks to see that doctors are providing patients with the tools they need, for example, to log how frequently they exercise and their daily calorie intake. Are physicians providing referrals to community resources and counseling to help them adopt healthy behaviors? All of this should be on-going and well documented in patients’ medical records.

With new guidelines in place to create more of a road map based on solid scientific evidence, the hope is that doctors will be better able to provide their patients with the help they need to make lasting change in their weight and their health.

Ryan says it’s ultimately about adjusting how we think about obesity. “The thing to understand is obesity is a lot like hypertension, it’s a chronic condition and patients will need ongoing help.”