Want to know what works for treating overweight and obesity?
This past week, the National Academies of Sciences, Engineering, and Medicine's (NASEM’s) Health and Medicine Division (HMD, formerly Institute of Medicine) hosted two events in which I participated: (1) a full-afternoon discussion on obesity prevention and management, (2) a full-day workshop on treating overweight and obesity.
The afternoon discussion occurred through the Innovation Collaborative known by the awkward abbreviation, ICSSPMO (Integrated Clinical and Social Systems for the Prevention and Management of Obesity). As with all HMD collaboratives, ICSSPMO is comprised of national experts representing diverse stakeholder groups. I’m not at liberty to share the specifics from ICSSPMO meeting at this time, but rest assured big ideas were discussed that will be ready for wider dissemination soon. I have no doubt that the models and initiatives under development will translate to better care for obese patients and improved health more broadly for communities.
What I am at liberty to share from the HMD last week is the content of the full-day workshop: The Challenge of Treating Obesity and Overweight - Learning What Works and Making it Happen. The workshop was hosted by the Roundtable on Obesity Solutions of HMD’s Food and Nutrition Board. It focused on treating obesity (including severe obesity) in adults and children, as well as where things stand and how to move forward in terms of obesity providers, payment, and policy.
Below are some high-level highlights from the day. Full details will be available soon on the HMD website in a full slide deck of presentations and complete video.
“If behavioral treatment were a drug, it would be approvable,” was one emphasized lesson from the HMD workshop. Unfortunately, the type of behavioral treatment offered most often in primary care offices is not effective. This “treatment” can take the form of little more than simple advice to “eat less and move more,” which is not at all helpful ... and in fact creates and blames victims.
Effective behavioral treatment entails not just advising patients what to change but how to change. It includes guidance on stimulus control, goal setting, problem solving, stress reduction, self-monitoring, and relapse prevention.
Intensity of treatment matters too; the more treatment contact (the less patients have to struggle on their own), the better. Intensive lifestyle interventions (e.g., around diet, exercise, sleep, stress reduction, etc.) produce meaningful weight loss and other health benefits.
But even with well-designed, high-intensity lifestyle interventions for behavior modification, there are currently disparities in outcomes. Patient age matters as “children are not just little adults” and their growth and maturity play roles in success. Race/ethnicity plays a role too as there are racial ethnic disparities in intervention effectiveness (although, reassuringly, disparities tend to diminish over time).
When behavior modification isn’t enough, there are weight-loss medications to consider—nine of them, in fact (five for long-term use). At least that is the case for adults. In children, only two meds are approved for use (or three if you consider kids who are 16 years and older).
Weight reduction early on with medication predicts later success. But effectiveness for the different drugs varies and some side effects can be unpleasant (for adults or children)—e.g., flatulence, stomach pain, and greasy anal leakage. Emerging medications may be more personalized, less problematic, and target novel pathways including gene mutations.
Failing behavior modification and medication alone, surgery may be an option. Of the three most common procedures, gastric bypass (Roux-en-Y) seems to be more effective than gastric sleeve (sleeve gastrectomy), and both procedures are more effective than gastric banding (a.k.a. “lap band”). For all surgeries, the safety has improved dramatically over the years and the complication rates have gone down—for adults and kids.
For kids though, decisional capacity and physiologic maturity are issues. Nonetheless, high-quality evidence supports weight-loss surgery in a pediatric population. In fact (as in adults) bariatric procedures or often termed “metabolic surgery” because a variety of factors like blood sugar, blood pressure, and cholesterol improve after surgery, largely independent of weight loss.
There are also several less-invasive procedures that are now approved, like gastric balloons, nerve stimulators, and tubes that suck stomach contents into external containers. At the present time, it is not fully clear what the role is for these emerging (and not always pleasant) options.
For the severely obese, combinations are needed—combinations of therapies (with medications added after bariatric surgery to a backbone of behavioral management, for instance) but also combinations in treatment-team members (which might include surgeons, gastroenterologists, obesity medicine physicians, dietitians, psychologists, and various support staff).
In spite of solid and growing evidence for behavioral interventions, medications, and surgery, there are still unanswered questions. For example, can we deliver effective behavioral therapies through modes of contact that are not in-person (e.g., telephone, text, remote sensors and various “apps”)? What is the long-term efficacy of medications? How do drugs and surgery work in disparities populations? What are the predictors of response to any treatment (demographic, genetic, etc.)?
Several presenters emphasized a need for greater infrastructure, training a provider workforce with specialized knowledge of obesity. Obesity Medicine is the fastest growing specialty field in medicine, and there needs to be additional fellowship opportunities. Also, all physicians need greater training in obesity, and testing for minimal competencies (of note: the current U.S. Medical Licensing Exam lacks any meaningful coverage of obesity).
Physicians need to understand obesity as a complex chronic disease (like hypertension or diabetes), not a moral failing. And allied health personnel, like nurse practitioners, physicians associates, and social workers, would also benefit from training (and certification).
All providers should be knowledgeable about disparities and inequalities, and all should use patient-centered, non-judgmental, patient-first language (e.g., “the patient who has obesity” [affliction] not “the obese patient” [stigmatizing identity]). Those providing primary care need not provide all interventions but should know what is out there and be able to link to obesity medicine specialists.
There were anecdotes of elected officials misunderstanding obesity as a problem of deficient will power, and one made worse by government handouts like Food Stamps (not my words, but very nearly a direct quote of one Senator). Policy makers need to understand that obesity is much more complex than mere calorie considerations. In fact, focusing on calories might mislead and harm public health.
For policy, there is urgency, related in no small part to growth in childhood obesity. Elected officials need to recognize that children develop the same weight-related problems as adults (e.g., diabetes, hypertension, high cholesterol) but carry them longer and have additional unique issues to bear (like orthopedic problems from extra weight burden on immature skeletons). Childhood body weight predicts preventable disease and premature death in adulthood. And beyond health implications, the cost considerations of increasing obesity and obesity-related chronic diseases (for individuals and our society) are staggering.
Given the substantial costs, it is not hard to make a case that treating obesity would be a good return on investment. Payers, of course, have to consider various factors in covering services, but when the same payer bears the cost of the intervention (e.g., medication) and the cost of not treating (e.g., worsening diabetes, hypertension, high cholesterol, arthritis, depression, respiratory illness, etc.), it is hard to understand pervasive coverage denials and ubiquitous prior-authorizations. Still, that is the current experience in practice. Emerging policies, like the Treat and Reduce Obesity Act for Medicare, might help move insurers across the board to better coverage for a variety of obesity treatments.
In the interim, we know a lot about what works (what really works) for the treatment overweight and obesity. As a society, we just need to do a better job of making it happen.