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Overweight and Obesity Management Strategies
Scott Kahan, MD, MPH
Impact of Obesity Interventions on Managed Care
Impact of Obesity Interventions on Managed Care

Overweight and Obesity Management Strategies

Scott Kahan, MD, MPH
Abstract

Comprehensive lifestyle interventions, including nutrition, physical activity, and behavioral therapy, are the foundation for clinical obesity management. New tools and treatment approaches help clinicians provide these interventions and support weight management in the primary care setting. Escalating treatment, such as using pharmacotherapy, medi-cal devices, or bariatric surgery, are important considerations for appropriate patients who do not respond to lifestyle counseling. This article provides a review of obesity treatment in primary care and managed care settings. Principles of lifestyle chang-es for weight management, behavioral counseling, and options for pharmacotherapy, medical devices, and bariatric surgery are discussed.
Am J Manag Care. 2016;22:S186-S196
Obesity is a chronic medical condition that requires a comprehensive approach for successful management. Although all affected patients should receive counsel-ing on nutrition, physical activity, and behavioral changes, those who do not respond to lifestyle interventions may benefit from pharmacotherapy, medical devices, or bariatric surgery. There are many new options for manag-ing obesity that managed care clinicians should consider, including tools, resources, and published guidance to support behavioral counseling and obesity treatment in primary care. This article reviews the standards of care and recommendations for the management of obesity.

In 2013, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Obesity Society (TOS) published a joint guideline that pro-vided evidence-based recommendations for comprehensive lifestyle interventions and a model for managing obesity in primary care.1 In 2015, additional guidelines focusing on obesity pharmacotherapy were published by the Endocrine Society.2 A 2013 treatment algo-rithm created by the American Association of Clinical Endocrinologists (AACE) and a 2016 position state-ment from the American Diabetes Association (ADA) provided recommendations for managing obesity in patients with or at risk for type 2 diabetes (T2D).3,4 Since 2012, the FDA has approved 4 new medications for chronic management of obesity – the first medica-tions approved for obesity in nearly 13 years: lorcaserin (Belviq), phentermine-topiramate extended release (ER) (Qsymia), naltrexone-bupropion sustained release (SR) (Contrave), and liraglutide 3.0 mg (Saxenda).5-9 In 2015, 3 minimally invasive devices for the treatment of obesity were approved, including 2 intragastric balloons (Orbera, ReShape) and an implanted vagal nerve stimulator (Maestro Rechargeable System).10-12 Bariatric surgery pat-terns have recently changed, with the use of vertical sleeve gastrectomy (VSG) increasing substantially and laparoscopic adjustable gastric band sharply declining.13

Comprehensive Lifestyle Interventions

Effective communication about obesity between healthcare professionals and patients is an important step toward improved care.14 A diagnosis of obesity is a strong predictor of receiving counseling and an obesity treatment plan.14,15 Data from the 2005 to 2008 National Health and Nutritional Examination Survey found that when patients were informed of their overweight or obesity status, they were significantly more likely to desire to lose weight, attempt to lose weight, and lose at least 5% of their body weight, compared with patients who were not informed of their excess weight status.16,17 Moreover, a systematic review suggests that primary care provider (PCP) involvement in obesity counseling has a positive impact on weight-management behaviors and goals.18 Since 2003, the US Preventive Services Task Force (USPSTF) has recommended that PCPs screen for obesity by measuring body mass index (BMI); however, just a minority of patients are appropriately screened for obe-sity, diagnosed with obesity, and documented with this diagnosis in their health records.19-21 In the 2005 National Ambulatory Medical Care survey, only 29% of patients with obesity received a diagnosis and 18% received weight-reduction counseling.9 Even patients with severe obesity frequently fail to receive weight-management counseling and support.22,23

Obesity can be a sensitive topic, and clinicians may feel unqualified or uncomfortable to initiate discussions. Further, few pharmacists or physicians have formal training in obesity treatment and counseling. A Strategies to Overcome and Prevent (STOP) Obesity Alliance and Harris Interactive survey found that among 290 PCPs, nearly 80% did not have training in obesity,24 and a review of obesity coverage in the US Medical Licensing Examinations (USMLE) showed few questions pertaining to obesity management or treatment.25

Initiating productive conversations about obesity that do not shame or embarrass patients improves the doctor-patient relationship and supports patient weight-manage-ment goals.26,27 One simple strategy to promote positive discussions is to avoid stigmatizing words such as “obese” because these may trigger negative emotional reactions. People-first language, such as referring to a “patient with obesity,” rather than condition-first language (an “obese patient”), is preferred.28,29

The American Medical Association Manual of Style states to avoid labeling (and thus equating) people with their disabilities or diseases.30 The STOP Obesity Alliance has created a practical tool called “Why Weight? A guideline to discussing obesity & health with your patients” (www.whyweightguide.org) that helps clinicians start productive conversations about weight management. Another important aspect of pro-viding care for affected patients is ensuring that office equipment can accommodate patients with excess weight and that the office environment is supportive for productive doctor-patient interactions.28

Barriers to obesity management, such as lack of tools, training, and time, as well as inadequate reimbursement, are being addressed. Medicare began reimbursing for obesity counseling in primary care in 2011—although reimbursement is limited to services provided by PCPs, not specialists or allied health professionals. Clinicians can be reimbursed for a maximum of 22 visits (15 minutes each) over one year, with reimbursement in the second 6 months contingent on patients achieving at least a 3-kg weight loss.29 Educational resources to help PCPs acquire obesity counseling and management skills have expanded, as well. A team-based approach with contributions from dieticians, nurse specialists, and obesity specialists, as well as commercial programs, such as Weight Watchers, can extend the reach of a PCP and relieve time pressures on busy clinicians.31 In addition, productive discussions about obesity do not need to be lengthy to be effective.28

Since 2003, the USPSTF has recommended that cli-nicians offer comprehensive lifestyle interventions to patients with a BMI of 30 kg/m2 or higher.19,20 The ACC/AHA/TOS guidelines recommend programs led by trained interventionists that provide at least 14 sessions over 6 months.32 The ADA recommends at least 16 sessions over 6 months for patients with excess weight and T2D.3 Additional participation in a comprehensive weight-loss maintenance program or ongoing counseling is recommended in order to minimize weight regain.3,32 Despite these recommendations and consistent data sup-porting the benefit of counseling, some studies suggest that weight-related counseling may be declining.33 Providers should increase the frequency and intensity of counseling for patients with obesity and those at risk for obesity.

Components of behavioral therapy include goal setting, self-monitoring, addressing barriers, problem-solving, positive reinforcement, and ongoing support.20 Motivational interviewing can improve behavioral counseling in patients who are ambivalent about behavior change and has been shown to improve weight-loss outcomes.34-36 This technique is a collaborative, patient-centered process that focuses on assisting and guiding patients to build internal motivation and supporting personalized problem-solving to achieve behavior change.28

The 5 As strategy, initially developed for smoking cessation counseling, has been adapted by several groups for behavioral therapy of obesity.37-39 The Society of Behavioral Medicine has developed a multidisciplinary 5As model in which the healthcare professional provides brief counseling and arranges additional care for patients with psychosocial issues or comorbid conditions.29 The components are:

Assess: Measurement of BMI, identification of comor-bid conditions known to interfere with weight loss (depression, sleep disorders, chronic pain, stress, binge eating), and discussion about readiness for change.

Advise: Counseling about the benefits of weight loss and behavioral changes.

Agree: Establish weight-loss goals that are specif-ic, measurable, attainable, relevant, and time-based (SMART). Establishing attainable weight-loss goals is important because patients often expect to lose far more weight than is reasonable.40 Self-monitoring of weight, nutrition, and/or physical activity is a key part of maintaining positive behavioral changes.

Assist: A problem-solving process in which barriers to achieving weight loss are identified and resolved. Identifying the underlying causes of, and contributors to, weight problems in individual patients can help them achieve weight loss.

Arrange: Based on assessment of the patient’s prog-ress, patients may be referred to more intensive or specialized treatment. Referral options include dieti-tians, hospital-based programs, behavioral medicine providers, and evidenced-based commercial weight-loss programs.29

The primary target for behavior change is to create an energy deficit by addressing caloric intake and energy expenditure.1 A caloric reduction of 500 to 750 calories per day can achieve weight loss of approximately 1 to 1.5 lb/week in the short term, with the rate of weight loss decreasing asymptotically over time.41 This typically translates to a rule-of-thumb caloric intake goal of 1200 to 1500 calories/day for women and 1500 to 1800 calories/day for men.1,3 Clinically meaningful weight loss can occur across a broad range of macronutrient compositions.19-21 For example, in one study that exam-

ined 4 diets that varied in content of fat (20%-40%), pro-tein (15%-25%), and carbohydrates (35%-65%), there was similar weight loss and no difference in hunger or satiety ratings among the interventions over 2 years. Thus, a key factor of diet choice is patient preference.1 However, there is a wide inter-individual variation in weight loss between groups, and there is mounting evidence that certain physiologic factors affect responsiveness to different dietary patterns. For example, patients with insulin resis-tance tend to respond better to either lower carbohydrate or lower glycemic index dietary patterns compared with patients with normal insulin sensitivity.42-44

To address energy expenditure, aerobic physical activi-ty on par with at least 30 minutes of brisk walking on most days of the week (≥150 minutes/week) is recommended to help achieve an energy deficit. Higher levels of activity, 200 to 300 minutes/week, are recommended over the long term in order to prevent weight regain.1 Strength and resistance training stimulate muscle production, which improves metabolism. Finding exercises that fit individual limitations, abilities, and preferences and/or supervision by an experienced fitness instructor with a prescribed exercise program can help improve adherence.22

Commercial weight-loss programs that have evidence to support their efficacy and safety are an option to pro-vide a comprehensive lifestyle program.1,3 However, the amount of weight loss that patients can expect to achieve with these programs is likely less than they expect.45 A recent meta-analysis of 13 randomized controlled trials (RCTs) found that, among the most popular programs, weight loss at one year compared with controls ranged from 2.6% for Weight Watchers to 4.9% for Jenny Craig. Few commercial programs had long-term data available.46

 
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