Building a Scalable Obesity Care Team: Amanda Velazquez, MD

Scaling obesity care beyond a single specialist practice requires a fully staffed, multidisciplinary team that spans physicians, advanced practice providers, dietitians, behavioral health, and surgical partners and is built around standardized protocols to keep patients from falling through the cracks as they move between care teams, said Amanda Velazquez, MD, director of obesity medicine at the Center for Weight Management and Metabolic Health at Cedars-Sinai Medical Center.

In part 1 of this interview with The American Journal of Managed Care^® (AJMC^®), Velazquez discusses the operational building blocks of a health system obesity program, how multidisciplinary teams coordinate care and communicate across specialties, where referral flows tend to break down and leave patients without a clear point of triage, the monitoring protocols needed to track patients at scale, and the evidence gaps that make it hard for health systems to build a business case for investing in obesity care infrastructure.

This interview has been edited for clarity and length.

AJMC: Standing up an obesity program at the health system level looks different from a single specialist practice. What operational building blocks have to be in place before care can scale to the volume of patients who will need it?

Velazquez: When it comes to building a system operationally for a comprehensive program for obesity care, the key is having a multidisciplinary team that is multipronged. That means having a diverse set of clinicians who can provide wraparound care for a patient—physicians and APPs [advanced practice providers], as well as the lifestyle support: dietitians, social workers, occupational therapists, physical therapists, clinical pharmacists, and psychologists; the list goes on.

In addition, obesity care is not just pharmacologic; it's also in the form of procedures and surgeries, in addition to that foundational aspect of lifestyle. You want to make sure that there's a team you can be working with in GI [gastrointestinal] or general surgery, who provides procedural support with endobariatric procedures for weight management. In addition, metabolic and bariatric surgery is one of the most durable treatment options for obesity, and that's an important element as well for the treatment paradigm of obesity.

Finally, I'll say that the last component for a comprehensive team would be including plastic surgery. For those patients who've lost excessive amounts of weight, perhaps 100 pounds or more, working with plastic surgery could be beneficial if needed for skin-reduction surgery.

AJMC: As these multidisciplinary teams are set up, how are they working together? What are the handoffs like, and how does the communication flow?

Velazquez: I think the key is that there's an overarching mission and vision for the program that allows the team to work in synergy. That helps drive the team to work synchronously, and our communication involves regular touchpoints. We have regular touchpoints with the multidisciplinary team monthly and individual touchpoints with subspecialties within the multidisciplinary team quarterly. We're doing regular check-ins on workflows on a day-to-day basis to optimize care and improve the way we deliver it.

Most importantly, we're trying to standardize and protocolize the care we deliver. We have written protocols explaining how we, for example, manage a message that comes in with questions about obesity treatment so we can triage it appropriately—from the first intake, which might be our front desk, to our nurses, to whether it gets triaged to an APP [advanced practice provider] or a physician, to how it gets leveled up if it needs to go to the surgery or endobariatric team for procedural or surgical questions. That way we have a smooth flow, so patients aren't getting lost in the system and can access that care all in one place.

AJMC: Where do you see referral flows breaking down most often, and what happens when a patient is lost in the system?

Velazquez: One of the biggest challenges is determining which patients can be effectively managed in primary care and which need specialized or multidisciplinary obesity care. Some patients may have obesity without related complications, while others have significant disease burden and complex medical needs, including patients preparing for transplant or other major procedures.

Health systems need clear referral pathways to help patients get to the appropriate level of care. That’s where I see breakdowns occurring when it isn’t clear whether a patient should be managed in primary care, referred to an obesity medicine specialist, or connected with a multidisciplinary team. Establishing clear triage points is critical to keeping patients from getting lost in the system and ensuring they receive the level of care they need.

AJMC: Longer term, when we look at longitudinal monitoring of things like weight trajectory, comorbidity markers, and adherence, all of that is essential to managing the patient but very resource intensive. What monitoring protocols are realistic to implement at scale when you have a lot of patients going through the program?

Velazquez: Monitoring at scale is about figuring out, first, whether a patient is in the weight-losing stage or the weight-maintenance stage of the weight management journey, because those are very different stages, and the protocols you'd implement for each would be different.

The cadence at which you'd be seeing patients in the weight-losing stage—when you're actively adjusting pharmacologic agents, actively adjusting the lifestyle plan, or bringing in other tools like endobariatrics, bariatric surgery, or plastics—is a dynamic period, and the cadence of visits and the protocol is going to be much more time- and resource-intensive. Focusing on that for hospital systems is an important first step. The second is long-term maintenance.

Once patients are in maintenance, that's less resource- and time-intensive, and it's really about how we can leverage primary care to be empowered to take on these patients for long-term management—for example, maintenance of a healthy lifestyle plan or monitoring in patients who have undergone metabolic and bariatric surgery annual micronutrient and vitamin labs—and to make sure that if patients are having increases in their weight or recurrence of obesity-related conditions, primary care feels empowered to manage that, and if they need additional support, understand when to refer back to the specialty team. I think that's going to be much needed.

AJMC: What evidence gaps make it hard for health systems to build a strong business case for investing in obesity care infrastructure?

Velazquez: I think one evidence gap is the cost-savings element of treating obesity early in the disease process through increased preventive care services. We have strong evidence around the health benefits of treating some of these chronic diseases upstream but the cost savings. For example, we know that one of the most common complications from diabetes is kidney disease, leading to end-stage kidney disease and often dialysis, which is a very cost-intensive process for our health care system and our economy as a whole.¹ How do we prevent that farther upstream? One example would be addressing obesity early in the disease process.

Right now, we need more studies demonstrating the cost-effectiveness of preventive care in patients with overweight and obesity and documenting its full range of cost savings. I think we have some, but not enough to move the needle to make a strong internal business case, unless you have a forward-thinking institution that can appreciate where the future of medicine is heading, which is really toward prevention—to be able to prevent the chronic diseases we're seeing day-to-day in our clinics, the way things were 75 years ago, when we weren't so burdened as a society by chronic diseases.

AJMC: As more real-world data accumulates outside of clinical trials, how are systems using that to refine protocols and how they do things at the various health systems?

Velazquez: One example: with GLP-1s [glucagon-like peptide-1 receptor agonists], we're seeing concerns in real-world data—vitamin deficiencies, undernutrition, malnutrition, and muscle wasting²—that haven't necessarily been demonstrated yet in clinical trials. We're trying to implement catch nets in our protocols to identify patients who are flagging with these symptoms and, more importantly, patients who are high risk for them, in order to prevent that downstream when starting them on pharmacologic agents like GLP-1s. What that looks like is identifying patients at the outset, at consult, for a patient living with obesity who presents to the multidisciplinary clinic—getting screened for disordered eating and eating disorders, for food insecurity, and for additional social determinants of health, or SDOHs.

These are numerous well-validated surveys that clinical programs can implement as protocols in the care pathway to identify these patients up front and monitor them more closely to prevent downstream vitamin deficiencies, malnutrition, and undernutrition.

References

1. Burrows NR, Koyama A, Pavkov ME. Reported cases of end-stage kidney disease - United States, 2000-2019. MMWR Morb Mortal Wkly Rep. 2022;71(11):412-415. doi:10.15585/mmwr.mm7111a3
2. Butsch WS, Sulo S, Chang AT, et al. Nutritional deficiencies and muscle loss in adults with type 2 diabetes using GLP-1 receptor agonists: A retrospective observational study. Obes Pillars. 2025;15:100186. doi:10.1016/j.obpill.2025.100186