Field of Dreams

Better Obesity Care: If You Build It, Will They Come?

Two recent analyses illustrate a core problem that confronts professionals who devote their careers to developing and delivering better obesity care. So many barriers stand in the way of access to obesity care that people are slow to use new options as they become available.

In Obesity Science and Practice, Shumin Zhang and colleagues describe a very low (0.7%) utilization rate of obesity medications among patients for whom they might be indicated. Patients who did receive obesity meds were more likely to be female, have a higher BMI, be commercially insured, and more frequently use antidepressants and NSAIDS.

In the Pink Sheet, industry analysts describe this situation as leading to “a slow goodbye” to the category from marketing partners for obesity drugs. They describe the departure of Takeda from their marketing agreement with Orexigen for Contrave (naltrexone/bupropion) and predict that Eisai, the marketer of Belviq (lorcaserin), may follow suit.

This is part of a much bigger problem in obesity care. While treatment options that range from intensive behavioral therapy to bariatric surgery are well-described in guidelines, they are utilized in a small minority of the patients who might benefit from them.

Without treatment, obesity progresses and leads to complications that harm virtually every organ system of the body. The result of routinely untreated obesity is the rapidly growing prevalence of severe obesity and costs attributable to obesity, its complications, and consequent disabilities.

Three factors interfere with the routine delivery of obesity care: widespread biases, a small cohort of healthcare professionals equipped to deliver obesity care, and health plans that routinely exclude coverage for obesity care, regardless of medical need. All three factors contribute to the problem, but none more than the widespread bias and misunderstanding of obesity.

Bias leads healthcare professionals to assume falsely that treating obesity is futile because people with obesity are non-compliant, weak-willed, and lack self-control. In a 2015 commentary published by the American Journal of Medicine, Robert Doroghazi exemplified this perspective by advocating that physicians address obesity by telling their patients, “You weigh too much because you eat too much. Your health and your weight are your responsibility.”

The literature on obesity and its treatment makes it clear how untrue these biases are. This chronic disease is much more complex and evidence-based care can slow or reverse its progression, yielding important improvements in health.

Compounding the problem is the limited number of healthcare professionals who are equipped to deliver good obesity care. Most primary care providers say that they are unprepared to treat obesity. Many primary care physicians still believe that obesity is largely a behavioral problem and share our broader society’s negative stereotypes about the personal attributes of persons with obesity.

Health plans routinely exclude coverage for obesity care because it has long been treated as a cosmetic or lifestyle condition. Employers that want to add coverage for obesity care must opt in to a lifestyle benefits package that cover conditions such as hair loss and erectile dysfunction, which are much less likely to contribute to patient morbidity and mortality.

Progress is coming, but it is frustratingly slow. Data on the tendency to blame people who have obesity suggests that this is becoming less prevalent. The American Board of Obesity Medicine reports that obesity medicine is now the fastest growing specialty certification in medicine. Coverage of the entire continuum of care for obesity, from intensive behavioral therapy to obesity medications to surgery, is slowly improving. Despite difficult odds, people are investing in better obesity care.

More progress is needed. Low utilization of current options for obesity care has the perverse effect of becoming a barrier to developing better obesity care. Providers will not acquire skills for which they will not be paid. Research investment is deterred for new treatments that will not be covered. Slow adoption of improved options for obesity care will harm millions of people living with obesity now and for years to come.

Click here for the study by Zhang et al. Click here for further perspective from Helio. Click here for perspective from the AJMC and here for a report from Stat.

Thanks to Harvard’s Fatima Cody Stanford for today’s post.

Field of Dreams, photograph © jimmy brown / flickr

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May 18, 2016

3 Responses to “Better Obesity Care: If You Build It, Will They Come?”

  1. May 18, 2016 at 8:12 am, Stephen Phillips said:

    Better Obesity Care: If You Build It, Will They Come? –

    Bariatric Science is an emerging evidence based science and most health professionals that devote their careers to the care and treatment of obesities have had minimal education and training in this new and necessary specialty.

    Our international multidisciplinary fellowship is comprised of professionals from both the physical and social sciences that want to enhance their education, advance their careers and become certified and credentialed as bariatric specialists.The AABC online program offers theory as well as hands-on clinical practice skills with focus on the biological mechanisms, psychological processes and social influences of obesities.

    Hospitals and health insurance providers recognize the need and often require this advanced training and certification and the public, finally, has trusted health and education professionals that they can rely on and identify as credentialed specialists.

    Proudly we are part of the solution

    Stephen Phillips
    American Association of Bariatric Counselors

  2. May 18, 2016 at 8:20 am, Mary-Jo Overwater said:

    If we expose people who need effective care to the options available and find ways to increase access to this care, I do think ‘they will come.’ Increasing access to more-effective treatment options for all people — not just the privately insured — will have to increase the ‘hope factor’, which, in itself, may invite increased momentum to seek evidence-based care vs. fad and fringe options — a multi-billion dollar industry! It would be lovely if all that money would be funneled into best obesity care options and into ever improving these options and funding/supporting the hard-working obesity care professionals/providers and specialists who seek to deliver best care and who devote their lives to truly resolving the obesity epidemic.

    • May 18, 2016 at 9:24 am, Ted said:

      Well said, Mary-Jo. Thanks!