LAS VEGAS — In theory, team management of obese patients makes a lot of sense.
But in the real world, it may not be possible, because the obesity epidemic is too big, trained specialists too few, and resources too scarce, Arthur Frank, M.D., said at the annual meeting of North American Association for the Study of Obesity.
Primary care physicians must diagnose and treat obese patients in their practices, according to Dr. Frank, medical director of the weight management program at George Washington University in Washington. Primary care physicians need to provide such care even if they have no special skills in managing obesity or access to the nutritionists, dietitians, behavioral counselors, and other specialists who make up weight management teams.
“In the United States, there are 220 million adults over age 18. If 65% are overweight or obese, we have 143 million adults who need care. How can any system care for 143 million people who are overweight or obese?” Dr. Frank asked, laying the problem at the front door of primary care practices.
His remarks opened a workshop on office management of obesity—a subject revisited several times during the meeting, cosponsored by the American Diabetes Association. Here are some practical suggestions from experts in the field:
Guidelines and Other Tools
“The best way to describe the current management of obesity is clinical inertia,” Robert E. Kushner, M.D., said. “If the patient doesn't lose weight, what does the doctor do? He talks louder.”
Treatment guidelines are part of the problem, said Dr. Kushner, medical director of the Wellness Institute at Northwestern University, Chicago. There are too many of them—more than 2,000 at last count, including 135 at the National Guidelines Clearinghouse (
For example, he quoted an algorithm that concluded with a recommendation for the clinician and patient to determine goals and strategies for weight loss. “What is a clinician supposed to do with this?”
Putting aside such caveats, he recommended “The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,” available on the North American Association for the Study of Obesity (NAASO) Web site (
www.naaso.org/information/practicalguide.asp
Still, “for managing obesity, guidelines are not enough. We really have to get down to tools,” Dr. Kushner said.
To start, he suggested large blood pressure cuffs, gowns, office chairs, and scales that can accommodate a patient who weighs 350 lbs. Medical history forms should have questions focused on obesity. Patients can be given diet and activity diaries along with specific instructions on how to cut calories and exercise more.
Tell patients to get a pedometer; patients who keep track of how many steps they take each day will become more active over time. “The pedometer—it's not rocket science,” he said. “It's not going to win a Nobel Prize, but what a useful tool to … get accountability.”
Getting Started
First impressions count, advised Donald Schumacher, M.D. Attitude, body language, and the amount of time a physician spends listening as opposed to lecturing a patient are all important when an overweight person seeks help.
“The last thing someone overweight needs is one more lecture,” said Dr. Schumacher, in private practice in Charlotte, N.C. Physicians must form a partnership with these vulnerable patients, and the role of the physician, staff, and patient should be established in the first visit.
Establishing the therapeutic bond is the most important first step, said Peter D. Vash, M.D., of the Lindora Medical Clinic of the University of California, Los Angeles. “Somehow the words, 'I can help you; please work with me,' to my mind set the stage for weight-loss success,” he said, calling the 7-10 minutes when the patient is with the physician “a therapeutic window of opportunity.”
The initial plan should go slow and be sensitive to the individual, Dr. Schumacher said. Ethnicity, work schedule, travel demands, and the obligations of motherhood are among the factors to consider.
Making too many changes too fast will lose the patient, he said. “Your patients have failed before. You do not want to set your patients up to fail once again.”
Some obese patients will ask their physicians to cite diabetes or hypertension or another condition as the primary diagnosis when billing for an office visit, Dr. Frank said. There is no code for obesity, and the cost might not be reimbursed if the real reason is stated.
Should the physician agree? Some clinicians argue that this is legitimate, because treating obesity can reduce metabolic syndrome, but Dr. Frank said not all physicians are comfortable with that solution. “This is a common ethical problem.”