Barriers to Obesity Care and How to Create a Support Team
The New York Times column “Why Do Obese Patients Get Worse Care?” offered the answer in the headline: “Many Doctors Don’t See Past the Fat.”The column cited current statistics that suggest one in three Americans are living with obesity, with the growth path on an uptick for two decades, and the author’s conclusion was that the health care system is failing this population in terms of “attitudes, equipment, and common practices.”
A person with obesity who needs a knee or hip replacement will likely be told to lose weight before the doctor will operate. From the doctor’s perspective, there’s a higher rate of complications and problems during surgery if the patient is living with obesity.
The doctor may also feel that the surgery will fail prematurely, given the weight load on the new hip or knee joint. But the patient is in pain, and may be struggling with mobility issues, and let’s face it, they can’t exercise if these issues persist. The patient will feel humiliated and defeated if the doctor refuses to perform surgery, especially if he or she has already started losing some weight. Quite often these patients can’t even get weighed because the scale in the orthopedist’s office cannot accommodate patients with obesity, and the hospital may not have radiology apparatus that can assess the joint, especially if the obesity is characterized as morbid.
Doctors tend to spend less time with the person with obesity. Doctors can also make easy assumptions and associate most presenting complaints and symptoms with obesity (shortness of breath, pain in the lower limbs with exertion, fertility issues, for instance), and never look beyond obesity for more serious pathology. On the other hand, doctors suggest that some patients will often deny that they have weight issues, or they may shut down the doctor’s efforts to even talk about how the weight may be contributing to physical issues, poor quality of life, or other conditions like diabetes, heart disease, or cancers.
Experts like Nikhil Dhurandhar, Ph.D., F.T.O.S., past president of The Obesity Society, will tell you that strides are being made to address the schism between the health care system and the needs of patients with obesity, especially the doctor-patient relationship. The first step occurred in 2013, when obesity was finally recognized as a separate and unique disease. The second milestone was the relatively new board certification that became available to doctors (about five years ago) who want to specialize in obesity medicine — The American Board of Obesity Medicine (ABOM).
The certification is currently available to doctors such as endocrinologists or physicians who treat other conditions that are connected to obesity, like cardiology, or to the practitioner who wants to exclusively practice obesity care. The education and preparation for the exam ensures that the physician will be fully trained to diagnose and treat obesity.
Last year, the Obesity Society released the Potential Contributors To Obesity infographic, highlighting over 90 "contributing factors" to the disease. This unique tool showcased the complicated nature of obesity, which helps to clarify just how difficult a disease it is to treat.
Scott Kahan, M.D. M.P.H., spokesperson for The Obesity Society, director of the National Center for Weight and Wellness and medical director of Strategies to Overcome and Prevent (STOP) Obesity Alliance in Washington, D.C., spoke to me by phone. He confirmed that most primary care providers, similar to much of society, have preconceived notions about obesity and patients with obesity. They also have negative and inaccurate beliefs that lead to poorer care and stigma. He listed:
Limited experience and expertise among healthcare providers to provide care to the person with obesity
Limited coverage from insurance companies to treat obesity as a disease
Structural set-up including patient examination gowns, chairs in the waiting room, wheelchairs, scales, blood pressure cuffs, radiology machines that are inadequately matched to the needs of patients with obesity
Other barriers include lack of consistency of care, lack of trust between patient and provider, and providers lacking not only the skill but also the confidence to tackle obesity. How society treats patients with obesity also makes matters worse, according to a study published in the Annals of Behavioral Medicine. People who experience weight discrimination are more likely to skip doctor visits, according to the study.
Dr. Kahan acknowledged that many of the barriers to obesity treatment discussed in “Barriers to Obesity Treatment,” published in the European Journal of Internal Medicine in 2008, still exist, though progress has been made. The fact that obesity is now a “highly discussed issue in the lay public, media, among policymakers and in the health care sector,” is evidence that it is main stream and has moved beyond just the research and specialty focus, he said.
Dr. Kahan suggested that a “first step for providers” is simply learning how to talk to the person managing obesity. Engagement can either support a healthy and productive interaction between the patient and doctor, or it can end with headbutting and the patient refusing help.
“Underlying stigma, even when the doctor genuinely cares, can result in poor communication,” he said.
The patient may have had prior poor experiences in a health care setting and bring their own preconceptions to the visit, preventing healthy discourse even with a willing and empathic doctor.
Medical schools need to include obesity education in the curriculum, and other health care providers (physician assistants, nurse practitioners, nurses, and others) also need adequate training in obesity care. Even the mental health system requires obesity education to be provided to licensed professionals, as mental health is often a component of the team approach to obesity. Dr. Kahan confirmed that orthopedics is the only area of medicine where patients are turned away from appropriate and necessary treatment because of their weight. “It’s just not reasonable to wag your finger and say to the patient, lose weight first.”
The pharmaceutical industry has no mandate to figure out dosages for the a person with obesity, or populations managing morbid obesity. I found one article in the British Journal of Anaesthesia by an anesthesiologist at Stanford University that attempts to provide anesthesia recommendations for the patient with obesity.
Dr. Kahan also offered that many dieticians and nutritionists have not received any specialized education focused to the person with obesity.
There is another side to this discussion. Patients also need to try to learn to be proactive. As a patient, approach your obesity treatment-centered visit with a list of detailed questions, especially if there’s been a change in your health or if you have a sudden acute health issue. That can help to prevent your doctor from simply dismissing your medical problem as “a consequence of your weight.”
Beginning in March, the first exam for certified specialists in Obesity and Weight Management will be offered by the Commission on Dietetic Registration (CDR). It will be open to a wide range of allied health professionals.
Early and consistent treatment is crucial to treating obesity, according to Caroline Apovian, M.D., a professor of medicine at Boston University School of Medicine. The range of therapies offered should include diet, exercise, medications, mental health support or treatment, bariatric surgery, and support groups. Intercepting childhood obesity is also crucial, and recently, a new pediatric obesity registry, POWER, was established in multiple institutions across the U.S. to identify best practices in pediatric weight management and to contribute to advancing evidence-based guidelines for effective interventions.
How to build your obesity management team
It’s important to create a personalized obesity management team. Dr. Kahan recommends that youstart your team with your current physician or healthcare provider — hopefully you have or can access a primary care provider. He then suggests that you build out from there with these actions:
Ask for a specialist referral or see if your doctor will reach out to a board-certified obesity specialist. Currently there are about 1,500 doctors nationwide. Telemedicine can help to connect you if you don’t live in a major city with easy access to these specialists.
Find out if your local hospital or large university hospital has an obesity-focused program.
Ask for a referral to a dietician (check out American Academy of Nutrition and Dietetics for more info on what dieticians do), diabetes educator, or certified nutritionist with expertise in obesity care. Your insurance may have a list with approved providers.
Seek mental health support from a psychologist or mental healthcare practitioner who has a track record working with patients diagnosed with obesity.
See what your insurance plan offers in terms of obesity care coverage. Medicare recently began to cover obesity-counseling services from a doctor, dietician, or recognized weight loss program.
If finances limit your options, seek help online from self-help websites like HealthCentral and online support groups.
There are also some well-received books that offer diet, exercise, and other basic obesity care guidelines.
My final question to Dr. Kahan was to ask him about the future of obesity care. His response?
“I'm quite hopeful.”
This feautre was produced in association with The Obesity Society to help provide helpful, reliable and up-to-date resources for successful obesity treatment and management. Be sure to explore other themes like 'barriers to care,' as well as the latest obesity research during **ObesityWeek2016!