The Intersection of Unraveling Obesity and the STOP Obesity Alliance

By‌ ‌Dennis Barley, DC, CCSP & Nermeen‌ ‌Asham‌, ‌BScN,‌ ‌RN‌

Following the recent launch of Unraveling Obesity Inc., some have asked how our obesity screening tool can be incorporated in a provider’s office or how it is used in a primary care setting to help with a patient’s weight management and metabolic health. For this reason, we decided to discuss these answers as well as show how Unraveling Obesity’s screening tool is aligned with the “Weight Can’t Wait” guide for obesity management in primary care settings. In 2013, the American Medical Association (AMA) declared obesity to be a complex chronic disease. (1) And yet today, 1 in 3 American adults are dealing with this medical condition. (2) If the current trend persists, by 2030, a mere 8 years from now, obesity is expected to impact nearly 50% of the adult population in the United States. (7) Even after COVID placed a spotlight on obesity’s impact on one’s overall health in response to the virus, we still find physicians reluctant to discuss their patients’ unhealthy weight. A patient’s weight may be the underlying reason or the foundation for their comorbidity/ies yet their doctor many times still avoids the weight conversation.

During the MacDonald Center for Obesity Prevention and Education’s (COPE’)s presentation, entitled “Obesity Treatment, Beyond the Guidelines: A Structured A-B-C-D-E-F Framework for Primary Care Practice”, Dr. Scott Kahan, the Director of the National Center for Weight and Wellness, explained the 2018 study on the question of why more physicians do not address obesity with their patients. In this study, 1500 healthcare providers were surveyed, and as Dr. Kahan stated, “close to 100% agree that the health care provider, at least has part of the responsibility, if not all of the responsibility with respect to obesity counseling. …But when we look at what healthcare providers are actually doing, very different story. Simple diagnosis of obesity happens in a minority of patients. When we look across the board, BMI greater than 30, much less than 25%. Even when we look in BMI greater than 50. So these are people who are 200 pounds overweight or so. It’s still only about 50% that get a diagnosis of obesity. Typically in the healthcare system, when you don’t have a diagnosis, often you don’t get treatment”. (3) Evidence indicates that healthcare providers are often not speaking to their patients about the disease of obesity. Providers perceive multifactorial barriers that influence their level of engagement. Dr. Kahan cited that a lack of knowledge of nutrition, a lack of time in a patient’s appointment visit, and the fear of reprisal online from the patient, led to this suboptimal obesity intervention. (4)

The lack of provider-patient engagement can adversely affect the diagnosis and management of obesity and the ultimate health of the patient. Barriers perceived by healthcare providers and patients influence their level of engagement. For these reasons, the Strategies To Overcome and Prevent (STOP) Obesity Alliance developed a practical guide, entitled “Weight Can’t Wait”, for obesity management in primary care settings.

The guide has 3 sections, namely the Pre-encounter, Encounter, and Post-encounter. It is based on the “Six A’s”:

“(1) Ask: ask permission to discuss weight, listen to patient concerns;

(2) Assess: review information collected at pre-screen;

(3) Advise: focus on positive benefits of weight reduction;

(4) Agree: use shared decision-making to establish next steps;

(5) Assist: present treatment options including referrals, depending on patient preference; and

(6) Arrange: in shared decision-making with the patient, make referrals for lifestyle modification, intensive behavioral modification, medication, or bariatric surgery, schedule follow-up, and coordinate care.” (5)

As explained in the second “A”, patients need to be assessed before the encounter. Information collected prior to the visit, during the Pre-Encounter stage, includes “BMI, weight trajectory, personal weight history, stress, sleep, quality of life, depression, 24hr dietary recall, physical activity, medications, and existing comorbidities or risk factors.” (5)

Providers taking the first step in addressing the issue of unhealthy weight is a must if we are to change the state of our patients’ metabolic health and the burden it places on their quality of life and associated health care costs. But how to break the ice? Unraveling Obesity’s screening tool, utilized at intake/reception, can be a step in the right direction. When patients enter the office and await their appointment, they can be offered the screening tool, which is essentially a brief survey. The patients answer the questions on the survey to not only indicate to them the potentially harmful consequences of unhealthy weight, but it can also be a starting point for the tentative physician opening up that delicate conversation. It could be as simple as, “Mrs. Jones, I see that you’ve filled out our screening tool for unhealthy weight. Is it alright if we talk about how your results indicate that your present weight may be affecting your health?” In the above example, the provider has not used “overweight” or “obesity” in the conversation, and more importantly, he/she has asked the patient’s permission to speak about weight using an indirect approach: how unhealthy weight may affect health. The “icebreaker” here is the Unraveling Obesity screening tool. In many doctors’ experiences, overwhelmingly when you ask a patient’s permission to discuss any weight issues, he/she is eager to talk about it and get professional support.

The core of Unraveling Obesity’s screening tool is essentially the Pre-Encounter section of the “Weight Can’t Wait” guide, namely the second “A”, or “Assess”, which includes reviewing patients’ information prior to the provider-patient encounter. It is a bridge to this necessary and important discussion between providers and patients. Our online comprehensive screening tool can be completed by patients in the waiting room prior to their doctor’s visit. The automation in the tool allows patients to get their overall score as well as their score per pillar. The four pillars for obesity management being: nutrition, physical activity, behavior, and medication management. The patient receives these results immediately and at the same time, their physician will also receive a copy of the scores to review prior to the visit. This allows for provider-patient collaboration during the encounter as they discuss goals together to improve the patient’s metabolic health.

Unraveling Obesity’s screening tool is fast, as it only takes 5–10 minutes to complete; proven, because it is created by qualified healthcare professionals, as well as tested and vetted, by obesity medicine experts and patient advocates; and, secure, since all responses are HIPAA compliant. For physicians, this valuable tool provides deeper insight into risks, reasons for, and why their patients may be suffering from the disease of obesity. It also guides a physician’s treatment options for high impact and when it may be time to refer to an Obesity Medicine specialist. (6)

In a nutshell, Unraveling Obesity’s screening tool can be a physician’s best friend by being the stimulus to initiating this delicate conversation concerning unhealthy weight. This is the beginning of a patient’s journey towards better metabolic health.

References:

1. American Medical Association. Council on Scientific Affairs Report 4. Recommendations for physician and community collaboration on the management of obesity. Annual Meeting of the House of Delegates. Chicago, IL. 2005. Retrieved from https://media.npr.org/documents/2013/jun/ama-resolution-obesity.pdf
2. Hales, C. M., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2017). Prevalence of obesity among adults and youth: United States, 2015–2016
3. Kahan, S. I. (2020, May). COPE presents: “Obesity treatment, beyond the guidelines: a structured “A-B-C-D-E-F” framework for primary care practice”. Retrieved from https://www1.villanova.edu/content/dam/villanova/nursing/documents/cope-webinars/Audiotranscript%20Kahan%20May2020.pdf
4. Kahan, S. I. (2018, March). Practical strategies for engaging individuals with obesity in primary care. In Mayo Clinic Proceedings (Vol. 93, №3, pp. 351–359). Elsevier.
5. STOP Obesity Alliance. (2021, April 28). The weight can’t wait guide. Retrieved from https://www.youtube.com/watch?v=toc_0Ic8DSY
6. Unraveling Obesity For Providers. Retrieved from https://unravelingobesity.com/for-providers/
7. Ward, Z. J., Bleich, S. N., Cradock, A. L., Barrett, J. L., Giles, C. M., Flax, C., … & Gortmaker, S. L. (2019). Projected US state-level prevalence of adult obesity and severe obesity. New England Journal of Medicine, 381(25), 2440–2450