The Time to Diagnose, Treat, & Monitor Patients With Pre-Obesity and Obesity is Now

As we turn the page to a New Year, we’re continuing to deal with the coronavirus disease 2019 (COVID-19) pandemic by following safety measures and the directions of state and local authorities as well as getting vaccinated. However, in reality, we are facing two pandemics at the same time, namely obesity and the coronavirus. Obesity continues to be on the rise and it is still not defeated. During the current obesity pandemic, it’s important to educate more physicians on how to promptly diagnose, sensitively treat, and carefully monitor their patients who are living with this disease. There is science behind weight loss and obesity management is not about “eat less and move more”. Physicians need to better understand the underlying science of obesity to provide optimal and compassionate care for their patients. Dr. Fatima Cody Stanford, an obesity medicine physician-scientist, describes the physician’s “limited knowledge” of obesity as “tragic because it is by far our most prevalent chronic disease. It’s sad because if we treat that one disease, then we can get rid of about 10 to 15 others depending upon what the patient has”. (4)

Pre-obesity and obesity are complex medical conditions, which need to be properly treated, monitored, and managed by qualified healthcare professionals using a comprehensive approach to help patients lose weight and keep it off. Dr. Kushner and Dr. Primack’s article about overweight being an overlooked risk factor, mentions that pre-obesity is defined as having a BMI between 25.0 kg/m² to 30.0 kg/m². They emphasize “People in the overweight category are more likely now than 30 years ago to continue to gain weight and develop obesity. These trends make it clear that early intervention efforts are needed, at lower BMI ranges before patients cross into the obesity classification”. (9) The Obesity Medicine Association (OMA), the largest organization of clinical leaders in the obesity space, describes obesity as a “chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences”. (13) Since obesity is a multifactorial disease, it must be addressed using a pillar framework, such as OMA’s “four pillars of clinical obesity treatment”, namely nutrition, physical activity, behavior, and medication management, which are also represented in the colors of their logo and the diagram below. “When combined and personalized, treatment plans involving the four pillars help patients lose weight and achieve better overall health”. (10) Dr. Craig Primack, president of the OMA, emphasizes “Trust real medical science, not pseudoscience, not patents, and for sure not magic”. (7)

As depicted in the diagram, OMA’s four pillars make the solid foundation or bedrock of obesity management and treatment as they provide a comprehensive evidence-based approach, which is necessary for successful and sustainable weight loss. (3) Dr. Ziltzer and Dr. Primack, founders of Scottsdale Weight Loss Center, underscore the importance of a comprehensive weight loss program that includes four essential components, namely medical management, nutritional or dietary change, activity plan, and education using their chair analogy, which is in alignment with the OMA’s four pillars. They describe “Any time you omit any one of these four components your plan is more likely to fail. Think of it as four legs of a chair. Remove one leg, and you will have a difficult time maintaining balance on that chair”. (14) Dr. Primack continues to explain “If you take just one aspect or one leg of the chair, let’s say that’s diet, and you don’t do any of the other pieces, your chair is not stable. And with just a little bit of stress, it easily falls over. As you add two or three and four legs of the chair, your chair is much more stable. When stress comes into the system, we know that a chair on four strong legs will do much better. Underneath the chair is a base that we call active maintenance, which is the maintenance program that’s been designed around our medical weight loss program. The stronger your foundation of your weight loss plan, the better your weight loss plan will be”. (6, 7)

Patients suffering from obesity have a right to promptly receive appropriate medical care that is free from bias. Dr. Stanford emphasizes “If we are not treating this patient population, then I think we are failing at our jobs’’. (4) “The prevalence of weight bias in medicine may stem, at least in part, from minimal education about obesity in undergraduate and graduate medical education. And there is even less education about weight bias and stigma and its impact on the health of individuals who struggle with obesity”. (12) Failure to diagnose, treat, and monitor obesity or having bias or discrimination is unacceptable and unethical. It is the same as failure to diagnose, treat, and monitor coronary artery disease, diabetes, hyperlipidemia, hypertension, and other chronic medical conditions. As healthcare professionals, we never learned to leave our patients with a BP of 180/100, or a fasting blood sugar level of 130 mg/dL, or a HbA1c of 15%, or total cholesterol of 300 mg/dL, or oxygen saturation of 85%, or a pain score of 10/10, etc; or to leave our patients in need of a referral to see a trusted specialist. Also, we were not taught to blame our patients or judge them for their medical conditions. So why should we leave our patients having a BMI of ≥ 30.0 kg/m² or a BMI of 25.0 kg/m² — 30.0 kg/m² with an abnormal body fat percentage, putting them at risk for many comorbidities? Why should they receive biased treatment?

Healthcare providers must look beyond their patients’ weight to provide compassionate care, determine the underlying cause(s) of the weight gain, and to provide accurate diagnosis and treatment for their condition. Dr. Kushner & Dr. Primack underscore the importance of screening for overweight early by discussing lifestyle and other nonpharmacological treatment as means of obesity prevention. “Without comprehensive treatment, adults with overweight continue to gain weight, moving steadily into the obesity (BMI 30–39.9 kg/m² ) and severe obesity (BMI ≥ 40.0 kg/m²) categories”…….Evidence indicates that the detrimental effects of excess weight on morbidity and mortality begin at lower BMI categories. Therefore, identifying at-risk patients who have overweight (BMI from 25.0 to < 30.0 kg/m²) and initiating treatment earlier may interrupt the progression toward further weight gain and the development of obesity-related comorbidities”. (9) In other words, if patients with overweight or pre-obesity are left untreated or not treated early, this can cause harm to them. The reason being they can end up suffering from obesity and its comorbidities, which affects nearly every organ and unfortunately can cause premature death. Also, weight bias in healthcare professionals not only harms patients but also leads to medical malpractice. Snyder & Wenner outline “six common types of medical malpractice”, namely misdiagnosis, delayed diagnosis, failure to treat, surgical errors, birth injury, and medical product liability. (11) Personal injury lawyers explain “Although obesity is a health concern that exacerbates many other health issues, sometimes the actual illness or problem an overweight patient experiences is not the direct result of obesity. In these cases, sometimes the medical staff wrongly assumes that the problem is a result of the patient being overweight, and the patient is left without having received adequate treatment”. (8) Colley Schroyer Abraham, a personal injury attorney, adds “When a physician examines an overweight patient, his or her bias towards a particular weight range may affect a diagnosis. For example, claiming that weight loss would result in less pain may not provide a realistic approach to a patient’s condition. Physicians owe a duty of care to provide patients with an accurate diagnosis. When a doctor knew or should have known that a patient required medical attention, and also negligently caused a patient to delay it, the harmed individual may have cause to file a malpractice suit”. (1)

As healthcare professionals, it is important to remember that patients dealing with obesity need our support and they need to be heard. They rely on us to be a professional resource and partner in health as they maintain or regain their health and well-being. They need our help, time, trust, patience, encouragement, positive attitude and non-judgmental approach, etc. In other words, it is important to show them that we believe in them which means celebrating their successes as well as their challenges with weight loss. Focusing on our patients’ strengths will help them work on their weight-loss struggles as they reach their health goals. This simple shift in thinking can encourage patients to accept themselves and use their inner strengths to deal with their current health issues or situation, regardless of what they are going through or their body image. Angela Chesworth, a Novo Nordisk DEEP member explains “I’ve struggled with my weight from the age of ten seeing dieticians and medical professionals. Over the years, I followed the ‘eat less, move more’ strategy that I’ve been advised from medical professionals. However, I now know that because I’m living with obesity, there is something going on within my body that’s out of my control. To eat a healthy diet and be active is a good strategy for anybody no matter what you weigh. However, if you’re a person living with obesity, it’s a lot more complex. Six years ago, the NHS performed bariatric surgery on me, a gastric bypass, and today I’m maintaining a 10 stone weight loss. Bariatric surgery is not easy. It’s a tool. It helps your body to maintain a weight loss. We need access to treatment. We need to stop the stigma and bias that people living with obesity face in society. We need education to our medical professionals because some don’t understand the complexities. We need support from other people who have shared the same journey, who understand how difficult it is to be in a body that you don’t feel like you fit in”. (2) Dr. Melody Covington, bariatrician and founder of Abundant Health & Vitality Associates, outlines five key points for treating patients who are battling obesity. These include “Be empathetic: always lead with compassion and refrain from blaming the patient for their weight; Check weight management bias at the door: it is imperative to understand that weight loss is not simply calories in and calories out, it is biology, chemistry, neurology, psychology, and much more….as a provider if you underestimate the treatment required for weight loss, you will fail to be effective in achieving lasting results; Avoid weight gaining medications when possible: providing specific solutions, as opposed to repetitive dietary visits, worked much better than watching the scale continue to climb; Do not dismiss weight loss solutions: if we are going to solve this obesity conundrum we have to keep an open mind and go beyond just diet and exercise; and Refer to an obesity specialist: treating weight loss is not for everyone and as with everything in medicine, refer when necessary….reject ignorance surrounding weight loss medicine and at all costs avoid arrogance”. (5)

More physicians need to realize the importance of addressing obesity as a health condition, like all the other ones taught in medical schools. This means promptly diagnosing, treating, and monitoring obesity as well as pre-obesity because they are a gateway for other diseases. It’s imperative that primary care physicians take the time to offer guidance and treatment like they would with other treatable diseases. OMA’s “four pillars of clinical obesity treatment” provide a comprehensive and evidence-based approach, which makes it a great framework for healthcare providers. Furthermore, physicians must learn to provide compassionate care while actively listening to their patients. This will also promote a sense of trust and collaboration between physicians and patients which leads to better health outcomes. Hence, it’s time for all physicians to respect and treat their patients regardless of their weight; consider their patients’ body fat percentage, fat mass, and lean body mass as vital signs; include dietary intake & eating patterns and physical activity as part of their patients’ health history; ask about any family history of obesity; discuss weight issues and identify the cause(s) of weight gain for their patients. The time to diagnose, treat, and monitor patients with pre-obesity and obesity is now so they can live a healthier tomorrow. If physicians have knowledge of obesity medicine, they can treat their patients suffering from pre-obesity or obesity in their primary-care practice. If physicians do not have the expertise in this field, then they need to refer their high-risk patients for obesity to nearby certified obesity medicine specialists, such as ABOM diplomates and NPs with Advanced Education, or to medical weight loss clinics that offer effective, proven, and safe treatments that maximize patient outcomes. By doing this, it will allow patients to receive the necessary help in their health journey, and thus have a better quality of life.

References

1. Abraham, C.S. (2020, Aug 23). Obesity and weight issues may lead to medical malpractice. Retrieved from https://www.colleyshroyerabraham.com/blog/2020/08/obesity-and-weight-issues-may-lead-to-medical-malpractice/
2. Angela Chesworth. (2020, July 20). I am a person living with obesity. Retrieved from https://www.youtube.com/watch?v=LrvhOpUxuZA&t=4s
3. Asham, N. (2021, Jan). The Obesity Medicine Association’s (OMA) 4 pillars of clinical obesity treatment. Retrieved from https://www2.slideshare.net/NermeenAsham/omas-4-pillars-of-clinical-obesity-treatment
4. Berg, S. (2020, March 3). Ending the obesity shame game. Retrieved from https://www.ama-assn.org/delivering-care/public-health/ending-obesity-shame-game
5. Covington, M. For providers: 5 tips for treating obesity in your patient. Retrieved from http://melodycovingtonmdconsulting.com/blog/
6. DoctorPrimack. (2020, Dec 30). Chasing Diets, a Book by Craig Primack MD and Rob Ziltzer MD. Medical minutes #28. Retrieved from https://www.youtube.com/watch?v=aSFAuvL8Yr8&feature=emb_logo
7. DoctorPrimack. (2020, Nov 24). Do magical diets exist? Medical minutes #25. Retrieved from https://www.youtube.com/watch?v=_sAJTTuInzE&feature=emb_logo
8. Ellis Law Offices. (2016, Nov 25). Four ways doctors’ treatment of obese patients can result in malpractice claims. Retrieved from https://www.ellislawoffices.com/blog/2016/11/four-ways-doctors-treatment-of-obese-patients-can-result-in-malpractice-claims/
9. Kushner, R. F., & Primack, C. (2020). Overweight: The Overlooked Risk Factor. The Journal of family practice, 69(7 Suppl), S51-S56.
10. Obesity Medicine Association. About OMA. Retrieved from https://obesitymedicine.org/about/about-oma/
11. Snyder-Wenner. (2015, Oct 28). Six common types of medical malpractice. Retrieved from https://snyderwenner.com/six-common-types-of-medical-malpractice/
12. Stanford, F.C. (2019, April 3). Addressing weight bias in medicine. Retrieved from https://www.health.harvard.edu/blog/addressing-weight-bias-in-medicine-2019040316319
13. Welcome, A. (2017, Aug 29). Definition of obesity. Retrieved from https://obesitymedicine.org/definition-of-obesity/
14. Ziltzer, R. & Primack, C. (2019) Chasing diets: stop the endless search and discover the solution. Dublin, OH: Telemachus Press, LLC