Proceedings of a Workshop
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July 2017 |
The Challenge of Treating Obesity and Overweight
Proceedings of a Workshop—in Brief
The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a workshop in Washington, DC, on April 6, 2017, titled “The Challenge of Treating Obesity and Overweight: A Workshop.” Bill Purcell, currently with Farmer Purcell & Lassiter, PLLC, and former mayor of Nashville, Tennessee, opened the workshop by describing the complexity of obesity as a chronic disease characterized by multifaceted considerations and interactions. Citing the national and worldwide prevalence of obesity that has more than doubled between 1980 and 2014, Purcell emphasized the need to think about solutions to end the epidemic. He noted that the focus on treatment should be placed in the context of the comprehensive approach to obesity solutions. The workshop discussions covered treatments for obesity, overweight, and severe obesity in adults and children; emerging treatment opportunities; the development of a workforce for obesity treatments; payment and policy considerations; and promising ways to move forward.
This Proceedings of a Workshop–in Brief highlights key points made by workshop participants during the presentations and discussions. It is not intended to provide a comprehensive summary of information shared during the workshop.1 The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.
THE TREATMENT OF OBESITY AND OVERWEIGHT IN ADULTS
Health care providers use three general modalities to treat obesity in adult patients: lifestyle interventions, pharmacotherapy, and bariatric surgery. Susan Yanovski, co-director of the Office of Obesity Research at the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, summarized what is known about the efficacy for each of these modalities in achieving and maintaining weight loss to improve health in turn to lay the groundwork for subsequent discussions at the workshop.
Yanovski reviewed evidence-based guidelines that recommend a comprehensive lifestyle program (including diet, physical activity, and behavior modification) of 6 months or longer for patients who need to lose weight. In particular, a high-intensity (≥14 sessions in 6 months), comprehensive, onsite lifestyle intervention by a trained interventionist using behavioral treatments for 1 year or more can lead to a mean weight loss of 5 to 10 percent.2 According to Yanovski, other approaches, such as Web-based interventions, lead to smaller weight losses. Less intensive treatments delivered in primary care settings have not been shown to be effective. Over time, some regain in weight can be
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1 Presentations, videos, and other materials from the workshop can be found at http://www.nationalacademies.org/obesitysolutions (accessed July 10, 2017).
2 “Sustained weight loss of 3%-5% produce[s] clinically meaningful health benefits, and greater weight losses produces greater benefits.” Jensen, M. D., D. H. Ryan, C. M. Apovian, J. D. Ard, A. G. Comuzzie, K. A. Donato, F. B. Hu, V. S. Hubbard, J. M. Jakicic, R. F. Kushner, C. M. Loria, B. E. Millen, C. A., Nonas, F. X., Pi-Sunyer, J. Stevens, V. J. Stevens, T.A. Wadden, B. M. Wolfe, and S. Z. Yanovski. 2014. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. Circulation 129(Suppl 2):S102-S138.
expected, even with continued treatment, said Yanovski. Randomized controlled trials of intensive lifestyle interventions have demonstrated some initial differences in weight loss by race or ethnicity, but these diminish over time, she noted.
The addition of drug treatment, as recommended by evidence-based guidelines, can enhance initial weight loss for patients who may not be responding to lifestyle interventions, explained Yanovski. Adding drug treatment in appropriate patients can increase weight loss from 3 to 9 percent more than lifestyle treatment alone and is more likely to respond with clinically meaningful weight loss at 1 year. Initial weight loss (at 12 weeks) predicts later treatment response and can be useful to reevaluate treatment options for the patient.
Bariatric surgery leads to the largest and most sustained weight reduction, stated Yanovski. The procedures differ in average outcomes, with Roux-en-Y gastric bypass providing greater average weight losses than sleeve gastrectomy, which produces larger average weight losses than laparoscopic gastric band. Within each procedure, weight loss and maintenance of weight show variability, and few predictors of treatment response exist.
THE TREATMENT OF OBESITY AND OVERWEIGHT IN CHILDREN AND ADOLESCENTS
Drawing largely on meta-analyses and systematic reviews, Ihuoma Eneli, associate director of the American Academy of Pediatrics Institute for Healthy Childhood Weight and director of the Center for Healthy Weight and Nutrition at Nationwide Children’s Hospital, reviewed what is known about the efficacy of treatment for obesity and overweight in children and adolescents. As a standardized measure of treatment effectiveness, Eneli chose a reduction of 0.2 in body mass index (BMI) z-score over 12 months because this corresponds to about a 5 percent decrease in body weight and is associated with improved cardiometabolic outcomes.
Behavioral lifestyle treatments for children that exceeded 52 contact hours over a 12-month period generally produced an effective change in the BMI z-score, whereas treatments that were between 26 and 51 hours produced a lower effective change, stated Eneli. For children younger than age 6, lifestyle interventions have been effective in reducing weight, with changes as high as 0.38 in BMI z-score 12 to 18 months from baseline. Evidence suggests that lifestyle interventions are equally effective for Latinos, African Americans, and non-Hispanic whites.
Evidence on the effectiveness of interventions in primary care and education settings is mixed and generally shows modest effects, said Eneli. There is little evidence of community-based interventions being effective.
Information on the use of medications in children is sparse compared with their use in adults, noted Eneli. The published trials show a small effect, but the effect is not as large as for lifestyle interventions. However, specialized diets could be an effective treatment option for some pediatric patients with severe obesity. Furthermore, the median decrease in BMI after 3 years with bariatric surgery in pediatric populations is 30 percent, but weight loss surgery occurs in only about 1,200 children per year in the United States. She acknowledged that having the right measures is important to understanding what constitutes effective treatment in this population.
THE TREATMENT OF SEVERE OBESITY IN ADULTS
Treating severe obesity requires experienced teams, including bariatric surgeons, gastroenterologists, obesity medicine specialists, registered dieticians, psychologists, and support staff, said Louis Aronne, the Sanford I. Weill Professor of Metabolic Research at Weill Cornell Medicine. But most communities do not have such teams, which means that many patients do not get the “support and intuitive care that is necessary in managing problems when they arise,” Aronne said. In addition to having an experienced team, Aronne said that treating severe obesity also requires combining surgery and devices with the management of drug-induced weight gain, treatment with antiobesity medications, and the use of intensive and intermittent dietary interventions.
For patients with class 2 (BMI >35 kg/m2) or class 3 (BMI >40 kg/m2) obesity and at least one obesity-related comorbid condition, bariatric surgery can produce major weight loss and health benefits, including remission or incidence of type 2 diabetes, hypertension, dyslipidemia, sleep apnea, psychosocial impairment, functioning, and employment status, noted Bruce Wolfe, professor of surgery at Oregon Health & Science University. Serious complications from bariatric surgery occur in a low percentage of patients, and safety has been improving over time. Long-term complications, including metabolic problems, nutrient deficiencies, and complications requiring subsequent surgeries, are more difficult to study as patients disperse into the population. Less than 2 percent of patients who are eligible for bariatric surgery undergo such surgery in any given year, and the number being treated with pharmacotherapy is similarly low.
Nikki Massie, a professional writer, marketer, and online community leader living in Baltimore, Maryland, recounted her experiences in 2008 with Roux-en-Y gastric bypass surgery, which reduced her weight from 340 pounds
to about 205 pounds. She exercises regularly, maintains a regular vitamin regimen, meets with a dietician to regulate her eating, and still sees her bariatric surgeon once per year. “I consider the outcome that I got very successful in terms of lifestyle intervention and changing how I move and how I eat.” One thing she noted is that her social relationships “completely changed for me after bariatric surgery.” She derives value from talking with other people about their experiences and providing support, she said. “Peer support is a very important part of aftercare with weight loss surgery.”
THE TREATMENT OF SEVERE OBESITY IN CHILDREN AND ADOLESCENTS
Multidisciplinary care and family support can help young people lose weight and maintain weight loss, observed parent advocate Nikki Highfield, whose son had severe obesity in fifth grade, but lost weight and excelled on his junior high school basketball team. His dietician and exercise physiologist taught him how to eat healthy meals and exercise regularly. “His goal is to make the [high school] varsity team next year. Will he make it? Who knows? But the support is there for him to make it.”
In the past, severe obesity has been defined as BMI being at or above the 99th percentile on growth charts, noted Susan Woolford, assistant professor and co-director of the Mobile Technology to Enhance Child Health Program in the Child Health Evaluation and Research Unit at the University of Michigan. However, new proposals to classify severe obesity3 would provide a better ability to look at changes in weight over time and better population measures, she said. Multidisciplinary programs remain the most common and likely way to treat severe obesity in children and adolescents, but they face many obstacles, including high costs, poor reimbursement, high attrition rates, low reach, poor adherence, and poor weight loss maintenance after the program ends. New medications, better integration of primary care with tertiary care, greater connections with the community, and new uses of technology could all yield progress, Woolford said.
Few adolescents undergo bariatric surgery, but the current evidence supports considering such surgery as an effective treatment for this population, observed Marc Michalsky, professor of clinical surgery and pediatrics at The Ohio State University College of Medicine. Despite favorable outcomes and standardization of care, the number of surgeries has remained stable. Michalsky cited limited access to care and public and professional awareness of weight loss surgery as an effective treatment strategy as possible explanations. Surgery does entail possible complications and risks, Michalsky acknowledged, such as micronutrient and macronutrient deficiencies. But that “speaks to the importance of being able to remain engaged with these patients long term.”
EMERGING OPPORTUNITIES
New medications, devices, lifestyle interventions, and digital technologies could provide innovative ways to control obesity. For example, targeted drugs to counter specific genetic defects, long-acting medications that can be taken orally, new combinations of drugs, and drugs that affect different biological mechanisms are offering new ways to overcome the complex genetic, epigenetic, and environmental interactions at work in each individual, said Steven Heymsfield, professor and director of the Body Composition-Metabolism Laboratory at the Pennington Biomedical Research Center of the Louisiana State University system. New devices that inhibit food intake or calorie absorption are also being intensively studied. Standing desks, fitness trackers, cellphone applications, and many other technologies offer new ways to change behavior, Heymsfield noted.
Gary Bennett, the Bishop-MacDermott Family Professor of Psychology and Neuroscience, Global Health and Medicine, at Duke University, elaborated on some of these technological options. Even more important than the devices people are using are the data those devices are collecting, he said. The past 7 years have seen nearly 300 million downloads of weight loss apps, all of which can collect data about the people using them. For example, electronic scales in people’s homes are being used to generate text messages from registered dieticians if people gain weight, followed by telephone calls if they continue to gain weight. Artificial intelligence is being used to deliver feedback to individuals when they need it and in the language they prefer. “If a patient is a woman who works outside the home and has kids and likes to exercise outside and it is going to rain, then she gets a recommendation that she find something to do with her kids inside over the weekend,” Bennett said. Furthermore, such approaches can especially benefit patients at the highest risk, such as people on the lower end of the socioeconomic spectrum and minorities who are likely to own and use their smartphones.
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3 Class 2 obesity = BMI ≥35 but <40 for >120% of the 95th percentile for age and sex; class 3 obesity = BMI ≥40 for >140% of the 95th percentile for age and sex.
WORKFORCE AND TRAINING
The development of the workforce is critical given how many millions of patients with obesity in the United States are underserved, said Bill Dietz, panel moderator and chair of the Sumner M. Redstone Global Center on Prevention and Wellness at the Milken Institute School of Public Health at The George Washington University. Goutham Rao, the Jack H. Medalle Professor and Chair of Family Medicine and Community Health at University Hospitals of Cleveland and the Case Western Reserve University School of Medicine, described a collaborative effort involving a number of participating organizations to develop competencies that articulate the skills and knowledge expected of the obesity care workforce. The competencies included (1) framework of obesity as a medical condition; (2) epidemiology and key drivers of the obesity epidemic; (3) disparities and inequities in obesity prevention and care; (4) interprofessional obesity care; (5) integration of clinical and community care for the prevention and treatment of obesity; (6) discussions and language related to obesity; (7) recognition and mitigation of weight bias and stigma; (8) accommodating people with obesity; (9) evidence-based care/services for persons with obesity or at risk for obesity; and (10) special concerns (e.g., providing evidence-based care/services for persons with obesity comorbidities).
Robert Kushner, professor of medicine at the Northwestern University Feinberg School of Medicine and director of The Center for Lifestyle Medicine at Northwestern Medicine, spoke about the need to build obesity-related education and professional development initiatives for physicians from both the top down and the bottom up to encompass both clinicians who are already in practice and current trainees. He described the new obesity medicine physician pathway created by the American Board of Obesity Medicine as a way to create a subspecialty or focused practice and provide continuing medical education for practicing physicians. Kushner also emphasized the need to target current trainees in parallel, citing the limited obesity coverage on U.S. medical licensing exams as a reason for developing obesity-related educational competencies and including more obesity-related items on the exams.
As another example of a program designed to increase expertise and credibility in the obesity domain among health professionals, the new Interdisciplinary Specialist Certification in Obesity and Weight Management was developed to confront the full complexity of obesity, said Linda Gigliotti, consultant with the Diocese of Orange County as director of Wellness Programs. The certificate, which was designed for registered dietician nutritionists, physician assistants, nurse practitioners, clinical exercise physiologists, licensed behavioral psychologists or therapists, and licensed clinical social workers, held its first examination just a few weeks before the workshop.
PAYMENT CONSIDERATIONS
Health care payers consider a number of factors when deciding whether to cover a medical treatment, explained Don Bradley, associate consulting professor in the Department of Community and Family Medicine at Duke University. Those factors include (1) customer demand/preference for a benefit or a service; (2) cost (especially costs that are as low as possible and predictable); (3) evidence for effectiveness and efficiency; (4) deliverable quality outcomes; (5) network for delivery; (6) customer experiences and satisfaction; (7) ease of administration; (8) compliance/mandates/ essential health benefits; (9) risk (including legal, financial, regulatory, public relations, and network forms of risk); and (10) profitability/margin. Three panelists followed Bradley’s introduction of the panel, addressing a number of these topics.
Obesity coverage is a challenge for employers, who represent the single largest segment providing health care coverage, said Thomas Parry, president emeritus and co-founder of the Integrated Benefits Institute. Employers are particularly concerned about costs, thinking that expanded treatment for obesity will raise their health care expenses. The answer to this dilemma, Parry argued, is to move beyond medical and pharmaceutical expenses to a broader consideration of costs. In particular, the costs of absences from work and lost productivity because of poor health exceed medical and pharmaceutical costs for a wide range of health conditions, including obesity. Using such data to demonstrate that good care will lead to better outcomes, including costs, will produce “a conversation that the employers are willing to listen to,” said Parry.
As a case study of a private-sector payer, Blue Shield of California covers a number of obesity treatments (including screening, pharmaceutical, and surgery) based on eligibility criteria, prior authorization, and other criteria. It is also interested in providing care in the area of lifestyle medicine, noted Bryce Williams, the company’s vice president for well-being. Interventions that are convenient and supported by evidence can increase engagement and results, he said. “We believe there is a right solution for anybody.”
With regard to public-sector payers, Medicaid is the largest single U.S. health care payer, covering more than 70 million children and adults. Along with the Children’s Health Insurance Program (CHIP), it plays a key role in
accessing obesity prevention and treatment services, said Deirdra Stockmann, lead for secondary prevention in the Division of Quality and Health Outcomes at the Center for Medicaid and CHIP Services at the Centers for Medicare & Medicaid Services (CMS). The Early and Periodic Screening, Diagnostic, and Treatment benefit; mandatory benefit categories for adults; expanded use of health homes; and other provisions can increase the delivery and quality of obesity treatment and prevention services. However, coverage varies from state to state, particularly for adults, and coverage of services does not automatically lead to usage of services or imply delivery of quality care.
POLICY CONSIDERATIONS
The workshop took place during a time of heightened debate around health policy, which has created highly politicized activity around the Patient Protection and Affordable Care Act (ACA), began Lisel Loy, vice president of programs at the Bipartisan Policy Center. Nevertheless, Matt Gallivan, health policy advisor for Senator Bill Cassidy (R-LA), said the ongoing activity in health policy “presents a lot of opportunities to move forward on legislation, in particular in a bipartisan manner.” More legislators are coming to understand the impact of patients with multiple chronic conditions on the federal budget, state budgets, the social safety net, and the importance of access to high-quality care to improve patient outcomes. “We have to have serious conversations about these issues so that we can get at the cost drivers and focus on the growing patient group that is driving a lot of the higher costs and worse outcomes,” said Gallivan.
Lynn Sha, senior health policy advisor for Senator Thomas Carper (D-DE), also emphasized the bipartisan opportunities that exist in health policy. “There actually are a lot of areas of agreement, a lot of areas where people feel like we need to work together to get something done. . . . Please don’t be too discouraged by what you hear. There is a lot of effort behind the scenes to try to come together on some of these major priorities,” including obesity, she said.
Anand Parekh, chief medical advisor for the Bipartisan Policy Center, described how the ACA has impacted obesity treatment for Medicare, private plans, and Medicaid, and highlighted the need to better understand the impact of and uptake of these policies. He described two ideas that his organization has been promoting for the prevention and treatment of obesity, including the development of a secretarial task force on obesity. “We have never had a high-level secretarial task force with agency heads focused on prevention and treatment where you could coordinate the activities of the Centers for Disease Control and Prevention, CMS, and all the federal agencies,” he said. The second area relates to payment and delivery reform focusing on the establishment of quality care outcome measures.
Finally, Joseph Nadglowski, president and chief executive officer of the Obesity Action Coalition, pointed to the proposed Treat and Reduce Obesity Act as an important piece of legislation that could have widespread benefits in regard to access to care. A major challenge, he said, is that obesity prevention and treatment does not have a large number of champions among policy makers. “Every legislator I have ever talked to is interested in addressing obesity, but we have had trouble getting them to make it that number one, number two, or number three issue.” Patients are better than physicians at convincing a legislator that obesity is a serious issue, he observed. “Many of you, through the programs you run, have wonderful stories. . . . Bring those folks with you to the [Capitol] Hill. That is what will change someone’s mind.”
INVOLVING COMMUNITIES AND INDIVIDUALS
In the final panel of the workshop, Marsha Schofield, senior director for governance and nutrition services coverage at the Academy of Nutrition and Dietetics, emphasized the importance of both communities and individuals for successful implementation and use of treatments for obesity. Working with communities requires time, conversations, relationship building, and trust, but “it is essential,” she said. “It is more than buy-in to a concept. It is building the design team that is inclusive of all the parties.”
At the same time, obesity treatment needs to be oriented to the differing needs of individuals, she observed. As with community involvement, that means getting the people who will be served involved in the design of implementation. Successful obesity treatment requires reaching individuals with the right approach, the right provider, and the right message delivered with the right language at the right time (i.e., person-centered care), Schofield said. “There are lots of things to get right. Our challenge is to think about the matchmaking between all of those things, and as we spread and scale, trying to get all of those things right. It is complex, but it is doable.”♦♦♦
DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Steve Olson as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual meeting participants and do not necessarily represent the views of all meeting participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Theodore Kyle, ConscienHealth, and Scott Kahan, STOP Obesity Alliance. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSORS: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Heart Association; American Society for Nutrition; Bipartisan Policy Center; Blue Cross Blue Shield of North Carolina Foundation; The California Endowment; ChildObesity180/Tufts University; Edelman; General Mills Foundation; Greater Rochester Health Foundation; Health Partners; Healthy Weight Commitment Foundation; The JPB Foundation; Kaiser Permanente; The Kresge Foundation; Mars, Inc.; National Recreation and Park Association; Nemours; Nestlé Nutrition; Nestlé USA; Novo Nordisk; The Obesity Society; Partnership for a Healthier America; Reebok, International; The Reinvestment Fund; Robert Wood Johnson Foundation; Salud America!; Weight Watchers International, Inc.; and YMCA of the USA.
For additional information regarding the workshop, visit nationalacademies.org/obesitysolutions.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. The Challenge of Treating Obesity and Overweight: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24830.
Health and Medicine Division
Copyright 2017 by the National Academy of Sciences. All rights reserved.
