The fifth and final session of the third workshop comprised three presentations exploring issues of patient–provider communication around obesity treatment. Jamy Ard, professor in the Department of Epidemiology and Prevention and the Department of Medicine at Wake Forest School of Medicine, moderated the session.
THE ETHICAL DILEMMA OF IMPLEMENTING RECOMMENDATIONS
Hunter Jackson Smith, chief of preventive medicine for the U.S. Army Medical Research Directorate—Africa, reviewed the U.S. Preventive Services Task Force (USPSTF) recommendation for childhood obesity, patient–provider communication challenges and ethical issues associated with the recommendation’s implementation, and systems-wide methods for addressing inequities in the implementation of childhood obesity recommendations.
Smith set the stage by reporting trends in the U.S. prevalence of childhood obesity, which has quadrupled over the past 50 years to the current rate of 19.3 percent of children and adolescents, with an additional 16.1 percent who qualify as overweight (Fryar et al., 2020). He emphasized that the prevalence of obesity varies by several factors, such as socioeconomic group and racial/ethnic population; for example, the prevalence of obesity for children and adolescents aged 2–19 years is around 25 percent for African American and Hispanic children (males and females), 15 percent for non-Hispanic White females, and 5 percent for Asian American females (Fryar et al., 2020). According to Smith, the consequences of childhood obesity manifest in the short term as conditions related to metabolic syndrome, such psychological problems as anxiety and depression, and low self-esteem and self-reported quality of life. Over the longer term, he said, they manifest in a greater likelihood of having obesity as an adult, which is associated with increased risk of such serious conditions as heart disease, type 2 diabetes, and cancer (CDC, 2021).
Having set this context Smith presented the 2017 USPSTF recommendation, which advises clinicians to “screen for obesity in children and adolescents six years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in
weight status.” The recommendation was assigned grade B, which Smith explained represents that the group concluded with moderate certainty that screening for obesity is of moderate net benefit in this population. Based on the evidence reviewed, he said, the USPSTF defined “comprehensive, intensive behavioral intervention” to mean at least 26 contact hours over a 2- to 12-month period. He added that interventions with at least 52 contact hours yielded even greater weight loss and improvements in metabolic risk factors, and that adherence to either the 26–contact hour or 52–contact hour intervention ranged from 65 to 95 percent (O’Connor et al., 2017). Smith explained that the interventions reviewed consisted of multiple components, such as the targeted behavior changes and the theories of change underlying the intervention, that varied by study; they also involved multidisciplinary teams of providers, such as pediatricians, exercise physiologists, dietitians, psychologists, and social workers.
Smith pointed out that it is beyond the USPSTF’s scope and mission to integrate such issues as cost and population-based implementation considerations into its deliberations on whether to recommend a preventive treatment or screening modality. Nonetheless, he said, the USPSTF recognized that children and their families may have limited access to effective, intensive behavioral interventions for obesity. This issue of access gives rise to several communication challenges for clinicians who want to implement the USPSTF recommendations, he explained, but are aware that resources for doing so are not readily available and/or accessible for all of their patients. As examples, he pointed out that the nearest location for such services may be a long distance from the patient’s home, or accessing the services may be cost prohibitive or logistically challenging for the patient’s family. Clinicians must therefore navigate a space within common-sense clinical advice but outside the evidence, he maintained, as they determine how to guide patients and their parents. He noted that they could provide general advice for improving eating and activity habits, but added that no evidence base exists to support the ability of such guidance to result in a meaningful impact on weight.
Smith then compared the USPSTF’s recommendations for childhood obesity screening and adolescent depression screening. In 2009, he said, it issued a grade B recommendation for screening 12- to 18-year-olds for depression only when systems are in place and accessible to ensure accurate diagnosis, effective treatment, and appropriate follow-up. However, he pointed out, that guidance was updated in 2016 to recommend the implementation of screening provided diagnosis, treatment, and follow-up systems are in place without requiring that they be accessible. Smith characterized the updated guidance as a significant shift from saying that screening should be conducted only when those services are accessible. Part of the rationale for the change, he elaborated, was the acknowledgment that
regardless of the accessibility of optimal services, there is an inherent merit and value in diagnosing and offering counsel for adolescents with depression and providing whatever interventions are available, even if they lack an evidence base in the primary care setting. A similar case could be made for the screening of childhood obesity, Smith suggested, so that regardless of the services available, it may be valuable to inform patients and their parents of the seriousness of the obesity diagnosis and advise that they pursue a sustained behavioral intervention.
Smith shifted to discuss ethical issues in three areas—research, screening, and implementation—in which gaps exist between the USPSTF recommendation and the status quo. Beginning with research, Smith highlighted the need for longer-term studies to evaluate maintenance of weight loss after completion of a behavioral intervention, noting that current evidence has followed patients up to only 1 year following intervention. More evidence is also needed, he argued, regarding what constitutes clinically important health benefits, as well as the amount of weight loss associated with those benefits. Studies addressing behavioral interventions in diverse populations and in children aged 5 years and younger are also needed, he suggested, to determine whether preventive interventions and screening modalities are effective for all groups or more tailored recommendations are warranted. Smith highlighted the National Institutes of Health UNITE initiative (see Chapter 13) as an example of a research effort to address the ethical gaps related to diversity and racial equity that he predicted will impact implementation.
Moving on to the screening gap, Smith proposed that core criteria for a good screening tool include the existence of an accepted treatment for patients who screen positive for the condition of interest, as well as the availability of facilities for diagnosis and treatment of that condition (Andermann et al., 2008). He reiterated that the lack of or only minimal access to an accepted treatment raises concern about the consequences of screening. This concern leads in turn, he argued, to the question of whether clinicians should recommend preventive interventions to their patients—based on USPSTF guidance—if patients have limited or no access to them despite their proven effectiveness.
Systematic inaccessibility of treatment becomes an issue for disadvantaged groups, Smith maintained, and can exacerbate existing disparities. He highlighted this issue as an exemplar of the difference between health equality and health equity. Equality, he stated, is achieved by offering everyone the same service, but such parity is insufficient when people need different solutions to resolve disparities—an issue of equity. Moreover, he said, equality exists when all children are referred to intensive behavioral counseling, but equality alone may not be sufficient for patients for whom those services are largely inaccessible—likewise an issue of equity.
Thus equality is meaningful only if accompanied by equity. If justice and equity are public health imperatives, Smith maintained, then efforts to achieve equitable distribution and accessibility of interventions are critical for addressing childhood obesity in an ethical manner.
Smith has observed a lack of urgency on the part of many clinicians and parents to address a positive screening for obesity, despite its health, quality of life, and social consequences. He drew a contrast with the response to screening results for other health conditions, where clinicians automatically feel compelled to refer a patient to the appropriate next step for intervention, however costly or difficult to access it may be. According to Smith, the lack of urgency to address a positive screening for obesity could reflect findings of public opinion polls that Americans do not generally perceive obesity to be a major problem for them or their family (Berry et al., 2018; Cyr et al., 2016; Roper Center, 2020), or maybe a response to a normalizing of excess weight in society.
Moving on to the gap in implementation of the USPSTF recommendation on screening for childhood obesity, Smith highlighted two questions: Who is responsible for ensuring that the USPSTF recommendations are implemented equitably, and how can we best fill the gaps in access for disadvantaged populations who are most afflicted by childhood obesity? These questions, he suggested, evoke fundamental considerations about defining the ethical responsibilities of states and governments for the well-being of their children. If health care is deemed a basic right, he continued, what does this right entail, and who is charged with protecting it? After such bodies as the USPSTF identify effective preventive actions, Smith argued, universal implementation must be ensured—particularly where the need is greatest—to avoid exacerbating disparities.
Creative solutions will be key in responding to implementation challenges, Smith proposed, citing as examples collaboration with community programs and the use of technology to enable telehealth opportunities. He urged clinicians to emphasize screening, documenting, and offering interventions and counseling as feasible in the meantime, but asserted that addressing core issues is a precursor to reaching the next level of progress. Some communities may be unable to offer evidence-based interventions, he acknowledged, but may be able to spotlight the issue and provide alternative, less resource-intensive options, recognizing possible gaps in the evidence for their effectiveness. Looking further upstream, Smith promoted the value of targeting social determinants to address childhood obesity, arguing that children deserve to reach adulthood with the ability to pursue their goals unencumbered by the physical and mental impairments resulting from obesity. He reiterated that lack of equitable access to childhood obesity screening and preventive interventions across populations creates and exacerbates disparities in health outcomes among groups.
AUDIENCE DISCUSSION
Following Smith’s presentation, Ard asked him whether different types of research and evidence need to be available before further childhood obesity recommendations are developed. Smith replied that although more evidence is desirable, it is unreasonable to wait for perfect data, and that failure to act on the available evidence would be a disservice to patients. Once a baseline of evidence for a particular intervention has been established, he suggested, the next step is to apply more robust and nuanced research methods to examine its effectiveness for various subpopulations and contexts.
Next, a participant asked Smith for his opinion on the potential for telehealth and remote patient monitoring to facilitate access to treatment. Smith maintained that telehealth is a key means of facilitating equitable implementation of childhood obesity counseling, particularly in rural locations that lack obesity specialists. He observed that the COVID-19 pandemic had improved people’s comfort and familiarity with telehealth modalities.
Another participant asked whether shared decision making could help bridge the gap between an evidence-based recommendation that seems unattainable and the need to act. Smith wholeheartedly agreed that shared decision making is a good alternative in these cases. A benefit of shared decision making is being able to engage more deeply and meaningfully with patients, he added, which enables a shared understanding of the kinds of common-sense solutions that can be pursued when the optimal solution is inaccessible.
THE EFFECT OF OBESITY ON PATIENT–PROVIDER COMMUNICATION
Kimberly Gudzune, medical director of the American Board of Obesity Medicine and director of the Healthful Eating, Activity & Weight Program at The Johns Hopkins University, reviewed evidence on how health care professionals’ attitudes, communications, and behaviors may differ for patients with obesity and proposed potential strategies for improving these patients’ health care experience.
Gudzune began by observing that multiple challenges to obesity care exist in health care settings. She cited the examples of incomplete insurance coverage for evidence-based treatments (e.g., behavioral weight-loss counseling, antiobesity medications, bariatric procedures) and medically induced causes contributing to obesity or impaired treatment (e.g., medications that promote weight gain) (Apovian et al., 2015; Kushner, 1995; Tsai et al., 2006).
The physical environment of a clinic may propagate stigma, Gudzune continued, if appropriately sized equipment and devices are unavailable to accommodate patients of all sizes. Although subtle, she said, such environmental factors can signal to patients with obesity that they are unwelcome and unable to be treated. As another challenge she pointed to clinicians’ lack of time to perform obesity care services—assuming they are even trained to provide them—as well as a broader problem of clinicians themselves serving as a source of stigma for patients with obesity (Gudzune et al., 2012; Kushner, 1995; Mastrocola et al., 2020; Puhl and Brownell, 2001).
Gudzune elaborated on clinicians’ biased attitudes toward patients with obesity, which she characterized as pervasive and persistent over time. According to surveys conducted on different continents as far back as 1969, she reported, clinicians associate obesity with poor hygiene, lack of adherence to recommendations, and dishonesty. Primary care physicians tend to believe that patients with obesity are less likely to follow medical advice, benefit from counseling, or adhere to medications, attitudes that Gudzune suggested may subtly influence their treatment recommendations (Foster et al., 2003; Hebl and Xu, 2001; Huizinga et al., 2009, 2010; Klein et al., 1982; Maddox and Liederman, 1969; Puhl and Heuer, 2009).
Gudzune maintained that in the context of these challenges, patients with obesity often have health care experiences that can negatively affect the treatment they receive. She gave several examples of these negative effects, beginning with patients’ avoidance of or delay in health care seeking. One study found that more than half of patients with obesity reported canceling an appointment because of anxiety about being weighed (Alegria Drury and Louis, 2002), Gudzune relayed, while another study found that patients with obesity delayed cancer screening tests because they feared being treated disrespectfully or otherwise stigmatized (Amy et al., 2006). In many cases, she added, patients with obesity have higher risks for adverse health outcomes, which heightens the importance of their prompt engagement in care.
A second example of these negative effects, Gudzune continued, is impaired continuity of care. Patients with obesity are 37 percent more likely to “doctor shop,” she reported, noting that some people engage in doctor shopping as a result of weight-stigmatizing experiences, such as the perception that their primary care provider has judged them on the basis of their weight (Gudzune et al., 2014b). They also have a 68 percent greater incidence of going to the emergency department although they are not at increased risk of hospitalization (Gudzune et al., 2013), which according to Gudzune indicates that they are accessing the emergency department for concerns that instead could have been brought to a primary care provider if they had a continuous relationship with one. Gudzune stressed how important it is for providers to understand a patient’s prior experience with
weight stigma in health care settings so they can promote a welcoming environment that fosters continuity of care.
Gudzune moved on to a third example—undermining communication—which she described using data comparing incidence rates of physician communication behaviors (during typical primary care visits) with patients who have overweight and obesity and those with normal weight. These data showed nonsignificant differences by patients’ body weight for medical data gathering (e.g., collecting information about medical history) and education/counseling (e.g., how to take a medication), as well as data gathering and education/counseling on lifestyle topics. Gudzune questioned the equitability of the counseling outcomes, however, given that patients with overweight and obesity may warrant more counseling, particularly for lifestyle behavior changes. Among patients with versus those without overweight or obesity, she highlighted a significantly lower incidence of physicians’ emotional rapport building (e.g., developing a connection between patient and provider, including exhibiting empathy, which Gudzune identified as critical for successful behavioral counseling).
As a fourth example Gudzune cited the influence of a patient’s weight on a clinician’s decision making and care. Gudzune pointed out that clinicians may avoid performing exams for patients with obesity if they encounter technical difficulty or lack the proper equipment, adding that diagnostic plans may differ for patients with versus those without obesity (e.g., physicians tend to prescribe more tests and to spend less time in the room with these patients) (Campbell et al., 2009; Ferrante et al., 2006; Hebl and Xu, 2001). This differential treatment extends to clinicians’ lower likelihood of counseling patients about weight loss, she continued, for such reasons as perceiving limited efficacy or futility of obesity treatment, feeling unprepared with respect to training, having limited time and reimbursement for services, and ranking weight-loss counseling low on the list of multiple issues to address during a care visit (Fogelman et al., 2002; Foster et al., 2003; Gudzune et al., 2012; Kristeller and Hoerr, 1997; Kushner, 1995).
Lastly, Gudzune mentioned effects on patient outcomes. She shared one example in which lower rates of cancer screening (mammography, pap smear, colonoscopy) were observed for patients with overweight or obesity compared with those with normal weight. She added that greater degrees of obesity were associated with lower rates of screening (Maruthur et al., 2009a,b, 2012).
Gudzune shifted to highlighting opportunities for clinicians and health care settings to play a positive role for patients with obesity. Among participants in a behavioral weight-loss trial, she reported, higher ratings of the helpfulness of the primary care provider’s involvement were associated with greater weight loss in primary care, as was combining population health management with an online obesity care program. She added that
discussing weight loss with patients in a way that they do not perceive as judgmental is associated with achieving clinically significant weight loss over 1 year, and that, contrary to some assumptions, non-Hispanic Black, Hispanic, and Asian patients want to have weight-related discussions with their clinicians (Baer et al., 2020; Bennett et al., 2015; Gudzune et al., 2014a; Lewis et al., 2016).
Gudzune pointed out that evidence-based communication and counseling approaches such as the 5A’s framework and motivational interviewing are associated with improvements in patient willingness and confidence with respect to changing their health behaviors, and are applicable in a variety of clinical settings (Alexander et al., 2011; Cox et al., 2011; Gallagher et al., 2021; Jay et al., 2010, 2013; Pollak et al., 2010; Washington Cole et al., 2017; Welzel et al., 2021). She suggested that, because clinicians can readily be trained in these techniques, and many clinicians may already be familiar with them, their regular use could change care for patients with obesity.
Gudzune ended her presentation with a list of ideas for addressing weight bias in health care settings, with the caveat that most are untested yet pragmatic based on relevant available evidence. One is to alter the clinic environment to provide chairs and medical equipment that can accommodate patients of any size, which she said could be facilitated by providing financial support or incentives for facilities to cover the expenses involved. Another idea, she suggested, is to provide sensitivity training to improve awareness of how clinician attitudes can impact patients with obesity, in combination with additional research to design and evaluate such trainings. A similar idea, she continued, is to increase empathy and positive affect among clinicians through perspective-taking exercises, and another is to increase their awareness of weight bias and help them examine their explicit and implicit attitudes (Alberga et al., 2016; Phelan et al., 2015). Gudzune added that interventions to address clinician barriers might include providing education—from medical school through board certification and in continuing medical education—on the multifaceted contributors to weight gain and loss; conducting training on evidence-based counseling techniques; leveraging electronic health records to support counseling; and improving access by advocating for coverage of evidence-based obesity treatments with insurers, employers, and government agencies.
AUDIENCE DISCUSSION
Gudzune answered a few questions following her presentation. First, Ard asked how race concordance affects patient–provider discussions about obesity. Gudzune responded by explaining that race concordance can be an important factor in how conversations play out; for example, having race
as a common shared experience can make it easier to bring up a topic like weight in a way that is well received. On the other hand, she suggested, race-discordant scenarios may increase the likelihood of the topic being sidestepped because of concern about offending the other party or not understanding how that person perceives weight or obesity. These reasons for avoiding the topic are understandable, she said, but at the same time, some studies suggest that non-Hispanic Black, Hispanic, and Asian patients want to discuss obesity treatment options. She added that race discordance may play a role in some cases in which these conversations do not take place. Gudzune also pointed out that, while race-concordant relationships can help, another solution is to empower the current clinician workforce to initiate these conversations with patients of all backgrounds. She suggested that further research could help inform strategies for approaching different populations in a way that is both sensitive and engaging.
A participant asked whether efforts for system change would be amplified by physician demand for referral mechanisms to connect patients with providers who have expertise in obesity medicine. While acknowledging this possibility, Gudzune maintained that two other aspects are important: first, that a comprehensive network of qualified obesity care providers is on the receiving end of the referral, and second, that insurance coverage is available to facilitate patient access to those services.
Asked to share her thoughts on the intersectionality of income, socioeconomic status, and weight and stigma in obesity treatment and health care settings, Gudzune suggested that race can be another layer in this dynamic. She called for equipping health care systems so they do not exacerbate disparities—for example, by increasing the equity of Medicaid coverage, which varies by state, for obesity treatments.
UNDERUTILIZATION OF BARIATRIC SURGERY: HEALTH INSURANCE DESIGN, WEIGHT STIGMA, AND PATIENT–PROVIDER COMMUNICATION
David B. Sarwer, associate dean for research and director of the Center for Obesity Research and Education at Temple University College of Public Health, discussed access to care and insurance coverage for bariatric surgery, along with the potential benefits of a shared decision-making approach for engaging patients in obesity treatment.
Sarwer began by reviewing the prevalence of extreme (also known as clinically severe) obesity in the United States (body mass index [BMI] ≥ 40 kg/m2), which he called a “subepidemic” embedded within the country’s broader obesity epidemic. He noted that nearly 12 percent of women and almost 7 percent of men are in this weight category, which he said translates to an individual’s having approximately 100 pounds of excess weight. He added that the prevalence
of extreme obesity is highest among non-Hispanic Blacks (13.8 percent) (Hales et al., 2020). He reported further that as of 2016, more than 32 million U.S. adults had either class II or III obesity (BMI 35–39.9 kg/m2) (Campos et al., 2020), making them potential candidates for bariatric surgery.
Sarwer elaborated on bariatric surgery procedures in the United States, which approximately 256,000 Americans undergo annually (ASMBS, 2021). He pointed out that this figure represents only 1 in 100 individuals who meet BMI criteria for the procedures (≥ 40 kg/m2 or 35–40 kg/m2 in the presence of an obesity-related comorbidity), and only 25 percent of those who have the surgery are Hispanic or African American despite the higher prevalence of extreme obesity in these populations (ASMBS, 2021). Sarwer pronounced this a profound health disparities issue, maintaining that the underutilization of bariatric surgery reflects issues of health insurance coverage and benefits design, weight bias and stigma, and patient–provider communication (Sarwer et al., 2021).
Insurance coverage for bariatric surgery procedures has expanded over the past decade, Sarwer reported, and as of 2018, coverage was provided by Medicare, 49 state Medicaid programs, 43 state employee programs, individual and small-group insurance markets in 23 states, and more than 90 percent of commercial insurers (ASMBS, 2018; Gebran et al., 2020). He added that insurance coverage varies by state and sometimes by region, which he said can create logistical complications for patients who reside at the intersection of different states or metro areas and seek care in a different area from where they live.
Sarwer emphasized that the existence of insurance coverage does not necessarily mean easy access to bariatric surgery. He highlighted several barriers to access, such as the major effort required to prepare the required documentation to seek insurance approval for a procedure. Time and resources are also required to satisfy precertification criteria for a procedure (e.g., completing 3–6 months of preoperative medical weight management [MWM]). Sarwer explained further that several studies have suggested that patients complete an average of eight separate visits to the institution performing the bariatric surgery prior to the procedure, with the intent of preparing them for optimal outcomes. A related barrier is patient cost sharing, which he clarified encompasses the costs of such expenses as visit copays, transportation or parking fees, and child care costs that accumulate during a bariatric surgery experience. Sarwer shared a personal anecdote on this topic, recalling that he used to assume that patients were disinterested or disengaged if they failed to attend presurgery visits, whereas in reality their absence may have reflected social determinants of health, such as financial or logistical constraints (Gasoyan et al., 2019; Tewksbury et al., 2017). Telehealth has tremendous potential, he suggested, to help reduce some of these barriers to obesity care.
Sarwer moved on to relay key findings from three studies examining relationships between insurance plan design and utilization of bariatric surgery, based on data from southeastern Pennsylvania during 2014–2018 (Gasoyan et al., 2020, 2021). During this period, he observed, rates of bariatric surgery increased nationally among African Americans and Hispanic Americans. Individuals with preferred provider organization (PPO) and fee-for-service insurance plans within the private insurance category had greater odds of undergoing the surgery relative to those with private health maintenance organization (HMO) plans. Similarly, among Medicare beneficiaries, those with Medicare Advantage PPO plans versus those with Medicare Advantage HMO plans had greater odds of undergoing the surgery. And individuals with traditional Medicare (Parts A and B) fee-for-service plans had lower odds of undergoing the surgery compared with beneficiaries of Medicare Advantage HMO plans. Sarwer cited data suggesting that preoperative MWM requirements are a barrier to care, as patients with versus those without that requirement were less likely to have the surgery within a year. He added that neither preoperative MWM nor cardiology and pulmonary clearances were associated with a reduction in inpatient health care utilization in the first postoperative year.
Sarwer next described implications of these findings, first for providers and patients. First, he maintained that it is time to reconsider insurance-mandated precertification requirements for bariatric surgery. As an example, he suggested that preoperative MWM may be necessary and helpful for only a subset of patients—those who have not already exhausted diet- and activity-related approaches to weight loss. Second, he appealed for reorganizing care around the patient instead of around the demands of insurance companies or specific clinics. He reiterated the potential of telemedicine to address barriers to completion of preoperative assessments and engagement in postoperative care. As for implications for payers, he argued that it is time to apply to bariatric surgery value-based insurance design that considers cost savings over the patient’s life postsurgery. According to Sarwer, payers would achieve higher return on investment if utilization of bariatric surgery increased among patients with BMI ≥ 40 kg/m2 and type 2 diabetes, and he suggested that patient out-of-pocket costs be based on the clinical value of a specific bariatric procedure. Some employers already incorporate bariatric surgery into their self-administered benefit plans, he noted, using a value-based insurance design. For instance, MGM Resorts International saw good clinical outcomes after offering an incentive for its employees who underwent weight-loss surgery: $5,000 in reimbursed copays after 2 years and another $5,000 to cover such procedures as excess skin removal after 4 years (Fendrick and Sonnad, 2012).
Sarwer moved on to discuss weight stigma as another major barrier to bariatric surgery. Weight stigma is ubiquitous in the general population,
he maintained, and is a well-established barrier to all forms of obesity treatment. It is associated with psychosocial distress, he added, with 50 percent of these patients meeting criteria for a psychiatric diagnosis (Hatzenbuehler et al., 2009), as well as with weight gain, increased waist circumference, elevated levels of C-reactive protein, and poor glycemic control (Pearl et al., 2017). He observed that internalized weight bias, whereby individuals absorb stigmatizing beliefs because of their own perceived failings, can be associated with increased odds of metabolic syndrome (Pearl et al., 2017).
To reduce weight-biased attitudes, Sarwer advocated for educating the public (and specifically health care providers) about the multifactorial contributors to the development of obesity, an understanding that he said challenges common assumptions that weight is exclusively within an individual’s behavioral control (Pearl and Lebowitz, 2014). Trainings that allow medical students to interact with standardized patients with obesity appear to hold some promise, he noted, for increasing empathy and confidence in delivering treatment (Kushner et al., 2014). He suggested that future research target the relationships among race; weight stigma; and patient–provider communication about obesity treatment, including bariatric surgery.
Sarwer ended his presentation by discussing shared decision making as it relates to navigating a patient’s options for obesity treatment. Shared decision making, he explained, is a process whereby patient and provider actively share information and work collectively to come to a treatment decision that meets the patient’s needs (McCaffery et al., 2010). Sarwer highlighted the importance of connecting patients with the education and support they need to make decisions and participate in their own care, including expressing their values and preferences for treatment (Hawley and Morris, 2017).
When applied to patients with clinically severe obesity, Sarwer proposed, shared decision making should start with the patient and provider overseeing or coordinating medical care. A thorough review of the patient’s weight history and history of weight-loss efforts is critical, he added, and should be conducted in a forthright yet respectful manner to avoid the patient’s feeling blamed for a lack of sustained success with previous treatments. Shared decision making that extends to all members of the multidisciplinary care team is useful, he continued, in discussing the benefits and limitations of different surgical interventions for a particular patient, as well as options for the delivery of postoperative care.
Sarwer pointed out that the idealized vision of shared decision making does not explicitly recognize the personal, interpersonal, and community characteristics that affect a patient’s capacity to engage. Racial, ethnic, and cultural minorities in particular may have limitations with language, communication skills, and medical literacy (Hawley and Morris, 2017). Individuals from underrepresented groups may be skeptical or distrustful of health care
providers whom they perceive as not understanding their lived experiences. The result, Sarwer said, can be to default to the traditional, hierarchical provider-as-expert approach to communication, which in turn can strain the relationship and lead to deferred or atypical care (Smith et al., 2009). Sarwer stressed the importance of provider efforts to develop rapport and empathy with patients, and cautioned that provider biases about which patients are most likely to take an active role in their care may impact provider engagement in shared decision making (Williams et al., 2008). He expressed enthusiasm about the potential for new decision support tools to facilitate and enhance shared decision making in obesity and bariatric care.
To summarize, Sarwer reiterated that bariatric surgery produces greater and more enduring weight losses relative to lifestyle modification and pharmacotherapy, but remains profoundly underutilized for reasons related to health care policy and delivery, as well as individual-level beliefs and experiences. He called for strategies for minimizing internalized weight bias and stigma, which he suggested could be addressed most effectively by education to create a new culture of understanding among medical students and other health professionals about the disease of obesity. Finally, he urged providers to identify novel strategies for ensuring that patients with clinically severe obesity and related morbidities are informed of the most appropriate treatments available to them.
AUDIENCE DISCUSSION
Following Sarwer’s presentation, Ard asked him to share his perspective on how people perceive surgical treatment in initial discussions about obesity treatment options. Sarwer replied that he believes misinformation about the risks of bariatric surgery is widespread, and he referred to anecdotes about health care providers who say they do not recommend bariatric surgery because they have heard about a patient who died or ended up in the intensive care unit following a bariatric procedure. He acknowledged that bariatric procedures are not risk free, but asserted that for most patients, risks for severe adverse outcomes are relatively low and outweighed by the potential benefits. He added that it can be a challenge to steer conversations away from misinformation in a way that is productive for changing the beliefs and attitudes of the misinformed party.
A participant asked Sarwer for suggestions for motivating employers to provide insurance coverage or related benefits that would encourage their employees to pursue bariatric surgery. Sarwer posited that such decisions are easier for large than for small employers because the latter are typically less able to negotiate with insurance companies. Thus, he said, they face the dilemma of absorbing or passing on to employees the extra costs of providing bariatric surgery coverage for their workforce.
Another participant remarked that preferences for body shape and size vary by ethnic identify and self-identity, and asked Sarwer how to balance those preferences with medical recommendations for bariatric surgery. Evidence indicates that body image improves postsurgery for a majority of patients, Sarwer reported, but he acknowledged that in his experience, some patients have expressed concern that they or their spouse or romantic partner would be dissatisfied with their appearance postsurgery. He pointed out that when 60–90 minutes can be dedicated to preoperative counseling visits, such concerns can be further discussed. He added that the challenge of shorter preoperative visits is another reason why it is important for all members of multidisciplinary obesity care teams to be trained in handling such concerns, or at least to be able to direct patients to another colleague with the appropriate expertise.
IDENTIFYING GAPS AND NEXT STEPS (PANEL AND AUDIENCE DISCUSSION)
The session concluded with a panel and audience discussion focused on identifying research gaps and next steps for improving patient–provider communication around obesity treatment, as well as access to treatment for all patients. Smith, Gudzune, and Sarwer discussed a range of topics that included initiating conversations with patients about obesity treatment, discussing the impact of social determinants on obesity, communicating the long-term nature of treatment, promoting shared decision making, integrating synergistic clinical care models, novel settings for weight management strategies, ideal coverage scenarios for obesity treatment, and key priorities for improving patient–provider communication about obesity.
Initiating Conversations with Patients about Obesity Treatment
Ard opened the discussion by asking the panelists for practical tips on broaching the topic of obesity treatment with patients. Sarwer replied that conversations about weight are expected when patients visit a clinic that specializes in obesity, but suggested that providers who are not obesity specialists are often on solid ground in discussing the health consequences of excess weight. At the same time, he continued, patient perceptions about their body image and appearance may be stronger motivators than health improvements for them to address their weight. Patients often find greater satisfaction in dropping a clothing size, he said to illustrate this point, than in lowering their hemoglobin A1c level.
Gudzune urged providers to consider the appropriate timing for initiating discussion of the topic of weight. In her experience, weight stigma can be reinforced for patients when they present for a visit or complaint
not directly related to obesity and the provider brings weight into the discussion—even if the complaint may be alleviated by weight loss—or mentions weight fleetingly at the end of the visit. She proposed that in these situations, the provider ask the patient about returning for a future visit to discuss weight loss as a strategy for addressing the problem. This framing asks the patient for permission to discuss weight, she explained, and it also conveys that the provider perceives the topic to be important enough to warrant its own visit. Even when weight is a planned discussion topic, Gudzune urged providers to first understand how patients perceive their weight before launching into their recommendations. This context helps set the stage for a better patient–provider partnership, she maintained, by aligning expectations and helping the provider provide appropriate treatment recommendations. Smith echoed Gudzune’s advice and shared his view that asking patients how they feel about their weight status is a way both to introduce the topic and to discover a patient’s level of readiness and willingness to pursue weight loss.
Integrating the Impact of Social Determinants of Health in Patient Conversations
In Smith’s view, introducing social determinants of health in conversations with patients who have obesity has value in helping to change the pervasive U.S. perspective that obesity is a completely self-inflicted condition. Individual behaviors play a role, he clarified, but social determinants of health also have a large role in a person’s obesity status, as well as a range of other domains of well-being. He suggested talking with patients about how to work together to overcome challenges within their built and food environments.
Sarwer agreed that social determinants of health are a fundamental concept regardless of disease condition, but submitted that for obesity, society tends to blame the individual. He recounted some of his conversations with patients with obesity, in which he said it resonated with them when he suggested that the condition is a logical consequence of living in an environment that is engineered to minimize physical activity and is replete with readily accessible unhealthy food choices. A person has to mount a valiant effort in such an environment, he suggested, not to gain excess weight. The concept of mindfulness may also have traction, he added, in helping people become more engaged in the moment when making food choices.
Gudzune built on Smith’s and Sarwer’s points in proposing that discussing the genetic heritability of obesity can help patients minimize self-blame. It is illuminating for many patients to recognize, she said, that they face a deck that is not stacked in their favor when a genetic predisposition is combined with an environment that favors weight gain, although it often
takes multiple conversations for this concept to sink in when the willpower perception is deeply ingrained. She shared that in her practice, she invites patients to describe the positive and negative aspects of their environments in terms of influences on weight management. They usually identify some positive aspects and resources, she recounted, which gives way to a joint discussion about how to leverage those resources. This exchange helps start what she called a “positive snowball” that she believes is important for countering feelings of hopelessness or ambivalence that can easily arise in some situations.
Communicating the Long-Term Nature of Obesity Management to Patients
Ard pointed out that obesity is a chronic disease that is likely to relapse if treatment stops, and asked panelists how to help set patients’ expectations about its long-term nature. Sarwer urged repetition and affirmed the value of delivering a consistent message that cuts through the clutter of background noise about weight. He stressed that, after giving behavioral recommendations to a patient, providers should follow up on those recommendations at the subsequent patient visit, arguing that failure to do so sends a message that the recommendations were unimportant.
Gudzune called attention to a societal misperception that weight loss is a temporary experience, whereas in reality it is often a chronic, relapsing experience whether the treatment approach is lifestyle modification, pharmacotherapy, or surgery. Weight-loss stories highlighted in the media often show dramatic, seemingly instant losses, which she said does not give patients realistic expectations about the progress and timeline of typical weight-loss journeys. These kinds of portrayals reinforce self-blame and internalization of stigma, she asserted, suggesting that patients might instead feel affirmed by their smaller victories if portrayals were more accurate.
Smith agreed that media portrayals of weight-loss success stories often fail to convey the tremendous effort that goes into achieving a substantial weight reduction. As a result, people may quickly become depressed or disenchanted with the gradual process of losing and maintaining weight. He suggested comparing obesity to other types of chronic relapsing conditions, such as chronic pain, to help convey the message that persistent effort is required to achieve and maintain weight loss.
Promoting Shared Decision Making
Smith suggested, first, that providers consider the various shared decision-making approaches and philosophies that exist and then choose a decision-making tool that corresponds to the approach they want to pursue.
Second, he said it is helpful to gather information resources that patients can use to make a decision about obesity treatment. Readily available resources can help guide patients in their decision making, he elaborated, so they are not starting with an open-ended Google search. Gudzune added that it is also important to understand a patient’s usual and trusted—and mistrusted—sources of information, which she suggested helps providers know how to tailor conversations with individual patients. She also urged the health care community to be engaged in communications and popular media to increase the public’s exposure to credible voices that can help raise societal awareness of obesity issues.
In Sarwer’s view, a provider’s approach to shared decision making depends on the clinical context. He contended that shared decision making is easier for providers in obesity-specific practice settings because patients know what they are getting into. In these situations, he maintained, the key focus is on building rapport with patients and communicating the evidence with both authority and empathy. For providers in primary care settings who are unsure of how best to treat a patient with obesity, Sarwer said, providing an evidence-based referral to another provider with the appropriate expertise is “the greatest gift” they can give to that patient. Another member of the treatment team may be able to step in, he remarked, adding that nonphysician, non–doctoral-level providers can also be trained to provide effective weight management counseling.
Integrated Synergistic Clinical Care Models
The three speakers agreed that reliance on comprehensive obesity treatment programs is insufficient and that multilayered approaches are imperative to address the systemic factors that contribute to the development of obesity and propagate weight stigma. Gudzune reiterated that a relatively easy win in this space is to adjust the physical clinic environment so that waiting room chairs, exam tables, and scales, for example, can readily accommodate people of all body sizes. This relatively simple, common-sense strategy still requires financial capital or other incentives to achieve, she pointed out, suggesting that quality and equity of care are rationales for this investment. Gudzune also argued that engaging different types of providers would help achieve a more integrated clinical care model. An alert could be programmed to appear in a patient’s electronic health record, she said as an example, when a certain threshold has been reached in terms of prescriptions for weight-gain–causing medications. Doing so would facilitate bringing pharmacists into decision-making processes, she observed, to discuss potential medication alternatives.
Sarwer agreed that pharmacists could play a more active role in obesity management and suggested that nursing and social work professionals
could also participate. These professionals often work in community settings and may even conduct home visits, he pointed out, giving them the opportunity to discuss patients’ specific lifestyle habits.
Novel Settings for Weight Management Strategies
Gudzune urged stakeholders to consider embedding weight management strategies in settings that are widely accessible, even in places where people typically would not think about receiving health care services. She pointed to pharmacies located in supermarkets as an example of a common setting for reaching people in the context of their everyday lives. From there they could be triaged into a more focused setting within the community for their specific health conditions, she added, facilitated by partnerships with the pharmacy and other community entities that provide care. Smith echoed the importance of diversifying the environments in which patients can receive care, adding that not all patients can access specialized clinical weight management programs.
Sarwer built on Gudzune’s idea about leveraging pharmacies and suggested that the field of obesity care needs champions who can approach potential funders to discuss such investments as housing weight management clinics in pharmacies or piloting programs that train pharmacists to deliver lifestyle modification interventions. He shared his view that obesity does not lend itself to philanthropic investment as much as do other diseases, perhaps in part because of bias and stigma, and speculated as to whether a celebrity endorsement would help maximize the reach of treatment solutions.
Envisioning an Ideal Coverage Scenario for Obesity Treatment
Asked to envision the components of a comprehensive health plan that would include coverage of obesity treatment for children and adults, Gudzune espoused coverage for three primary categories of intervention: lifestyle/behavioral counseling, pharmacotherapy, and surgical procedures. She stressed the importance of having multiple options for patients within each type of intervention, describing an example scenario whereby a plan would cover behavioral counseling in primary care settings, but this treatment would become inaccessible if the provider were not trained to offer that service. She suggested that partnerships with evidence-based commercial weight-loss programs could be additional avenues for lifestyle solutions. With regard to pharmacotherapy, she explained that coverage for a single agent—particularly if that agent can be prescribed for only 3 months, for example—is insufficient to address the long-term nature of most weight management efforts; she also highlighted that Medicare does
not cover antiobesity medications. With respect to surgical procedures, Gudzune maintained that it is important to have an evidence base to support their coverage. She indicated that bariatric surgery has solid supporting evidence, but that emerging minimally invasive techniques, such as intragastric balloons, have less evidence. She explained that the latter techniques are important for patients who have contraindications to pharmacotherapy or bariatric surgery but have a medical need to lower their body weight, such as to prepare for an organ transplant or knee surgery. In Gudzune’s view, a lack of options for these people creates a persistent sense of hopelessness.
Smith and Sarwer agreed with Gudzune that an ideal coverage scenario would include various treatment modalities, multiple specialties, and multiple options within those specialties. Smith appealed for another layer of coverage to reduce the practical and financial barriers to accessing care for obesity, such as transportation, child care, and time off from work. Sarwer proposed that coverage also could include incentives that promote healthy lifestyle behaviors, such as purchasing fruits and vegetables and gym memberships, though he acknowledged that such provisions would be challenging to substantiate with evidence and to implement.
Improving Patient–Provider Communication about Obesity
The panelists’ final comments highlighted key priorities for improving patient–provider communication about obesity. Smith reiterated his emphasis on discussing the influence of social determinants of health on obesity status. The evidence base in this area is still developing, he conceded, and consists predominantly of relatively short-term studies that modified single aspects of an environment. These studies tend to produce modest results, he observed, and he asserted that research examining the effects of modifying multiple determinants of health over a longer time period would more likely observe greater impact. Such studies are challenging and expensive to conduct, he admitted, but would help build an evidence base about the synergistic benefits that would likely result from a focus on multiple interconnected determinants.
Gudzune focused on the need to train both future and practicing clinicians in how to treat obesity. She called for more robust research on how to tailor training for the next generation of clinicians, pointing out that some evidence indicates that training can exacerbate weight bias in certain situations. She observed that many medical students and residents are interested in providing better treatment for obesity, but their supervising clinicians sometimes have attitudes and biases that impede them from obtaining appropriate training. Gudzune argued that this observation points to a need to find ways of supporting both upcoming and practicing clinicians at the right level.
Sarwer echoed his earlier comments about the importance of emphasizing the chronic nature of obesity treatment, stressing that, regardless of modality, the duration of obesity treatment is similar to treatment for other chronic diseases, such as diabetes or hypertension, not a quick fix of 3–6 months. Sarwer’s second point was that many unanswered questions remain about the 20–30 percent of patients who fail to respond well to bariatric surgery. More research is needed, he asserted, to better inform the field about how to care for those patients. Lastly, he envisioned an ideal scenario of comprehensive obesity care centers where multidisciplinary professionals would converge to provide holistic, patient-centered care. In closing, he argued that the prevalence and severity of obesity truly warrant this kind of approach.
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