COPE Webinar Series, Oct 2019: A Proposed Standard of Care for Adult Obesity Treatment

COPE Webinar Series, Oct 2019: A Proposed Standard of Care for Adult Obesity Treatment


Good afternoon. Welcome to our October webinar for health professionals. We’re so glad you’ve joined us for this hour of learning followed by some good discussion. Today we are honored to welcome Bill Dietz and Christine Gallagher today as they present on A Proposed Standard of Care for Adult Obesity Treatment for All Providers. While it’s pretty well known, of course, that obesity is now affecting nearly 40% of the adult population in the United States, we are really less in lockstep about what to do about it. Specifically what standards of care should universally be followed when treating adults with obesity. We have over 200 health professionals registered for what promises to be an informative webinar affording us the opportunity to hear from two experts in the field about a brand new proposed set of obesity treatments standards of care. We will also have time at the end for a bit of discussion and Q&A. My name is Lisa Diewald and I’m the program manager at the MacDonald Center for Obesity Prevention and Education at Villanova University’s Fitzpatrick College of Nursing. I have the pleasure of being the moderator for today’s program. Villanova is home to the first College of Nursing in the country to have a center devoted exclusively to obesity prevention and education. As the bottom of this slide illustrates, COPE’s goals are to enhance nutrition and nursing education and topics related to obesity, nutrition, and health promotion strategies, to provide continuing education programs, such as this webinar on obesity and obesity related topics. And lastly, to participate in research to expand and improve evidence-based approaches for obesity prevention and education in the community. Before we begin the presentation, I would just like to remind our listeners that PDFs of today’s slides are posted on the COPE website at villanova.edu/COPE. After going to COPE’s website simply click on the webinar description page for this month’s webinar. Please use the question and answer box on your screen to submit questions for our speakers. All questions will be answered at the end of the program as time permits. The expected length of the webinar is one hour. The session, along with the transcript, will be recorded and placed on the COPE website within the next week. If you used your phone to call in for the webinar today and want CE credit for attending the webinar, please take a moment after the webinar to email us at [email protected] and provide your name, so that we can send you your CE certificate. The objectives for today’s webinar are to discuss the need for developing a standard of care of obesity treatment, to review the proposed standards of care for obesity treatment and the research leading up to their development, and to identify how the proposed standards of care align with other obesity care guidelines, including obesity care competencies, development of an ideal benefit, and coverage for obesity treatment. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. Villanova University College of Nursing continuing education, COPE, is also a continuing professional education CPE accredited provider with the Commission on Dietetic Registration. Our webinar this month awards one contact hour for nurses and one CPEU for dietitians and DTRs. The suggested CDR learning need codes are 5370, 5410, 6000, 9020 and the CDR level of this webinar is 2. Next I have the distinct privilege of introducing our speakers for today’s webinar. Bill Dietz, MD, PhD is the Sumner M. Redstone center chair at the Milken Institute School of Public Health at George Washington University, a member of the National Academy of Medicine, and serves as the director of the “Stop Obesity Alliance” at George Washington University. He is the former director of the division of nutrition physical activity and obesity at the Centers for Disease Control. Dr Dietz earned his MD from University of Pennsylvania and a PhD in nutritional biochemistry from Massachusetts Institute of Technology. He has authored over 200 publications in the scientific literature and is the recipient of numerous awards recognizing his outstanding contributions in advocacy, as well as for his many contributions to the field of nutrition of infants, children and adolescents and pediatric research. Christine Gallagher, MPAff is the research project director for the “Stop Obesity Alliance” at the Milken Institute School of Public Health at George Washington University. She has spent over 20 years working in Washington, D.C. on health, human services and education policy. She served at the US Department of Health and Human Services in the office of Secretary Donna Shalala as well as the Office of Legislation on issues ranging from welfare reform to Medicaid. She earned her master’s in public affairs from University of Texas’ LBJ School of Public Affairs. In addition to coordinating research for the “Stop Obesity Alliance”, she also plays a key role in analyzing and publishing data related to obesity costs, including costs related to weight bias and stigma. While we are preparing for the presentation to begin, I just wanted to mention That while Dr Dietz has a disclosure related to a commercial entity associated with the content of this program, all material associated with this presentation was reviewed by the Nurse Planner and determined to be free from commercial bias. Accredited status does not imply endorsement by Villanova University, COPE, or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity. And with that, I welcome Bill Dietz and Christine Gallagher to our COPE webinar program and I will turn things over to them for their presentation. Thank you both so much for being here and offering your thoughts, expertise and most recent guidelines and research on that. Thank you, Lisa, and thank you to everyone who’s joining us today. We will begin our presentation with . an outline of what we plan to discuss during this webinar. We’ll start with an introduction to the “Stop Obesity Alliance”, and then I’ll provide some background on how we got to develop the proposed standard of care. And then I’ll pass it on to Bill who will talk about the principles for all providers, the principles for clinical providers, the need for an essential obesity care benefit and we’ll give a little update on some of our coverage research that we’ve done. So the “Stop Obesity Alliance” has been around for a little over 10 years now. It was started here at the School of Public Health at George Washington University, and our purpose is to bring together a diverse group of individuals and associations who are dedicated to reversing the obesity epidemic in the United States. As you can see here on this slide, we have several goals and these goals really help guide us in research that we do, and the advocacy that we do, and the outcome of the research. The Steering Committee members are listed here. We have 15 of them, and then the associate members are as far as eclectic group of chronic disease organizations, consumer organizations, minority health and provider groups. And we’re open to additional members; if you’re interested, please contact me after the presentation. We’re funded by 4 corporate members as well as we ask our members to provide a voluntary membership fee each year. So the research that we have done in the past started with some doc style survey that we did, where we added some questions to try and assess what provider knowledge is on obesity care. And what we found was that provider knowledge is quite limited. Less than half of those that we surveyed knew the correct minutes per week of physical activity that are necessary to achieve weight, or a sustainable weight. Only a third knew that any suitable eating pattern can be recommended for weight loss. And and this was really low number, only 16% knew what the USPSTF guidelines are for the number of sessions that a person should have during their first year for treatment of obesity. We’ve also done some research looking at the patient-provider interaction and how that impacts whether a person is treated for obesity in their primary care or with their health care professional. Some of the things that came out of that research were that we found that time is very important and it’s a big barrier for whether patients are treated. As well as patients who have a high BMI are often not even told that they have obesity and those that are told that they have obesity Are advised to lose weight but they don’t give any sort of plan for how to do that. Many of the providers, health care professionals that we interviewed also said that no one in their practice is trained to deal with obesity or weight issues. And a large issue that we have found are that follow-up appointments are not scheduled. So the patient might be told that they have obesity but then they don’t follow-up after that. And now I’m going to turn it over to Bill to walk through the proposed standard of care. Thanks, Christy. So as Christy described, the purpose of the “Stop Obesity Alliance” is around innovation and strengthening systems of care. And part of what we did was, as you’ll see, was to convene a bunch of stakeholders who were interested in this whole problem. The proposed standard of care is designed for both clinical providers and all providers more generally, so the latter would include community groups like Weight Watchers. And in the proposed standard of care, we outline the core principles of care and address, in part, coverage and payment policy standards. So as we’ve done with a variety of other products that the “Stop Obesity Alliance” has produced, we convened a diverse group. We first convened a steering committee which plan three roundtable meetings. And the attendees at these meetings included over 50 stakeholders, a very wide mix. So they were patients, they were community providers, they were payers and patient advocates. That happened in 2018 and led us to produce a document that was published in the journal “Obesity” in December of 2019 in which we outlined these core principles of care. So the principles of care are those shared by all providers and we distinguish between all providers, and we have a subset that we’ll come back to which are clinical providers. So the core principles of care were included treating obesity as a chronic disease. This is not a one off counseling session that you would do for an infectious disease, this requires ongoing care. And the care should be evidence-based, pragmatic and deliverable. That means that it does need to adhere to the principles of US Preventive Services Task Force, if possible, although that’s a major challenge. Who should deliver it is another important discussion issue and our perspective is that as long as a weight loss outcome is achieved, that the program can be delivered by a variety of providers. These would include nurses, this would include physician assistants and as well as physicians and psychologists. A core principle is providing access to the appropriate level of care, regardless of the point of entry. And what this means is that if somebody has already gone through some counseling and has been unsuccessful, that they would not necessarily need to enter that care at that level again to repeat the counseling, but rather might be candidates for more aggressive therapy like pharmacotherapy. A critical element, with respect to care, is the provider should be sensitive to bias and provide appropriate accommodation. Bias is one of the most important factors in the the treatment of obesity and it has a variety of adverse effects. So the more severe the obesity is, the more likely it is that that patient has experienced bias and stigma. That increases with the severity of obesity. Provider attitudes about patients with obesity are also a problem because providers often blame people with obesity for being lazy or they lack self-control. And it’s critically important to know that the perceived provider bias, that is if the patient perceives that the providers bias, that that affects the quality of care and mistrust so that it makes patients less likely to seek care. And this image that we’ve included is purposeful because it doesn’t show a face. This is common with how obesity is caricature that its guts and butts and no faces. So people are automatically discriminated against or demeaedn by the by the absence of anything other than how fat they are. The effects of bias and stigma are also important to recognize that when biases internalize that self blame, patients are less likely to seek therapy and many times patients will not raise the issue of their weight with the provider because they see it as their problem, not a problem that a provider can help them with. This is a cascade effect so that the internalized bias increases the risk of depression, low self esteem and a poor body image. And that, in turn, can lead to more severe obesity and it certainly increases with more severe obesity. And finally, as a result of this cascade there’s increased vulnerability to unhealthy behaviors that contribute to weight gain. So that inappropriate counseling or the perception of stigma may actually lead a patient to binge eat or to more severe eating disorders. The other problem is that how comfortable a patient is in the office is really the first step in delivering care. And the accommodations are a critical element. So things like providing wide-based, higher weight capacity chairs potentially armless so patients don’t get stuck in their chair and they can get up and down from that chair easier is one strategy to make it easier for patients. Patients should have a higher capacity scale, ideally greater than 500 pounds given how severe obesity has become in our society and large size or thigh-sized cuffs and extra large gowns recognize their weight and still allow privacy and the determination of blood pressure. It’s important to locate the scale in a private or near-private area to minimize the anxiety or discomfort that patients feel with being weighed. And often in some practices the weight is verbalized which also is not appropriate for patients because it’s embarrassing. Wheelchair accessible bathrooms and floor-mounted rather than wall-mounted toilets are also essential. And it’s particularly important that staff throughout be educated about stigma and bias, and that extends from the person who checks the patient in, to the person who weighs the patient, to the provider who introduces them into the treatment room. The other issue is language. And if you take nothing else away from today, please take away the need to use people first language. Overweight is descriptive but obese is a an identity. So when we talk about an obese person, that’s not a father or mother, or a person characterized by achievements. They are nothing more than obese, whereas an obese person is more likely to be held responsible for their weight. But obesity is a disease and describing a person with obesity focuses attention on the cause. And that’s a very important distinction as we talk on the wards or we talk in offices to talk about people with obesity or who suffer from obesity, rather than obese people. So coming back to the core principles of care, providers need to be trained to initiate conversations about weight and shared decision-making and bidirectional communication is an essential element of care. So part of what transmits bias is the use of inappropriate language. And this has been tested, both in pediatric patients and adult patients and the language to use are terms like overweight or increased BMI or severe obesity, as opposed to calling a patient fat or obese or having morbid obesity. It’s more appropriate to use terms like unhealthy weight or a healthier weight as goals or targets. And improved nutrition and physical activity are much more accepting terms than diet or exercise, which are often perceived as challenging. An exercise is perceived as repetitive and not much fun. One of the resources that we’ve published, or put on our website, is this “Why Weight? Provider Guide”, which is a guide for how providers can initiate productive discussions about weight, assess the patient’s readiness to change, how to engage in active listening, and most importantly, to build trust. This is a sensitive issue and patients are not going to share their challenges or the difficulties they’ve had unless they trust the provider not to dismiss them or to give them a relatively simplistic direction about what to do. Establishing realistic goals is terribly important, more important here than almost any other disease because this involves a negotiation with the provider and the patient. And it really turns on what the patient thinks they can do rather than what the provider thinks they should do. Our website for the “Why Weight? Provider Guide” is shown at the bottom of the slide and on this website there are two videos of how a provider delivers care in an appropriate fashion and how a provider doesn’t deliver care in such an appropriate fashion. And here are some useful questions. In contrast to other diseases, given the sensitivity of weight, it’s important to ask permission if it’s okay to talk about your weight. And leading questions are things like, would it be all right if we discussed your weight? Or, are you concerned about the effect of your weight on your health? If the patient is interested in this and willing to discuss it, then the question becomes how likely are you to consider several small lifestyle changes, such as increasing your physical activity or eating healthier? . And it’s important to to begin to engage the patient around values. So what kinds of things would change if you accomplish your weight loss goals? What changes to your eating or physical activity habits could you reasonably make? And how much support would you like from me if you make these changes? So this sets up a situation in which the patient and the provider are agreeing on what to do and how to do it and what type of follow-up is important. We know, for example, that if a provider raises the issue of weight in a sensitive fashion then patients are more likely to initiate weight reduction efforts. We also know that many providers, even after they’ve raised the issue of obesity don’t schedule a follow-up appointment, which makes no sense given the chronicity of this disease. So it’s very important not only to address it in the short term, but to also be ready to address it in follow-up. Now the other problem with core principles of care is that there have been no competencies outlined for providers. And we, through the roundtable on obesity solutions with the National Academy of Medicine, we developed a series of competencies that were agreed upon by a variety of provider types. So this was a group that we convened several years ago in collaboration with the Bipartisan Policy Center, The American College of Sports Medicine and the Alliance for a Healthier Generation. And even though you can see a lengthy list of participants, basically, there were 14 core organizations involved in this process and beginning to outline what the minimal competencies were for an obesity provider and those are shown here. So it begins with core obesity knowledge, including recognizing obesity as a medical condition and a chronic disease. Some awareness of the epidemiology and the key drivers to the obesity epidemic, recognizing that although genetics are important in addressing and causing susceptibility, that the real issue is the environment in which we live, that discourages physical activity and increases the consumption of unhealthy foods. It’s important to recognize the disparities and inequities in obesity prevention and care. So we know that obesity and severe obesity are higher in African American women, followed in descending order by Hispanic women and Caucasian women. We also know that in contrast to what is widely perceived, that poverty only plays a role in obesity in Caucasian women; that the wealthier you are, the less likely you are to have obesity if you’re a white woman. Often obesity requires interprofessional care and how to work in groups rather than on an individual basis. And importantly, this is not a problem that we’re going to solve unless we begin to integrate our services with community systems for care so that the clinic is the place where this is addressed, but the place where the changes in behavior can be sustained depends on the community and access to healthful foods and opportunities for physical activity. As we said before, evidence-based strategies for care discussions and language related to obesity and recognition and mitigation of weight bias and stigma are all very important strategies as well as accommodation. And there needs to be special considerations for comorbid conditions. So the problem is, these are the competencies so how do we begin to achieve those competencies? Well, as I think most of you know, obesity is not a subject that’s covered in many curricula. We know that from the organizations that we’ve talked about and you heard that Villanova has an active program in obesity. Here is one of the examples that we found when we were looking for model programs. This is the UNC Chapel Hill School of Nursing, which involved the simulation program of undergraduate public health nursing students in assessing a patient with obesity in an ambulatory care setting and this simulation highlighted the need to integrate community and primary care to support these population health outcomes. There’s some components here that are readily accessible- there are videos, developed by the Rudd Center at the University of Connecticut on weight bias and stigma. Several years ago, “The Weight of the Nation” of four-part series developed by HBO was developed. This is a lengthy thing to watch but there are a number of short videos that are attached to it that crystallized how communities can address obesity in terms of increasing physical activity or healthier options. And there are also components that indicate how you do a community-focused impact assessment of obesity on practice. And this was quite successful. As you can see, the students reacted very positively to this. It was one of the few times that obesity have been highlighted during their clinical education. And we’re now the “Stop Obesity Alliance” is now involved in collecting model programs across the board. So if you think that what you’re doing is model program and very effective, we would be very interested in learning about it and you can contact Christie Gallagher at the stop obesity lines to share that with her. The other area that is critically important to obesity care is recognition of the social determinants of health, in this case the social determinants of obesity. It’s critical to consider the patient’s home, work and community environments. Are there opportunities for physical activity? Is their access to facilities? To grocery store? So for example, here in the District of Columbia there are two wards, seven and eight, which are wards within the city predominantly African American. High rates of poverty with only three grocery stores for 150,000 people. And many of these patients are on SNAP benefits. So a provider who says, well, you need eat more fruits and vegetables, which already violates one of the strategies because that’s not shared decision making, but a prescription, which says eat more fruits and vegetables ignores the challenges that that patient would have in DC in finding fresh fruits and vegetables at a reasonable price, assuming that they had the capacity to access a grocery store. It’s also important to understand where obesity fits in the pantheon of concerns that a patient has. So stressors such as marital dysfunction or depression may be a much more important issue to address than the patient’s obesity, and addressing obesity may not succeed unless that stressor is identified. One of the sensitive areas, and this involves a lot of trust between providers and patients, is the role that adverse childhood experiences can play in severe adult obesity. This was described years ago in Kaiser Permanente in Southern California Where Vince [inaudible], who was an internist seeing patients with obesity found that adverse childhood experiences like sexual abuse, verbal abuse or physical abuse were associated with severe obesity in adults. And it may not be possible for, or even plausible for patients who have had those exposures to lose weight because of the stress that event may impose. Cultural preferences about physical activity and diet need to be addressed. This is well known to the patient, but not necessarily to the provider. And it’s also very important to address the interpersonal relationships and family dynamics. Unless the family is engaged in changing diets and physical activity patterns, it may not be possible for the patient to change those practices. And a clue to this comes from the Framingham Heart Study. This was a study that was done in 2007. The Framingham Heart Study was a longitudinal study and this slide shows the spread of obesity across social networks. So each of these little yellow dots is a person with obesity and the size of that dot indicates the severity of their obesity. And you can see that obesity tends to move out along these chains of human interconnectedness. And it’s important to recognize that the most important elements associated with the risk of obesity are those of your friends. And your risk of obesity increases by 60% if a friend develops obesity, but only by 40% of a sibling develops obesity or about the same if a spouse develops obesity. And as this slide shows, there’s a greater effect of same sex relationships. But what’s particularly interesting about this study was that there was no effect on the weight gain in neighborhoods by the immediate neighbors. And the promise of this network analysis is that if the network can cause obesity, then maybe the network can also be used to prevent obesity or sustained weight reduction or prevent obesity in the first place. The other important principle for clinical providers, more so than community providers, is to assess for obesity related co-morbidities As this slide shows there’s no system in the body that is immune or spared by obesity. The most important elements here are certainly coronary heart disease, type two diabetes and hypertension. But nonalcoholic fatty liver disease is also a growing problem and often will lead through the deposition of fat to hepatitis and throws us and is rapidly approaching the one of the higher rates of liver transplantation. So these screens are important to do because if they’re present they heighten the urgency of interventions. The other core principles for clinical providers are to employ evidence-based counseling techniques, like a cognitive behavioral therapy or motivational interviewing. I listed the five A’s on here, even though it’s probably not the most optimal counseling technique, particularly because they were derived from tobacco where he ask is certainly important- ask a patient whether they’re concerned about obesity in the same way you would ask whether they’re a smoker or not, but the advice piece of the of the second A preserves the hierarchical relationship because in tobacco, the advice is to urge every tobacco user to quit, whereas in obesity the issue is around joint decision making. So I’m not sure that the five A’s applies as readily as cognitive behavioral therapy or motivational interviewing. Its critical in consultation with a patient to refer to an evidence-based program that can be delivered in the specific practice, or to recommend an evidence-based strategy. One of the areas that has recently become apparent is that a number of patients have obesity as a result of medications that are causing weight gain. And if a patient is on one of those medications, and and those lists have been published, those are medications that ought to be changed to ones that are weight neutral, or some may actually cause weight loss. But when it is appropriate, when a patient, for example, has gone through counseling or repeated efforts to lose weight, it may be appropriate to prescribe obesity medications and when appropriate, to discuss or refer for bariatric surgery and provide follow-up care. So given all this, what should we expect from an appropriate outcome for treatment? Well, the standards for a community-based intervention are lower than those for a clinical intervention. So we can expect a 3-5% weight loss from a Weight Watchers program, for example. Whereas we would expect a greater reduction in weight from a program like the diabetes prevention program, which arguably is a mix of clinical and community program. But for medication or a really good counseling program, we can achieve results that are well in excess of 5%. And one of the outcomes that we’re particularly interested in is are the co-morbidities also reduced? One of the expectations is that these programs can be deemed effective if they’re sustained over a six month period. And one of the newer areas that we’ve been thinking about is perhaps we should also add to outcomes, activities of daily living, improvements in the day to day function of patients. Now all of this is well and good, except that most of these strategies are not covered and I would refer you to this paper that came out of our group on obesity coverage and state Medicaid and state employee plans. And you can see that this is improved over time- well you can’t see it from here, but we know that this has improved over time. But notice that there are disparities between state programs and the state Medicaid programs So state employees often have greater benefits than state Medicaid participants. Secondly, notice that the screening counseling is pretty widely recommended, as is bariatric surgery but these interim or these more appropriate first steps like nutrition consultation or drug therapy or weight management programs are not recommended, are not in place as often. And even when you dig a little deeper into these each of these programs, some of them are very, very inappropriate. So one state, for example, approves only one counseling intervention per year which is hardly enough to lose weight on a chronic basis. So this has led us to begin thinking, okay, what should a core program consist of? We talked about competencies, we’ve talked about reimbursement and we’ve drafted the standard of care. And so now we’ve begun to think about what are the elements relevant in the essential care benefit? What are the core benefits that we ought to have? And as we did for the standard of care, we’ve convened a number of advisory groups to begin to bang out these obesity care benefits. So our goals here are to identify evidence-based obesity treatments supporting clinically significant weight loss. And this benefit would provide guidance on the amount, scope, duration and delivery of obesity-related benefit offering including highlighting examples like those that we were able to identify in the state insurance review that were real world examples that were model programs and could be shared across plans. And the other goal for this is to standardize the scope and availability of treatment covered across plans. So the way we’ve drafted this is that we have this core benefit, which includes counseling, drug therapy and bariatric surgery but a more comprehensive benefit would spell out more specifically, what more could be done to increase physical activity, for example, like a gym membership. What could improve nutrition therapy such as home delivered meals or some benefit like that. But these elements are for a model program and we’re in the process of vetting these and refining them. So once we’ve refined those, and I think we’re pretty close to having done so, how do we get these adopted? As you remember, I said that patients blame themselves for their obesity and they’re less likely to look to a medical provider for care. Likewise, they’re less likely to demand that their insurance cover or their healthcare include comprehensive obesity benefits. So part of this comes from increasing the demand on the part of patients, but part of it also comes from the promotion of the benefits and what an impact they’re going to have on outcomes to employers because employers negotiate their care package and that’s an opportunity for employers to assure that these core essential benefits are in place. One of the other problems is the issue of coverage versus cost and the cost benefit. And that’s kind of an open book, but we know that this is a concern that pharmacy managers have in terms of the cost of obesity care. But when you apply or compare the cost of obesity care against the impact of obesity on absenteeism, or on what’s called presenteeism, that is under- productivity at work, those costs may be a wash. As I mentioned, we’re interested in model programs. We’ve identified some of those in our review of Medicaid and state employee programs but those are still a high level of- we’re still interested in collecting more of those examples. And finally, it’s important to recognize that we’re not going to reduce the epidemic of obesity by improving care alone. 40% of patients, as Lisa mentioned, 40% of Americans have obesity and that the prevalence of obesity exceeds the number of providers. We have got to achieve an integrated system of care which integrates what happens in the clinic with what happens in the community. And that involves all sorts of additional elements, not the least of which is trust between the community programs and trust on the part of medical providers. In addition, when community programs can achieve weight loss, it’s usually the medical plan which benefits from that. So how do we assure that the savings achieved on the medical side are return to investments on the community side? So I hope I’ve given you, I hope we’ve given you a review of how we got into looking at first, the proposed standard of care, then the proposed standard of care itself and the elements that we think are critical to to care and how we’re now moving towards a more comprehensive promotion of this core obesity care benefit. So thank you for your attention, and this is our address on the web and where you can send questions or if you’re interested in a membership or if you’re interested in registering with us your ideal model for around medical or nursing or whatever education around obesity. So thank you for your attention. I’ll turn it back to Lisa for questions. Okay. Thank you very much. Bill Dietz and Christine Gallagher have done a great job outlining some sort of gold standards to look at in obesity treatment. And we’re going to have the opportunity today to have some discussion. So, but before we do that, I just wanted to cover a few housekeeping tips if you did want to get continuing education credit for this webinar. I just want to remind you that everyone who has completed the webinar will be emailed a link to the evaluation within a week. The email will be sent to the email address you use to register for the webinar. Just remember that the evaluation will expire in three weeks so complete it as soon as possible so that you can get your CE certificate quickly. Once the evaluation is completed, the CE certificate will be emailed separately within two or three business days. And just a reminder, if you phoned into the webinar today please email us at [email protected] just to let us know your name, so that we can provide you with your CE certificate. Also included in the email, you receive will be a link to the article referenced in the presentation today and published in the journal “Obesity” in July of this year. The article referenced by Dr. Dietz and Christine Gallagher provides a thorough summary of the project presented today. I wanted to also let you know about an upcoming webinar on Wednesday, November 13. If you are like many and are curious about the online genetic testing kits that are now readily available and how they’re being used to fine tune dietary and lifestyle risks and needs, you’ll want to join in this webinar. Dr. Ruth Loos, An expert in genetics Testing and the strengths and limitations of them will be presenting a webinar called, “Using Genetic Information to Predict and Treat Obesity: Are We Ready for Precision Medicine?’. So, you can register at villanova.edu/COPE as you can register for many of our programs. Okay. And with that, we do have some questions for the two of you. So thank you for being there ready and willing to answer some questions. One question that came up- registered dietitians provide evidence-based care in the community and clinical area and the good news is insurance coverage is starting to improve, as you had mentioned in terms of nutrition coverage, still there’s that struggle with connecting registered dietitians as partners in outpatient practice. So question came through was the American Academy of Nutrition Dietetics included in this project, and could They be or how can registered dietitians become more involved in this, in this project, so that even more patients and clients can be served? Yes, so AND has been represented throughout our activities. They were Jeanne Blankenship, who’s here in Washington, was part of the competencies development and she and others in AND were members of the steering committee and then the working groups that drafted the standard of care, the proposed standard of care, as well as other activities that we’ve been involved in so yes, I don’t know quite how to solve the the connections between nutritionists and practices. I think it’s a critical element. And I’m pleased to see that it is increasing. I think one of the principles that I mentioned, as part of our standard of care, is the assertion that it doesn’t matter who delivers that care as long as the outcome is achieved. And so that opens the door for a wide variety of providers and builds on what you may be aware of the in the DPP, which is that a variety of providers there who are certified and not necessarily credentialed with an MD or a nurse practitioners degree or even an RD can deliver that care. So I think that the connections are going to really need to be made on the local level through just contact with with providers. There are, somebody in our audience may know this, but the American Board of Obesity Medicine is a really good group that is credentialing providers, I think largely MDs, around obesity care and they, I think they have their membership and locations online. Christie- there’s another group that has, isn’t it ASNBS that also has access to names and contact information?
Oh. I think its the OAC, that would be the Obesity Action Coalition.
Yeah, so the Obesity Action Coalition is a patient advocacy group for obesity and they have online, if you go to OAC, a listing of obesity providers. That would be another way to identify somebody in your area with whom you could work. And I would just also add that on the advocacy side, AND has been very active in sort of advocacy and lobbying efforts to try and pass what’s called the “Treat and Reduce Obesity Act”. And a lot of the nutritionists and dietitians that are part of AND have probably been asked to to lobby their members to get this legislation passed. So if you’re interested in that side of the equation, which would really help change the way that Medicare is done and then therefore, hopefully help change the way that other healthcare payers cover obesity medicine. That would be really helpful to all of us. Okay, great. Thank you. Another question. In your presentation, you mentioned, I think it was part of a research study, that one third of patients who were advised to lose weight weren’t given a plan to do so, which means the two thirds of the patients were given a plan. In this case, what constitutes a plan? What were you finding from your research or from the research out there. in terms of the plans that were given out? So this was, I don’t know the answer to that because I was quoting another study and I think that the question in the survey in that study was, “were you given a plan to lose weight?”. So I think it was a yes/no answer with no details about what that plan was. And that’s a really- I appreciate the question because I think some providers would say, well I told the patients that they needed to lose weight and they needed eat better, and exercise more, and that was the plan. But that’s not a very effective plan. So the bottom line is that I can’t answer that question because the the survey that was done didn’t explore in greater detail what the plan was. Yeah, it does give lots of opportunities, though, as we move along for moving into the one third of the patients who who were advised to lose weight that weren’t given a plan, there’s opportunities there for referral and for community connections and so forth that’s also an opportunity. Lisa, I might expand a little bit on that. So there’s going to be two papers in Obesity, or one paper in Obesity, and I’ve written a commentary to go along with it that talks about how infrequently drug therapy is prescribed. But one of the insights is that it’s also not clear how often obesity is present and not documented in the medical record. And among residents, in a study that was done, obesity was not documented either at intake or discharge. So if a problem is not documented, it’s not going to be addressed. So the whole care approach and care delivery has to begin with documenting the patient’s BMI and whether obesity is present or not. And that’s what should trigger the next step, so about appropriate types of care that are delivered. It speaks to the importance, as you mentioned earlier, of treating one of the standards I guess, of treating obesity as a chronic disease. And if you are treating it as a chronic disease and managing it as such, of course you would want to see it documented so it’s an interesting point you bring up. There were many recommendations made for accommodations to reduce weight bias and stigma, you know, wider chairs, higher capacity scales, private areas for weighing, yet, in my experience anyway, these accommodations are the exception rather than the rule. How often do you see these accommodations in place? And where they’re not in place, what’s the largest barrier you see? Is it lack of knowledge? Is it cost? What can we do to make those accommodations less of the exception and more of the rule? That’s really a good question. I don’t know to what extent people are sensitive to it. I do know that providers who specialize in obesity care are much more likely to accommodate patients and I’ve taken the steps to do so because I think one of the things that is notable, although it’s certainly not 100% yet, with obesity care providers is their sensitivity to stigma and bias. I would say in the last five years what’s changed the most in the obesity field and obesity care is a sensitivity to stigma and bias and the role that it plays in the adequacy of care delivery and the responsiveness of providers to patients with obesity. I would hope that’s followed by the kind of steps around accommodation that I described in this presentation, but I don’t have a sense for the extent to which that happened. Okay. Just got a question that came in- one of the first of the five A’s is to ask and I guess to alleviate weight bias, asking someone if it’s okay to talk about obesity or asking them if they want to get weighed is a respectful way of managing the situation, but yet if they refuse, it a patient refuses the discussion, or the opportunity to be weighed, how do you document that in a way that respects that it is a medical condition? I think that’s a difficult question and hard for providers to confront. I think that the providers need to be respectful of their patient’s decision and I think a provider can say, I respect your not wanting to be weighed or I respect that you’re not ready to deal with obesity, but when you are I’d be happy to talk to you about it, or if if you would rather not see me or if I can refer you to somebody who you would prefer to see, I’m happy to do that. So you’re not dismissing the patient, you’re trying to establish a way forward. I think also one of the talking points that that I did not include was something to the effect like yes, I understand you’re reluctant to address your weight, but I feel obligated as a physician to share with you some of the consequences of obesity, particularly, and in the hope that you have a family history, particularly in view of the fact that your father died of obesity and a myocardial infarction at age 45 or things like that. But the other point here is that primary care physicians and providers, more generally, are in an ideal position because even though they may not be able to take care of a patient or address a patient’s needs at this visit, there’s always an opportunity for that patient to come back to them as their primary care provider. And that’s why our focus is so intent on developing standards or approaches that primary care providers can use. I think with that kind of approach, it does leave the door open that perhaps the patient at another time may wish to continue the discussion, and opening the door to do so is is is a welcoming way to do that. Right. Last we have time for one more question. Registered dietitians often see patients in private practice and they may see a patient referred to by a physician after they’ve gained a substantial amount of weight That may, in part, be due to the side effects of medications that you had mentioned earlier, particularly antidepressants. In your discussions, in your research is the likelihood of weight gain routinely looked at when evaluating options for medications? So many people on antidepressants and the increasing epidemic of obesity. How can we best make the medical community better aware of this problem? That’s a great question, and another one to which I don’t know the answer. I hope that that sensitivity is spreading. I think that if a provider is doing their job, they would see a patient back within a relatively short period of time on one of those medications and if the patient, and I would hope that they’re weighing that patient again, and noting that weight gain is occurring and thinking about alternatives. But I’m not sure how many providers are sensitive to that. I wish I did know and it’s a great question and one that I think we’ll try to find an answer to. Working together we can certainly make some inroads Thank you. Thank you both for such a wonderful and enlightening hour. I encourage listeners to go to the- when you receive the emai with the survey for today’s webinar, please look for the link containing the obesity standards publication that was just, as I mentioned, published in July of this year and you’ll get even more information. And with that, we’re out of time for today. Once again, I want to thank Bill Dietz and Christine Gallagher for their insights and for their willingness to share. I just want to encourage participants to please go to the COPE website, sign up for upcoming webinars. Look out for the evaluation email if you do need a CE certificate. We’re very pleased to be providing these webinars. We do appreciate your input and feedback, so please feel free to share that in your evaluation. So thank you very much again for participating in the COPE webinar series. Thank you to Bill Dietz and Christine Gallagher for sharing. And we wish you the best of luck and success in getting the message out. Thank you. Take care, bye bye.

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