The New England Journal of Medicine (NEJM) Catalyst regularly publishes insights on crucial topics in health care, the September issue authored by Dr. Kevin Volpp from the University of Pennsylvania and Dr. Namita Seth Mohta from Brighman and Women’s Hospital is focused on Obesity. For the record, I have long been a follower or Dr. Volpp’s work on incentives which has dramatically expanded our understanding of how to optimize their use to promote behavior change.
The insights reflected were obtained by surveying 725 leaders across the healthcare spectrum- the findings indicate an incomplete understanding of the complexity of obesity as a chronic relapsing condition that has genetic, environmental and physiological aspects regularly at interplay with each other. This incomplete understanding also leads to some conclusions for which I will offer different interpretations.
Patient First Langauge
The Journal of Obesity and other publications have moved to a patient first language so I was hoping to see NEJM adopt that framing- people are more than their disease so throughout the document I would have liked to see “people with obesity” as the terms used to describe the population discussed in the survey results.
The Path to Engagement is not linear as Obesity is not linear
The survey respondents report low engagement in weight loss activity among their patient population with only 10% reporting they are engaged in managing their weight. Obesity is a chronic relapsing condition, engagement isn’t linear, people will view their success primarily by the number on the scale, but the literature shows positive impacts on quality of life, sleep and mood even from modest weight loss- this would be missed in traditional healthcare where only weight is measured and recorded. The survey reflected a high degree of personal responsibility on the individual with obesity to make changes to manage their weight but doesn’t seem to indicate the complex obesogenic environment most people find themselves in across the USA. The survey also discusses the role primary care doctors play, often a most trusted source in a person’s health care team and also, based on the literature often a source for weight bias which hinders the therapeutic relationship. Annually more doctors are seeking board certification in Obesity Medicine which gives them additional clinical knowledge and tools to partner with their patients to manage the chronic relapsing nature of obesity. I would argue a tremendous gap in knowledge exists in primary care today about the more current clinical methods to address obesity and this, in turn, contributes to the perceived lack of engagement as the dose of existing methods is inadequate to address the complexity of obesity.
The authors reflect that medical treatments for obesity are ineffective except for bariatric surgery which they frame as a significant risk taken by few. I disagree with this assessment. It discounts the evidence-based continuum of care that exists. Recently the Center for Medicare and Medicaid started covering the Medicare Diabetes Prevention Program (MDPP), this program is a year-long intensive behavioral lifestyle program with 16 weekly sessions which then transition to monthly to total 24 contact hours. Multiple randomized control trials show people who engaged in the DPP and lost 5% of their weight reduce or delay diabetes by 58% over three years and 29% over ten. Given the tremendous burden of diabetes on people living this with the condition being able to give people more healthy years of life seems prudent. The survey cites sustained weight loss as a barrier but fails to reference the physiological aspects that accompany weight loss that lead to some regain and the current obesity medications can play a role in blunting the impacts of weight regain- they are also a tool in the toolbox that is underutilized. Additionally, the newer digital therapeutic solutions to support people with obesity are not referenced as evidence-based supports that can help someone daily as they navigate the journey of improving health, companies like Omada Health have published numerous studies on how their virtual DPP is assisting people to succeed in reducing their risk for diabetes.
A multi-stakeholder effort to address obesity is necessary, and it needs to be long-term, one to two-year engagements to change food and physical activity environments are required but not sufficient to make long-term changes. Recent publications from Kaiser Permanente show a ten year series of investments can provide benefit in changing activity environments- a long-term strategy is warranted. The survey results lightly touch on the physiological aspects of obesity which will also need to be examined with the same rigor that behavioral elements have been up to now, continuing to see “failure” in efforts won’t translate to success until the complex adaptive nature of obesity is framed and understood. The survey is a useful snapshot into current thinking across healthcare in the USA, and it would behoove those of us expert in the complexity to continue to educate and influence policy and approaches to the complexity of reflected, and future investments can move into practical strategies.
Thanks for reading – Trina
(Opinions are my own)
New England Journal Catalyst
Patient Engagement Survey: The failure of obesity efforts and the collective nature of solutions. https://catalyst.nejm.org/failure-obesity-efforts-collective/
Evidence of a gap in understanding obesity among physicians