The complexity of obesity: When to refer patients to a specialist
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Obesity is a complicated disease resulting from interlocking causes that vary with each patient, including genetics, nutrition, hormones, medication, environment and sleep.
Unfortunately, it is the most common chronic disease in the United States, and its prevalence continues to grow. According to the CDC, about 93.3 million American adults were affected by obesity from 2015 to 2016. And from 1999 to 2018, U.S. obesity prevalence increased from 30.5% to 42.4%. The latest estimates from the agency show that 16 states have at least 35% of residents with obesity — nearly twice the number reported 2 years earlier. This trend is also expected to rise, with studies estimating that within the next decade, 50% of the U.S. adult population will have obesity.
The increase in prevalence of the disease of obesity has created an imbalance between patients and the number of obesity medicine specialists who can provide treatment. The more clinicians who treat obesity, whether they are specialized in the field or not, the better for everyone. For example, a patient with a BMI of 32 (class 1 obesity) who has access to online lifestyle management programming via their employer or insurance, or who follows a healthy lifestyle already, will do quite well with an online tool plus anti-obesity medication without needing to see a specialist in obesity. A patient with a BMI of 45 who needs to get to a BMI of 35 for a knee replacement (> 20% weight loss) may need a more intensive intervention that requires an obesity medicine specialist. Health care providers (HCPs) should remember that the most important thing is to treat obesity or refer to someone who will. Continuing to recommend eating less and exercise more is not the best treatment approach as it is not effective in treating the disease of obesity.
The right treatment approach for obesity varies with each patient. Any patient with a BMI of more than 25 who is motivated to change their weight can be referred to obesity medicine. However, there is no single factor to determine when a patient should be referred to a specialist. This decision should result from a combination of factors, including the comfort level of the treating clinician, the complexity of the patient and the variety of services the patient has access to for accountability and lifestyle change. As HCPs, it is critical that we consider the spectrum of unique circumstances that comes with each patient to best determine if and when they should be referred to an obesity medicine specialist to achieve desired results.
How obesity specialists approach treatment
When a patient is referred to an obesity medicine specialist, the first step is determining which treatment option (medication, procedures, surgery or prescriptive nutritional interventions) is best to help reach the patient’s weight and wellness goals. We evaluate which level of support and accountability will be most helpful to long-term success. We typically check blood work to evaluate for secondary contributors to obesity, such as thyroid disease and insulin resistance, and evaluate for adiposity-related complications of obesity. We then assess which medication might be best for the patient based on other medical and psychological conditions and the side-effect profile. This shared decision-making process in obesity treatment helps support the patient to achieve successful outcomes. This approach is very similar to how other chronic diseases, such as diabetes and heart disease, can be treated by all clinicians, not just obesity specialists.
Medication vs. surgery
When treating a patient with obesity, it’s critical to understand if they are a candidate for medication or surgery. If a patient has a BMI of 27 or above with adiposity-related comorbidity, or a BMI greater than or equal to 30 without comorbidity, they are a candidate for medication treatment. If a patient has a BMI greater than or equal to 35 with comorbidity, or BMI greater than or equal to 40 without comorbidity, they are a candidate for surgery.
More often than not, obesity treatment requires medication for effective results. Using medication for obesity much like we use medications for hypertension or diabetes and becoming comfortable with prescribing these medications to people with obesity is key to treating the disease effectively. Using medication and surgery for obesity earlier in the course of the disease is warranted for better long-term disease remission and outcomes.
Treatment with medication or surgery should be based on the fact that medication and surgery provide for a better treatment outcome and not a moral failure of the patient to treat their disease with lifestyle intervention. There are many diseases that have a lifestyle component to them, and making healthier lifestyle behavior choices is always a good thing for many reasons. But these changes alone do not typically treat diseases effectively, and medications and surgery are often needed. Take heart disease for example. We have developed medications, surgeries and therapeutic procedures (angioplasty) to help treat heart disease more effectively than lifestyle alone. The same is true of obesity. Lifestyle as a disease treatment intervention has limited efficacy in disease resolution — this is not a failure of the patient, but a limitation of treatment effect. In well-conducted studies, lifestyle intervention produces a 10% weight loss in 25% of people, meaning 75% of people do not get adequate treatment effect with this intervention. With medication intervention, 50% to 75% of patients can achieve 10% weight loss. This doubles or triples the odds of reaching their goal with the help of medication.
Leveraging available tools
There are a variety of helpful and innovative tools available to help HCPs with obesity management. The Obesity Medicine Association offers resources, education and community to physicians and other HCPs in the field of obesity medicine, including conferences, meetings, events and webinars, that help practitioners gain comfort in prescribing medication for obesity.
The Obesity Algorithm helps clinicians keep up with the latest obesity treatment recommendations and learn how to implement evidence-based medical approaches to help patients achieve weight and health goals. It also includes an extensive template on how to start an obesity medicine practice and practical recommendations for treating patients with obesity via telehealth.
Our knowledge of obesity continues to evolve. Learn more about treating patients with obesity, keep up with the latest developments in obesity medicine and leverage resources to utilize in your daily medical practice here.
References:
Athinarayanan SJ, et al. Front Endocrinol (Lausanne). 2019;doi:10.3389/fendo.2019.00348.
CDC. Adult obesity facts. https://www.cdc.gov/obesity/data/adult.html. Accessed Sept. 20, 2021.
CDC. Number of states with high obesity prevalence rises to sixteen. https://www.cdc.gov/media/releases/2021/s0915-obesity-rate.html. Accessed Oct. 4, 2021
CDC. NCHS nutrition data. https://www.cdc.gov/nchs/about/factsheets/factsheet_nutrition.htm. Accessed Sept. 24, 2021.
Jebb SA, et al. Lancet. 2011;doi:10.1016/S0140-6736(11)61344-5.
Maciejewski ML, et al. JAMA Surg. 2016;doi:10.1001/jamasurg.2016.2317.
Wadden TA, et al. Obesity (Silver Spring). 2011;doi:10.1038/oby.2010.147.
Wadden TA, et al. Obesity (Silver Spring). 2019;doi:10.1002/oby.22359.
Ward ZJ, et al. N Engl J Med. 2019;doi:10.1056/NEJMsa1909301.
Wilding JPH, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2032183.