“We have an obesity epidemic,” Apovian said in an interview with The American Journal of Managed Care®. The obesity rate is now around 40%, and higher in some parts of the country, she said. Traditional physician education still calls for addressing the complications of obesity—such as higher blood pressure, or cardiovascular disease—instead of treating obesity itself, said Apovian, who was among the nation’s first fellows in obesity at Geisinger Medical Center.
Educating a new generation of young physicians will help change this, said Apovian and Todd Hobbs, MD, vice president and chief medical officer for Novo Nordisk. Hobbs said a core competency list has been developed by the Obesity Medicine Education Collaborative, which seeks to bring these competencies into medical school curricula, residencies, and fellowships. These competencies are:
* Good interpersonal skills, emphasizing non-judgmental communication.
* Medical knowledge, including the underlying etiology, diagnosis, treatment, and care guidelines. Patients need personalized obesity management plans.
* Patient care that Hobbs said focuses on “eliciting an obesity-focused medical history.”
* Practice-based learning and improvement, including the ability to assess data.
* Systems-based practice that shows the ability to work as part of a team.
* Professionalism, which shows the ability to act with respect, compassion, and integrity.
Trained fellows in obesity medicine will affect patients beyond the ones they treat personally. As those trained in the subspecialty of obesity medicine become integrated into primary care practices, they will share their knowledge with colleagues; significantly, Hobbs said, “the training will add credibility to a disease state that is so often associated with stigma and bias.”
Five years ago, delegates at the American Medical Association annual meeting voted to declare obesity a disease, a change that many hoped would bring broader reimbursement for treatments, either therapies like liraglutide or bariatric surgery. Both Apovian and Hobbs see progress with payers, although there are some notable exceptions. Current law prohibits Medicare coverage of “weight loss” medications, and Medicaid coverage is limited, Hobbs notes. Apovian said Medicaid’s failure to cover liraglutide’s obesity formulation, sold as Saxenda, is her biggest obstacle, because obesity is so closely tied to poverty. “I can’t use the most efficacious medication on those patients,” she said.
Obesity now accounts for $300 billion in healthcare costs a year, and this is catching payers’ attention. “As payers continue to become aware of this growing epidemic, they are more than ever recognizing the need to act, but they require outcomes-based evidence to guide their decision making,” Hobbs said.
Stigma associated with obesity—the idea that people with the disease could lose weight if “they just tried harder,” to eat healthy diets or exercise—is easing among healthcare professionals, but it still burdens patients. Last fall, the ACTION study<https://www.ajmc.com/newsroom/most-with-obesity-dont-get-a-diagnosis-or-referral-for-care-study-finds>, funded by Novo Nordisk, found that only 55% of those who have obesity get a formal diagnosis. And stigma persists among patients themselves, Apovian said.
For those with a body mass index of 40, or 35 with comorbidities, surgery is the only way that most will lose 100 pounds and keep it off for 20 years, she said. “Only 1% of the patients who are eligible actually get this procedure,” she said. The most common reaction when Apovian suggests surgery? “They say, ‘I don’t want to take the easy way out.’”