Overcoming Common Barriers to Obesity Care

So the focus here is on barriers to obesity care.

So we'll start with these questions and see where, see where it takes us.

I'll start just kind of by going down the line.

If anyone wants to raise their hand or jump in, feel free.

OK, so I don't know if you're in the same order on your screen as on my screen, but I see Doctor Golden this first here.

So based on your experience, how do you ensure that your patients have access to obesity related services, referrals and treatments?

And I want to look at this kind of in a 2-part question wave.

First is we know obesity is a disease and should be treated like a chronic disease, but not everyone does and not everyone treats it like that.

So one, how do you get patients, communities, providers to realize that and approach treatment?

And then the second part is the barriers as far as insurance coverage and finding medications.

I think the first part of that question is I spend a lot of time helping my colleagues in my community understand what my services are for patients with obesity.

I have a medical management program and talking about how they can refer to that, but also how I can do just consultations.

So they can refer a patient for a 1 time consultation and the patient comes back to their practice with recommendations for treatment.

And I find that a lot of primary care providers really like that idea, that concept where I basically do an extended visit with the patient and then the patient has ideas and spend a lot of time in their own shared decision making with me in creating a plan of treatment.

And I think that that's one way to use an obesity specialist, especially with so many obesity programs overwhelmed that, you know, it's months before a patient can get in to see them.

Well, part of that is because obesity specialty programs are trying to do everything for the patient as opposed to doing it in collaboration with primary care.

So I think that's another model that we could be looking at and one that we're using in my community that we're look, we're that's really working out pretty effectively at this point.

Another is to make sure that if you are treating obesity in your practice and you have someone in your practice who's interested, get them educated about it.

Maybe there's an RN in your practice that has an interest and they could go through some of the obesity training through OMA or through the program.

That is an open program for all professions to learn about obesity and be able to do a lot of that work in your practice that the clinician or the prescriber doesn't need to be doing.

I think that's another way to utilize resources that are available in your practice.

Dr. Angela Golden (NP Obesity Treatment): The clinician or the prescriber doesn't need to be doing. I think that's another way to utilize resources that are available in your practice.

And then finally, I think another really, really important thing is it's great to have referrals out to health clubs or community dieticians, community nutrition services. But it's really important that you're sure they understand obesity as a chronic disease, because there is nothing worse than referring a patient with obesity to a physical therapist who shames the patient because they have a chronic disease, because they don't understand it. They think the patient just should eat less and move more.

And so I would really encourage you to have a discussion with any of your referral sources to be sure that they understand that first. And I think that's the way we change what's happening in our own communities is really one person at a time, one provider at a time, one clinician at a time.

And, you know, I have a handout that after I talk to somebody, I send them the handout because we all know that people remember somewhere between 10% and 15% of what they hear. And so we want them to have something to refer back to. So, you know, that's the kind of thing that I'm doing in my community.

Dr. Christopher Weber (Ascension Wisconsin): Yeah. That's fantastic. Just having sort of a network of people who get it and are interested and you can help with education. Yeah. And we have felt the same thing where we're looking out 5 months, 6 months plus for a new patient visit. So then we, like you said, started empowering some of the—the specialty groups to have a kind of an obesity champion in their clinic to get things started. So –

[00:01:49]

Angela Golden: I think the second part of that question is I'm going to say it's simple for our audience, and that is to get online and get your senators and your congresspeople to support Treat and Reduce Obesity Act. Because in order to get insurances to have the requirement to cover obesity, and now that we have a congressional budget scoring, maybe we can get there.

The TROA Act would make all the difference. If we could get TROA passed, we could start to have insurers required to treat obesity. And so whatever your professional organization is AAFP, ANP, AAPA, the RD, psychology, they almost all of them have that.

But the Obesity Action Coalition may be the easiest one to send you to. On their website, they have a way that you click a button and it goes to your senator, your representative, to say, please support the Treat and Reduce Obesity Act so that we can get this passed and make it a mandated chronic disease coverage.

Dr. Weber: Good point, and thank you for mentioning advocacy. It's very important. I know you do a lot of work in it. So Dr. Benson-Davies, moving to you, so you can respond to that question. I want to add something also. What if—because there aren't a lot of obesity specialists around, right? There's more than there have been, but there's still not a lot.

So how do you work in an area to get someone treatment when they don't have the specialist easily available?

Dr. Sue Benson-Davies (University of South Dakota Stanford School of Medicine): That—that's a tough question. And we definitely are short resources in my particular area. I would also say it's tough to get referrals because the reimbursement is very difficult for dietitians or—depending on what kind of program you're in, well, nutrition services be covered.

So we're looking at a lack of resources just with people educated, especially dietitians educated in treating obesity. You—it's tough to see dietitians not recognize this as a chronic disease. And unfortunately, that's part of the concern when we—when we aren't educating the individuals within the community. So I fully agree with Dr. Golden and you, it's a challenge because we have a huge waitlist.

Dr. Weber: All right. Thank you. And Dr. Alencar, what are your thoughts?

Dr. Michelle Kulovitz Alencar (inHealth Lifestyle Therapeutics): You know, I couldn't agree more with Dr. Golden and your point that it's about the collaborative effort and how we can all bring, you know, our resources together. And, you know, from my experience, you know, just from what we do at Inhealth, as we support different provider types with providing those resources for behavior change through health coaching and, you know, either cash based, reimbursable, those kinds of models.

[00:05:07]

But it's about making sure that you're able to deliver what that patient really needs, being able to give them the resources that are necessary for their particular lifestyle, for their particular location, for their cultural, you know, intricacies. Those different components are really key for how we—how we go about providing resources.

And again, I really love the point that Dr. Golden made is knowing your referral resources and making sure that they know that the complexities of obesity is completely—it's another—it's another thing that we really just need to ensure that we're doing. And I—and I love that you brought that up.

And so for us that—that's—that's music to our ears because it's about the complexities of obesity that are just multifaceted and being able to provide those resources coaching, driving accountability, all those factors. For us, is where we see just really the collaborative efforts.

Dr. Weber: Yeah. Very good. And Dr. Alencar, I'll stay with you on, on that topic. This is a complex situation, right? And not everyone in primary care has an hour or 2 or a half day like this to cover everything. And it's great to know those community resources, but can you give us some practical points? Like, let's say I'm seeing someone and I don't have a dietician. Can I refer them to this website or that website? How do I know that?

Dr. Alencar: Yeah. I mean, it's—it's a—it's a challenge. And we definitely need to be sure who we're referring out to is, you know, really knows their—you know, complexities of obesity. But to me, it's looking at various online resources.

Obesity Medicine Association has fabulous resources for patients, also for providers at large for resources for you to download and have available. You know, it's—it's something that we can do to keep everybody updated on that way. And so different resources that I like are the Obesity Action Coalition, which Dr. Golden already mentioned.

Healthy People 2030 has a lot of really great resources as well. And then the CDC has some great obesity strategies handouts that I thought were really nice. And so those are some ones I would look at if you were looking for some resources to be able to provide patients.

Dr. Weber: Yeah. Very good. Thank you. So I—I'm just familiar with the Obesity Medicine Association better than other organizations, but I know they have a mentor program. So if someone—you know, one of you is interested in, hey, how do I start or build or grow or improve my obesity care, whether you're doing all obesity or not or you're just dabbling? That's another thing that they offer. You can be teamed up with a mentor who's—who's been in the field for a while.

All right. Very good. So, Dr. Benson-Davies, with your dietary background, there a lot of diets out there, right? There's—there's a few people who've been eating food for a long time. So there are a lot of thoughts and emotions and maybe misconceptions. How do you address a patient who—or how do you—how do you look at the, I guess, the food marketing with all these different things coming at a patient, and they just want to do what's healthy and—and help them to lose weight. But it's confusing. So how do you get them to what's kind of true and helpful?

Dr. Benson-Davies: So my philosophy is, is to think—and it's an old phrase, eating clean. Okay. Eating more simply. Don't follow what's on the media, what's cool, and in the grocery store be taken by the specials and whatnot.

I really like to have patients bring in a food record, and a lot of them, you know, will just bring it on their phone. And then we can talk about, okay, are you getting the bang for your buck out of your nutrition with the processed foods? What can we change? And how does that work into your budget?

So I don't make assumptions until I have more data from a patient, what are they really doing? And also, I'll—I'll point out that the American Nutrition Association this week had their national convention. The term diet is disappearing. We're really looking at food patterns, food behaviors and individualizing that in the clinic. So that's where I gravitate to. What are they doing? And then let's talk about those specific behaviors or changes or items in the diet that maybe we could—we could work on.

[00:10:01]

          Ensure your patients are using obesity pharmacotherapy appropriately?

Dr. Weber: Great. Thank you. Okay, let's—let's look at this one. How do we ensure that patients are using obesity pharmacotherapy appropriately. So we can interpret this kind of however you want. I don't know if this is getting into compounded medications or, you know, online services or getting medications from outside of the United States or managing side effects, those sorts of things.

So Dr. Golden, I'll start with you. How do you ensure that patients are using the medication appropriately?

Dr. Golden: I think it starts with education. I think it starts with that shared decision making of helping. Let them know what each medication can do for them, what the expectations are. Let them be part of deciding which medication they're going to start.

And then, you know, when they're coming back in for refills, is it the right time for the refills? You know, many patients, especially with some of the shortages that we faced or the concepts of higher deductibles for some of these medications, they try to stretch the days in between their doses. And, you know, we just sit down and we really talk about what—what can these medications do? How are they impacting the pathophysiology of the disease of obesity?

And what happens when they try to do those things. How does that impact the disease? And we talk about what are your symptoms look like when you do that. Right? And I think that a lot of times it's really just about being sure the patients have the knowledge that they need to utilize their medications correctly.

And that's probably true for every chronic disease that every patient has. I mean, we've all had patients who have lipid disorders, and it's been 9 months since their last refill on their statin. And you're like, “What have you been doing?”

“Well, I ran out and I just never got it refilled”. “Okay, well, let's get you back on the wagon and get some blood work done.”

But, you know, I think—I'm going to come back to the concept that was brought up earlier today. Part of it is about tracking. You know, if patients are tracking what they're doing, whether it's what they're eating, it's how much activity they have or it's how they're taking their medication. Tracking just brings attention to how they're taking care of themselves. I think that has so much power for any chronic disease and makes it where the patient starts to feel they do have some power over what is happening to them, and they have felt powerless for a long time.

So I think that sometimes it's just a matter of sitting down and saying, “Tell me what's going on”. Asking it in an open ended, non-judgmental way. Because people with obesity especially, have been judged pretty harshly by many of us in the clinical setting. So sit down with an open ear and—you know, I'll come back to something that Dr. Benson-Davies just talked about.

[00:13:27]

She talks about from her experience. I mean, she has time to go through all those food logs. But in primary care, even if you only get 2 days of their food log, you can get a lot of information there. And in primary care, that may be plenty of information for you to be able to see. You know what? “On the weekends it looks like you're eating more. Do you take your medications on those days?”

“Well, no, I save it for the week because that's really when I'm hungry, when I'm at work and there's all this extra food around”. so you can find out so much information from noticing things like that. When you look at the tracking the patients doing. So I think it's really about just asking the question and then listening for the answer.

Dr. Weber: All right. Thank you. I think I'll do this a little bit like—like jeopardy. I think you just gave me the answer. And now I'm going to ask the question, but I'll open it up to Dr. Alencar and Dr. Benson-Davies. So thinking about barriers to obesity care. Often we recommend tracking, whether it's weighing or tracking your exercise or tracking your food intake.

A lot of people don't want to, right? It's extra work. So, Dr. Golden, kind of have your answers. How about the others here? How do you get someone over that barrier?

Dr. Alencar: Maybe I'll jump in on that one. You know, just speaking from the health coach perspective, you know, coaches are there to be an extension for, you know, different medical providers were that sort of person, that's the safety net to like get them to do it, right. The accountability partner, the cheerleader, the whatever you want to call that person is really where, you know, I love to sit many times with patients.

And what you really find when you start to dig into that question is you start to find out what really matters to that person. And when you find out what really matters to that person, whether it be their kids in their life or, you know, whatever it is, and you start to really see that person as a whole person, that's when you start to connect the dots, right? And so you start to connect their health goals with what they're doing and why it's important for them.

And so every single person has a very unique why, why they're doing what they're doing. And so when you can help them create that connection, you start to really put things into motion. And that's the behavior change that we're looking for.

So you know, your earlier question, Dr. Weber, was ensuring patients are using their anti—or their obesity pharmacotherapy appropriately. If a coach is there to listen and hear, you know, maybe some side effects that they may be hearing or they forget to take them as Dr. Golden said. And you know they're saving it for whatever reasons. Being able to hear those kinds of things is really key, and being able to guide and help patients to make those changes is—you know, it really makes a meaningful impact in their life.

[00:16:25]

So to me, like the bottom line for this group is hear their why, find out their vision and try to connect those 2 things. And you will get yourself so much further with behavior change than trying to connect it for them. Right? And so that's one piece that I think would be very meaningful for this group.

Dr. Weber: Thank you.

Dr. Golden: The University of Texas at Houston, Dr. Deborah Horn's group did that research on the single most important outcome. And that has just become such a guiding force for me with all of my patients. We've called it the why for so long. But I think knowing what that single most important outcome is for the patient, and you tie everything back into that and you can overcome almost any barrier if you know that for your patient.

Dr. Alencar: 100%.

Dr. Benson-Davies: And I fully agree and understanding and just listening, okay, what is their environment? You know, what else is going on in their lifestyle. So I do not push tracking food intake until that patient is ready to move forward. And maybe, you know, hardcore lectures do this, do that really churns off patients. And we've kind of come from old school now back into listening, where is that patient? So I really appreciate your comments on that.

If I do need some food records to really help establish better goals, I might say, would you be willing to do this for 1 or 2 days a week just to kind of be aware, be mindful of what you're doing, not force this every single day. So let's get a snapshot where you're at. We want to maintain long-term weight loss. So—so we can work with that. And so that's kind of my gentle approach rather than, okay, we're very structured here.

          Overcome challenges with long-term pharmacologic management?

Dr. Weber: So earlier today we—we saw the chronic nature of the pathway pathophysiology with obesity. And we also saw really how relatively short of a time period people use anti-obesity medications for, right? So there's a disconnect there. So how do you all can you hypothesize why there's that disconnect, why people are using medications relatively short term? And then how do we overcome that to get them what we know is an adequate long term treatment?

Dr. Golden: I think there have been a couple of studies that have actually looked at why people quit. And the number 1 reason is they go into taking the medication because they think they just need a jump start to get started, which comes back to they don't believe obesity is a chronic disease. This is a disease that I don't have enough willpower to overcome. So I'm going to use the medication just to help jump start my willpower.

And when I start to see some success, I can take it from there. And I think that mindset, it's pretty much societal mindset. And so it's hard to overcome that. And I think that's where having providers like we have online with us today, who are willing to learn about the chronic disease of obesity. Patients don't do this with diabetes. They understand their endocrine system is broken. They don't understand with obesity that their endocrine system is broken, that hormones aren't working correctly.

And so I think that being patient and continually reinforcing the chronicity and the dysfunction of the hormones in the body, not the willpower, are so valuable when a clinician is sitting in the room with the patient, whether it's the RD, the exercise physiologist, Just the NP, the PA, the physician. It doesn't matter who the clinician is, if they can continue to help patients until the message isn't just heard in the brain, but it's heard in the heart, where all of us who live with obesity continue to feel like we're failing if we start to see weight regain.

And I think until we get to that, people are going to see medications as a short term option for kick starting my weight loss efforts.

[00:21:03]

Dr. Alencar: Completely agree.

Dr. Weber: Dr. Benson-Davies, other thoughts?

Dr. Alencar: Yeah, I was just going to say I completely agree with that. It's more than just, you know, writing a prescription. It's about the education that goes alongside that. It's about the education that this is a chronic condition. It's something that we, you know, are here to support. You have a team to support you. It's—I think it's—it's just like any other chronic condition. We need to treat it as such, and we need to make sure that that's the message that the patients understand and that they are open and willing to make action towards.

And that's where, you know, having a team to support that individual is really what it's about. And yeah, to me it's—it's just making sure that it's treated as such, right? And this team and everybody that is on this call today, you know, marches out there and does the same, right? And is sort of singing the same tune. Right.

Dr. Benson-Davies: And I would add that, I see patients more with side effects in eating, the gastroparesis, the nausea, the vomiting. And that that is part of the reason why they're shortchanged, not interested as much in the medication. So maybe looking at adjusting it, stepping it back a little bit, it's not a race to get to the end.

So working a little bit more from that perspective, the side—the side effects is what our obesity medicine team does.

Dr. Weber: Yeah. Tying those—those thoughts together, educating patients on the potential side effects up front can be very helpful. If someone's expecting a little bit of nausea, it's easier to get through than to say, where did this come from? And then you stop the first time, you know, you have a little a little heartburn. Often you can get through it. Not always, not always. But the expectation is.

Dr. Benson-Davies: Yeah.

          Ensure continued follow-up and monitoring for patients who have undergone bariatric procedures?

Dr. Weber: So we talked just a little bit this morning or earlier today about bariatric surgery, if you remember that that graph where people lost a bunch of weight initially and then around year 2 it started to rebound a little bit. So I don't know if—if any of you work with patients who have had bariatric surgery in the past. What are your experiences in that world, especially if you start seeing weight regain, and how do you—how do you work with those folks?

Dr. Benson-Davies: We definitely—

Dr. Golden: Go ahead, Dr. Benson-Davies. Go ahead.

Dr. Benson-Davies: We definitely see that in our bariatric practice, patients coming back and then having the discussion, gee, if—if we start the medications or do we need to have a surgery?

So we really look at the behavioral side of it. What else is going on in the environment? Is the weight gain due to an anatomical problem? So those questions need to be sorted out for sure. Some of our patients that are just coming out of surgery, the weight loss has really slowed significantly earlier than it should have. That might be a good point of when to add a medication to help boost a little bit more—more weight loss in those individuals.

But I think this is a real interesting area and we should not be afraid to address it with the medications or exploring, why is that waking coming back on?

[00:24:35]

Dr. Golden: So I think some of the—the research that we're starting to see out of post-bariatric surgery, about 35% of people lose their weight and absolutely maintain it lifelong. The other 65% are somewhere gain some of it back, maybe 20% of it back. And then there's a percentage that gain back a lot, if not all of it. And it looks to be from some of the early research that it's back to metabolic adaptation, that it's not because “old habits have come back”, but that at about 18 months, the hypothalamus is actually back to defending that higher fat mass again.

So why did it take so long for it to start defending it? That's—we don't have an answer to that yet. Certainly a very interesting question that might help us on the medical side of the world, too, but there seems to be a percentage of patients that the pathophysiology of the disease of obesity actually sees metabolic adaptation back in those patients.

And if we can catch it early, you know, the research from Fatima Cody Stanford clearly demonstrates, if we can catch it early in their weight regain for those patients who have metabolic adaptation, that we can use some of our older medications to stop the weight regain.

And so I think that's an important point in primary care, where the vast majority of these patients are being seen post-bariatric surgery.

Have the—give these patients grace. Don't assume they're eating wrong. Understand that their ghrelin levels may be increasing, their satiety hormones may be decreasing, and they are hungrier again. So start to work with them or get them—encourage them to get back with their bariatric surgery program so that they can be seen by an expert. And if they can't, because maybe they're too far away or they've had tourism, like in Arizona, we see a lot of tourism, bariatric surgery, they go to another country, work with them, use some of our older medications and see if we can't stop that weight regain from occurring.

So I would encourage everybody to park your bias and stigma outside the door. And don't assume that people have just fallen back on bad habits, and instead recognize that the endocrine dysfunction may be rearing its ugly head again.

Dr. Alencar: I'll just –

Dr. Benson-Davies: And I will add that we also do body composition to kind of look at the lean mass. We use DEXAs actually, and then also look at the changes in bone density, bone mineral content, those kinds of things.

[00:27:40]

The other thing that I do is indirect calorimetry. So now we can actually measure in clinic, what is going on with that resting metabolic rate. And especially for those patients that have had cycles and cycles of various dieting episodes in our obesity medicine clinic, as well as our post-bariatric surgery clinics, I can tell a lot about where their caloric kind of sweet point is, so to speak, to help guide them going forward.

That may not take care of the hunger, the hormone issues, the—the food noise and all that that's going on. So that's why that pharmaceutical tools can be very helpful.

Dr. Alencar: Yeah. I was just going to mention the same thing, Dr. Benson-Davies, about the body composition analysis. I've personally done some evidence—research in this area and have seen that the changes that happen from patients that have undergone bariatric surgery where, you know, a classical sort of reduction in lean body mass to fat mass ratio is about a 3 to 1. It can be almost 1 to 1 at times for bariatric patients if we're not encouraging the resistance training, we're not encouraging exercise, we're not encouraging the high protein.

So it's—you know, it's being able to track that. And back to Dr. Golden’s point about the accountability and bringing them back into the program. That's key, right? The more that they can have that support in the program—I mean, they spend a lot of time pre-op, you know, doing the things that they need to do. But the post-op op really is where we got to keep our hands on them as much as possible.

So yeah, back to our primary care folks right here on this webinar. I mean, if you're starting to see it, bring them, encourage them to—to—to make reconnections with those resources because they will help them, you know, potentially get back on track.

Dr. Weber: All right. Thank you so much, everyone. We're going to shift gears a little bit here and move on to our audience question and answer session.

Dr. Golden: Dr. Weber, while you're starting to look for those, I just want to say that something that's being mentioned a lot, that is why it's so valuable to get people back to their bariatric programs are all those monitoring devices that they have that we would not have out in primary care. DEXAs, body composition scales, those things. And then of course, the full team that's available where in primary care or perhaps like a practice like mine, a single obesity specialist may not have access to—to that whole.

That's why bariatric surgery patients can be so much more successful, if you can get them referred back to that team that worked on them beforehand. So just want to put a little plug in for that.

Dr. Weber: Absolutely. Thank you.