Moving Obesity Care to the Forefront of Medicine

Obesity has evolved over the past century. The risk of excess body weight on cardiovascular and total mortality was analytically identified in the early 20^th century by the an insurance company when they examined death rates among its policy holders.¹ Initially called ‘ideal, desirable or best weights', the metric and terminology used were subsequently replaced with the body mass index (BMI, kg/m²)) using the term ‘healthy weights' once larger and more diverse datasets were analyzed.² Subsequent research in the 1940s and 1950s identified the importance of upper body fat distribution as a high-risk phenotype for insulin resistance and cardiometabolic disease.³ Accordingly, waist circumference was incorporated as one of the five components of the metabolic syndrome as a surrogate marker for visceral fat.⁴ These early epidemiological and clinical observations were followed by a burst of investigations over the past several decades that provided a deeper understanding of the biology and pathophysiology of obesity, including body weight regulation, the causative effect of adipokines and lipotoxicity on health outcomes, and the impact of metabolic adaptation on weight recurrence.^5-7 More recently, highly effective therapeutics have been developed that harness the effect of naturally occurring intestinal and pancreatic hormones that impact appetite, filling the treatment gap between lifestyle modification and bariatric surgery.⁸ Yet despite these exciting advances, the delivery of obesity care by healthcare professionals remains unacceptably low.

The AHA scientific statement Implementation of Obesity Science into Clinical Practice⁹ is both timely and appropriate. The greatest challenge we face is to translate the remarkable advances in the science and practice of obesity into patient care. Previous studies have identified multiple barriers to obesity management that include patient, economic, environmental, cultural, physician, and medical system factors.¹⁰ The scientific statement primarily focuses on gaps and implementation opportunities among healthcare professionals, noting that they must first be equipped with proper knowledge and skills in order to diagnose, prevent and treat obesity using evidence-based interventions that include lifestyle counseling, pharmacotherapies, and metabolic and bariatric surgery. Other targeted implementation strategies include using the 5A's counseling framework for the clinical encounter, harnessing technology, and leveraging the patient's social support network.

The time lag between research discovery to clinical practice, also called "know-do gap" or "implementation gap" is well known and expected in medicine.¹¹ The gap occurs when healthcare professionals grapple to integrate the knowledge gained through research into real-world clinical practice.¹² Obesity care is currently in this void. The use of implementation science, defined as "the scientific study of methods to promote the systematic update of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services" is needed to actualize the delivery of obesity care in general practice.¹³ This will require trans-disciplinary teams that focus on the delivery gaps at the provider, clinic, or healthcare system level. One dissemination and implementation framework that can be used to systematically evaluate programs and outcomes is called RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance).¹⁴

One of the most difficult challenges of delivering obesity care at the clinic level is that our current healthcare setting is designed to primarily focus on acute care problems. To address this discrepancy, the Chronic Care Model (CCM) framework was proposed over 20 years ago as a systems approach to address the needs of patients with chronic illness.¹⁵ The model incorporates three overlapping domains: the community, the health care system, and the provider organization.¹⁶ Key features that resonate with quality care include delivery system design (e.g., creating practice teams), decision support (e.g., clinical practice guidelines), and clinical information systems (e.g., registries and best practice alerts). A systematic review concluded that implementation of CCM in primary care can substantially improve medical outcomes, enhance patients' quality of life, and decompress social burden in a multidimensional manner.¹⁷ Further reengineering of health care delivery that includes self-monitoring devices, mobile technology, and analytics has been proposed.¹⁸

The implementation opportunity that is perhaps most in need is to provide the knowledge, skills, and behavior required to provide competent obesity care since without these qualities, healthcare professionals will not be able to optimally utilize any of the proposed CCM features discussed above. A recent survey among 107 primary care providers identified the need for more training in obesity support options, counseling, and self-help resources as the most important opportunities to enhance obesity care.¹⁹ In a 2004 commentary, Holman noted that few if any schools are preparing their students adequately for the roles they will need to play for management of obesity.²⁰ Recent surveys of the provision of obesity education in medical schools²¹ and graduate programs²² found that obesity curricula were limited and inadequate for training. Furthermore, review of obesity coverage on the US medical licensing examination (USMLE) was similarly found to be insufficient.²³

However, progress is underway in improving undergraduate and graduate medical obesity education. Obesity competencies for medical education were published in 2019 to provide an evidence-based framework for developing interventions in teaching and assessing obesity medicine knowledge, skills, behaviors, and attitudes.²⁴ Similarly, objective structured clinical examinations (OSCE) designed to assess obesity counseling in undergraduate²⁵ and graduate²⁶ training have been published. A state of the art review on how to conduct an obesity-focused history is fundamental to the clinical encounter.²⁷ In a new program-based curricular quality improvement initiative called FORWARD -- Focus on Obesity Education, ten medical schools will work collaboratively to create lectures, case-studies, simulations and small group learning experiences that address the science and practice of obesity.²⁸ These educational initiatives, along with the other implementation strategies discussed above, will hopefully lay the foundation for moving obesity care to the forefront.