New ACP guidelines target obesity management
From the April ACP Observer, copyright © 2005 by the American College of Physicians.
By Janet Colwell
In the fight against obesity, internists are on the front lines daily—and they have little ammunition to use.
Urging patients to make lifestyle changes can be hollow advice, if patients don't have resources to help them. Prescribing weight loss drugs may result in only modest weight reduction—and insurers frequently don't cover them.
Bariatric surgery can lead to lost pounds, but only the severely obese are candidates and the procedure carries significant risks and side effects. And while obesity is now considered a chronic illness, it isn't the target of chronic care improvement and performance measurement programs, as are diabetes and congestive heart failure.
In newly released guidelines on the pharmacological and surgical management of obesity in primary care, ACP for the first time formally recommended surgery as a treatment option for the severely obese. With the number of bariatric surgeries rising, internists are increasingly being called upon to manage the post-surgical care of these patients. (See "Providing care after bariatric surgery.")
But for most overweight and obese patients, physicians must give them the same tried-and-true advice—cut calories, start exercising and try drug therapy. At the same time, experts say the key to success will be how well internists can muster a team of professionals to help them treat this chronic disease.
Frequent access to weight loss services—especially when those services are comprehensive
—can have a big impact.
"We're at the point where almost 70% of the population is affected by this problem," noted endocrinologist Charles J. Billington, MD, associate director of the Minnesota Obesity Center in Minneapolis. "Do we really want to fight it one-on-one? If we're to have success, physicians must be advocates for healthier lifestyles and help people find ways to improve their family lives, homes and communities." (See "Obesity statistics.")
Recognizing the disease
According to new ACP guidelines published in the April 5 issue of Annals of Internal Medicine, physicians should counsel all patients with a body mass index (BMI) of 30 or higher on necessary lifestyle and behavioral changes. The guideline further recommends that internists should help patients determine individual goals, which should target other health care problems, such as hypertension or diabetes, as well as weight loss.
Experts point out, however, that although internists are adept at managing conditions related to obesity, they sometimes don't treat it as the underlying disease.
"A lot of obese patients get weighed in, then start talking about their diabetes and whether they're taking their medications," said Dennis Gage, FACP, attending physician at Lenox Hospital in New York and author of The Thinderella Syndrome, a book on weight loss that was published last year. "Physicians get lost in treating the diabetes, but there's no mention that the patient happens to be 50 pounds overweight."
Even when they recognize obesity as the underlying disease, physicians often fail to treat it aggressively or discuss with their patients the full range of weight loss strategies. A study of almost 13,000 obese adults published in the Oct. 27, 1999, Journal of the American Medical Association, for instance, found that physicians during routine checkups advised only 42% of these participants to lose weight.
But physicians point out that obesity, like other chronic illnesses, demands a level of management that they don't have the time or resources to provide. That's why obesity experts say physicians should develop networks of other providers, including dieticians and psychologists, who can help relieve physicians of trying to treat this disease by themselves.
"The important thing is to develop a virtual 'team' that shares a common philosophy and communicates with each other," said Robert F. Kushner, FACP, director of the Wellness Institute at Northwestern Memorial Hospital in Chicago. "The doctor can't do everything, but it's also inappropriate for the physician not to be involved in the care of a patient's weight."
Centers that specialize in obesity management typically have well-established resources for its management, with a variety of weight loss specialists on-site. At Northwestern's Wellness Institute, for example, physicians work side-by-side with nine dieticians, four psychologists, two exercise specialists and a smoking cessation specialist.
Having such extensive resources apparently increases the likelihood of successful weight loss. In Dr. Billington's clinic, for example, 40% of his patients manage to lose some pounds and keep them off, while about 45% of patients at the University of Pittsburgh's Weight Management Center have success, said Madelyn Fernstrom, PhD, that center's director. Those figures may not sound spectacular until compared to the primary care setting, where a 20% success rate is considered exceptional.
For example, Nick Fitterman, FACP, a general internist at the 40-physician NorthShore Medical Group in Huntington, N.Y., said that a 20% success rate would be a "high estimate" for his practice. "And I'm probably higher than the norm," he added, "because I have a very educated, motivated patient population." Dr. Fitterman, who helped develop the new College guidelines, said his multispecialty group has a nutritionist and diabetic educator on staff.
Frequent access to services—especially those that are comprehensive—also has an impact. For instance, Mary C. Vernon, MD, a bariatrician in Lawrence, Kan., provides nutritional counseling in her office. She sees patients frequently in the beginning: every one to two weeks for the first month, then every two to four weeks to keep them on track. Patients who are in the weight maintenance phase come in to see her once every three months.
Internists who aren't part of obesity centers or large multispecialty groups, however, must develop their own community network of dieticians, nutritionists, psychologists, exercise trainers and commercial weight loss programs, Dr. Kushner said.
"The internist needs to be the quarterback," he said. Even when physicians spend only a few moments reviewing a patient's progress with a nutritionist, for instance, "it tells the patient that this is important, that my doctor talked to me about it."
Internist Patricia P. Barry, FACP, a geriatric specialist at the Merck Institute of Aging & Health in Washington, agreed that referrals not only offset physicians' limited time, but help keep patients motivated.
"Dietary counseling is often a helpful psychological boost," said Dr. Barry, who also helped develop ACP's new guidelines. "It encourages patients to be accountable to someone for what they're eating."
Fortunately, a few insurers are now paying for counseling and obesity management. This year, for instance, Blue Cross & Blue Shield of North Carolina is launching a new benefits package that covers four physician visits annually, counseling with a dietician and prescription drugs.
Last year, Medicare removed language from its manuals stating that obesity was not a separate illness, paving the way for expanded obesity coverage. And earlier this year, the Medicare Coverage Advisory Committee voted to recommend that Medicare cover doctor-supervised diet and lifestyle programs for preventing heart disease.
Currently, however, the agency does not compensate physicians for overseeing diet, exercise programs or nutritional counseling, nor does it cover weight loss drugs. And Medicare covers bariatric surgery only when it is part of treating a comorbidity such as hypothyroidism or hypertension.
And although the government is sponsoring several chronic disease management programs to test the effectiveness of paying physicians case-management fees, these programs have yet to target obesity.
However, Kevin Weiss, FACP, Chair of the College's Performance Measurement Subcommittee, noted that the College and others already have recognized that obesity will likely figure into the trend toward pay-for-performance and are trying to educate physicians on developing comprehensive programs.
"ACP and the U.S. Task Force on Preventive Services have developed guidelines on screening, diagnosis and now treatment," said Dr. Weiss. "Clearly, the next item on the agenda will be to develop national demonstration programs designed to improve obesity care and performance measures to monitor these improvements."
The drug debate
If patients can't lose the necessary weight by modifying their behavior, the new College guidelines state that physicians should offer drug therapy, under the following conditions: Physicians must counsel patients about the drugs' side effects, the lack of long-term data on weight loss drugs and the transient nature of weight loss with medications.
The guidelines point out that medications generally help patients lose less than five kilograms (about 11 pounds) a year. Still, the authors stressed, even modest weight loss has been shown to improve obesity-related cardiovascular risk factors, such as lipid levels and hypertension, and can halt progression to type II diabetes.
Some physicians, including G. Michael Steelman, MD, a bariatrician in Oklahoma City and president of the American Society of Bariatric Physicians, are very comfortable prescribing the drugs, considering them safe and effective when used appropriately in conjunction with lifestyle modifications. While the drugs don't result in dramatic weight loss, he said, they often work better than diet and exercise alone.
Others are cautious because there are little long-term safety data. "I view drugs as a last resort," said New York's Dr. Fitterman. "After we've explored at least two or three different modalities with diet and exercise programs, as well as any metabolic causes and lifestyle changes, then and only then, would I explore drug therapy if patients aren't heading towards their goal."
Cost is another big barrier, noted the University of Pittsburgh's Dr. Fernstrom. She said most of her patients try weight loss medications, but most insurers don't cover the drugs, which can cost $100 a month. About 35% of her patients who take weight loss medications are losing more than 10% of their starting weight—enough to justify the cost for most patients.
"The majority of our patients have some success with medications," she said, "and would like to continue, but do not have the resources to spare. We have no patients discontinuing effective medication therapy when their insurance plan will cover the monthly cost."
To save patients money, some physicians recommend prescribing older drugs. Many use phentermine, for example, instead of orlistat or sibutramine. However, Dr. Billington pointed out that he prescribes sibutramine and orlistat because the Food and Drug Administration has approved them for indefinite use and because evidence exists of their effectiveness.
"Many physicians may be reluctant to get into obesity treatment because of the history of bad drug experiences," Dr. Billington said, citing fenfluramine and phenylpropanolamine as examples. "In that setting, relying on evidence—which sibutramine and orlistat have, in my judgment—is crucial."
The pros and cons of surgery
In its new guidelines, ACP formally recommends surgery as a treatment option for the most severely obese patients, those with a BMI of 40 or more.
To be a surgical candidate, the guidelines state, patients should have failed an adequate exercise and diet program (with or without adjunctive drug therapy) and present with obesity-related comorbidities, such as hypertension. A recent study in the Oct. 13, 2004, issue of Journal of the American Medical Association found that bariatric surgery in morbidly obese patients reversed, eliminated or significantly improved diabetes, hyperlipidemia, hypertension and obstructive sleep apnea.
While surgical referrals may be relatively rare in the average primary care office, obesity centers are seeing a sharp increase in surgical candidates. According to the American Society of Bariatric Surgery, more than 140,600 surgeries were performed in the United States last year, up from 103,200 in 2003. (See "Sharp rise in number of bariatric surgeries.")
The College guidelines stress the importance of referring patients to only experienced surgeons and high-volume centers to reduce risks associated with surgery. The authors cited findings that surgeons who had performed fewer than 20 surgeries had mortality rates of 5%, compared with mortality rates near 0% for those who did more than 250.
While surgery is far more effective than other treatments, it has its limitations, Dr. Billington said. "It works better than anything else, but the number of people whose weight normalizes is not very high in my clinic. They lose typically around 100 pounds and their health is better, but many plateau at a lower but still obese level."
At the same time, "the patient has to understand that surgery is a tool to make the lifestyle easier, but it doesn't replace the lifestyle," said Dr. Fernstrom. Shrinking the stomach with gastric bypass surgery limits patients' ability—but not necessarily their desire—to eat. Patients must still make significant lifestyle changes to keep the weight off and avoid painful side effects such as anastomotic leaking. (See "Providing care after bariatric surgery.")
What's on the horizon?
Given the high failure rate of diet and exercise and the meager number of available therapies, what can physicians look forward to?
"There are 300 drugs in the pipeline," said Richard L. Atkinson, MD, president of the American Obesity Association, who left private practice to start a biotech company focused on identifying a virus linked to obesity. "Over the next 10 to 15 years, I think we are going to have a lot more drugs available." Ideally, he added, researchers will figure out how surgery changes the body's biochemistry—and develop a pill that mimics those effects.
One potential new drug now in phase II trials is rimonabant, the first in a new class of agents called selective cannabinoid type 1 blockers, which suppress appetite and nicotine cravings. At an American Heart Association meeting last fall, researchers announced that 63% of patients taking 20 mg a day for two years lost at least 5% of their total body weight, compared to 33% taking placebo.
However, no data exist on the drug's long-term safety. And experts point out that no pill or surgical remedy will ever fix the underlying cultural factors that foster excess weight.
"What we've done in our homes and our communities is perfect the availability of the most desirable food that we can possibly imagine in non-limiting amounts," said Dr. Billington, "and our plan for weight control is to try to resist it. There's no surprise that it doesn't work."
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
When patients decide to undergo gastric bypass surgery, they often view surgery as their last and best hope. But surgery, while effective, is far from a perfect solution.
"Despite our efforts to tell people that all the surgery does is make the stomach smaller, many believe it has a magical quality," said Charles J. Billington, MD, associate director of the Minnesota Obesity Center in Minneapolis. "They think they will be thinner and that the lack of control they feel will be fixed."
Instead, he pointed out that patients must deal with post-surgical complications and psychological adjustments—issues that can sometimes derail their efforts to maintain weight loss. After the initial postoperative period, the American Society for Bariatric Surgery recommends that patients be seen within three months, then at six months, then annually for three years, again at five years and then at five-year intervals for life, with additional visits as indicated by their condition.
Experts point out that primary care physicians can expect to deal with the following patient issues in the months and years following surgery:
Psychological adjustments. The surgery changes patients' relationships as they develop a new self-image and are perceived differently by their spouse, family and friends. Patients may also have trouble dealing with the reality of surgery's effects if they still fail to reach a "normal" weight.
Nutritional deficiencies. After surgery, people still must change the way they eat and become accustomed to eating smaller portions. Physicians must monitor patients' diet and nutritional needs, including vitamin supplements.
Medication management. Surgery often improves or eliminates high cholesterol, hypertension and other conditions associated with obesity. As a result, many patients experience a rapid change in their medication needs, which requires careful management.
Complications. Potential post-surgical complications include abdominal hernias or hanging skin, which require additional surgery, and gallstones.
Weight gain. If patients don't change their eating and exercise habits, they may start to regain in a year or two. At this point, their stomach pouch may have stretched, allowing patients to eat more. Returning to a support group may help these patients get back on track.
Sharp rise in number of bariatric surgeries
Since 1992, the number of patients undergoing bariatric surgery in the United States has increased more than five-fold. Here are annual figures for bariatric surgery cases:
Obesity has reached epidemic proportions in the United States, with about 65% of Americans considered to be overweight or obese.
The rate of obesity is rising, its prevalence increasing 16% in the past 10 years.
According to the Centers for Disease Control and Prevention, obesity costs about $117 billion a year in related health care spending.
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