Obesity: New Disease on the block

More screening, counseling expected as a result of AMA declaration

Healthcare providers are bound to feel the effects of the American Medical Association’s decision in June to recognize obesity as a disease requiring a range of medical interventions to advance obesity treatment and prevention. Physicians are likely to conduct more frequent – and longer – discussions with their patients about obesity, good nutrition and physical activity; engage their staffs in obesity prevention activities; and collaborate with entities they might otherwise pay little attention to, including parks/recreation departments and fitness clubs.

“Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans,” said AMA board member Patrice Harris, M.D., at the association’s Annual Meeting in Chicago. “The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.”

Good news, bad news
The good news about obesity is that the rate of increase has been slowing. The bad news is that it remains high.

After three decades of increases, adult obesity rates have leveled off in every state except one – Arkansas – in the past year, according to F as in Fat: How Obesity Threatens America’s Future 2013, a report issued in August by the Trust for America’s Health and the Robert Wood Johnson Foundation. But 13 states now have adult obesity rates above 30 percent, 41 states have rates of at least 25 percent, and every state is above 20 percent, according to the report. In 1980, no state was above 15 percent; in 1991, no state was above 20 percent; in 2000, no state was above 25 percent; and, in 2007, only Mississippi was above 30 percent.

Since 2005, there has been some evidence that the rate of increase has been slowing, according to the report. In 2005, every state but one experienced an increase in obesity rates; in 2008, rates increased in 37 states; in 2010, rates increased in 28 states; and in 2011, rates increased in 16 states.

“While stable rates of adult obesity may signal prevention efforts are starting to yield some results, the rates remain extremely high,” said Jeffrey Levi, PhD, executive director of the Trust for America’s Health. “Even if the nation holds steady at the current rates, Baby Boomers – who are aging into obesity-related illnesses – and the rapidly rising numbers of extremely obese Americans are already translating into a cost crisis for the healthcare system and Medicare. In order to decrease obesity and related costs, we must ensure that policies at every level support healthy choices, and we must focus investments on prevention.”

The treatment of choice
The AMA’s decision will reinforce the important role providers they can play in the prevention of obesity and the counseling of those with it, says Julie Wood, MD, FAAFP, vice president for health of the public and interprofessional activities, American Academy of Family Physicians.

“Ideally, we’ll see improved screening and communication between physicians and patients, so you will see better discussions about prevention and treatment, as well as chronic disease treatment and management. We’ll see some impact on our culture and country on the urgency of the need for intervention. Another hope is, we’ll see improvement in the training for medical students and residents, which is inconsistent today.”

AAFP has already chosen to take a broad view of obesity, as evidenced by its AIM-HI program, says Wood. The program, whose acronym stands for Americans in Motion-Healthy Interventions, helps physicians encourage patients to lead healthy lives through physical activity, healthy eating and emotional well-being, that is, through fitness. AIM-HI presents fitness as “the treatment of choice” for prevention and management of many chronic conditions. The program offers physicians a toolkit for their use and that of their staff, as well as handouts to be shared with patients to keep them on track between visits. (Another AAFP tool – FamilyDoctor.org – offers healthcare consumers education on a variety of diseases, including obesity. It includes a body mass index calculator and other non-obesity-related tools, such as an immunization schedule and the ability to check symptoms.)

“AIM-HI is a complete assessment of where the patient is,” says Wood. “It identifies nutrient deficiencies, encourages people to keep a food journal, and gets them involved in what their health goals are. It’s an overall wellness program, not focusing on just one thing. That’s really important. And the community outreach piece [reflects the fact] that we can’t just do five to 15 minutes in the office and then send patients out with a ‘Good luck.’”

Team approach
In 2012, the United States Preventive Services Task Force recommended screening all adults for obesity. The Task Force said that weight-loss outcomes improved when interventions involved more sessions (12 to 26 sessions in the first year), adding that “although intensive interventions may be impractical within many primary care settings, patients may be referred from primary care to community-based programs for these interventions.”

Indeed, prevention and management of obesity calls for teamwork, not just among those in the physician’s office, but among many outside the office as well, says Wood.

“We did concur with the Task Force recommendations,” says Wood. “We’re doing a much better job of screening with the implementation of electronic medical records,” she says, adding that more than 70 percent of AAFP members have an EMR system, most with BMI calculators.
“The big issue is developing a systematic way to perform interventions in a meaningful way. [Family physicians] are pretty good at performing some kind of intervention or discussion, but is the patient finding it meaningful or helpful? Is it done in a way that motivates and engages the patient, and gets community resources involved? That’s where I think we can make a real impact.”

Obesity management and prevention has to begin with or include the family physician, she says. But the entire team has to be on board. “You also need psychologists, social workers and other healthcare workers,” she adds. People in lower-resource communities, many in so-called “food deserts,” are in particular need of nutrition counseling.

Successful obesity programs may include a variety of community resources, such as the local YMCA, the parks and recreation department, the local public health department, faith-based organizations, worksite wellness programs, the food and beverage industry, even local farmers’ markets. “We all have to come together,” she says, adding that AAFP continues to work to integrate public health and primary care.

Reimbursement
If physicians and providers are to spend more time counseling patients as a way to bring about meaningful and lasting improvement, will they be reimbursed accordingly?

“We’re hopeful, but it’s still a little nebulous on how that will work,” says Wood. Many family physicians are already billing for obesity treatment, if the patient has co-morbid conditions, which obese patients often do. AAFP is encouraging its members to conduct group visits for patients who are open to the idea. “Given the AMA’s decision, our hope is that more insurance carriers will provide coverage” for obesity management.

There is progress to report. In June 2013, U.S. Representative Bill Cassidy, MD (R-La.) introduced the Treat and Reduce Obesity Act of 2013. (A corresponding bill was introduced into the Senate.) The bill would allow physicians, registered dietitians, certified diabetes educators, and instructors trained and certified by the National Diabetes Prevention Lifestyle Coach Training program of the Centers for Disease Control and Prevention to provide – and be reimbursed for – intensive behavioral therapy for obesity furnished outside of the primary care setting, so long as any such non-physician provider or instructor communicates any recommendation or treatment plan to the individual’s primary care physicians or practitioner. The bill would allow cover medication for treatment of obesity or for weight loss management for an overweight individual with one or more comorbidities under Medicare part D (Voluntary Prescription Drug Benefit Program).

Wood is hopeful about one more thing – the ability of tomorrow’s physicians to help their patients prevent and manage obesity. “They are emerging from medical school better trained in providing interventions in a systematic way,” she says.


Sidebars:
Leveling off

After three decades of increases, adult obesity rates have leveled off in every state except one – Arkansas – in the past year.

But….

Thirteen states now have adult obesity rates above 30 percent, 41 states have rates of at least 25 percent, and every state is above 20 percent, according to the report. In 1980, no state was above 15 percent; in 1991, no state was above 20 percent; in 2000, no state was above 25 percent; and, in 2007, only Mississippi was above 30 percent.


Sidebar:
Screening for all

In 2012, the United States Preventive Services Task Force recommended screening all adults for obesity.
The Task Force said that weight-loss outcomes improved when interventions involved more sessions.


Sidebar:
Adult obesity: Some improvement seen

After three decades of increases, adult obesity rates remained level in every state except for one, Arkansas, in the past year, according to F as in Fat: How Obesity Threatens America’s Future 2013, a report released in August by the Trust for America’s Health and the Robert Wood Johnson Foundation.

Key findings from the report include:

  • Rates vary by region. Of the states with the 20 highest adult obesity rates, only Pennsylvania is not in the South or Midwest. For the first time in eight years, Mississippi no longer has the highest rate; Louisiana, at 34.7 percent, is the highest, followed closely by Mississippi at 34.6 percent. Colorado had the lowest rate at 20.5 percent.
  • Rates vary by age. Obesity rates for Baby Boomers (45-to 64-year-olds) have reached 40 percent in two states (Alabama and Louisiana) and are 30 percent or higher in 41 states. By comparison, obesity rates for seniors (65+ years old) exceed 30 percent in only one state (Louisiana). Obesity rates for young adults (18-to 25-year-olds) are below 28 percent in every state.
  • Rates by gender are now consistent. Ten years ago, there was nearly a 6-percentage point difference between rates for men and women (men 27.5 percent, women 33.4 percent). Today, rates are nearly the same (men 35.8 percent, women 35.5 percent). Men’s obesity rates have been climbing faster than women’s for this last decade.
  • Rates of “extreme” obesity have grown dramatically. Rates of adult Americans with a body mass index (BMI) of 40 or higher have grown in the past 30 years from 1.4 percent to 6.3 percent – a 350 percent increase. Among children and teens (2-to 19-year-olds), more than 5.1 percent of males and 4.7 percent of females are now severely obese.
  • Rates vary by education. More than 35 percent of adults aged 26 and older who did not graduate high school are obese, compared with 21.3 percent of those who graduated from college or technical college.
  • Rates vary by income. More than 31 percent of adults aged 18 and older who earn less than $25,000 per year were obese, compared with 25.4 percent of those who earn at least $50,000 per year.

The report includes a set of strategies that have improved health – but its authors stress that they are not yet implemented or funded at a level to reduce obesity trends significantly. Some key recommendations from the report regarding strategies that should be taken to scale include:

  • All food in schools must be healthy.
  • Kids and adults should have access to more opportunities to be physically active on a regular basis.
  • Restaurants should post calorie information on menus.
  • Food and beverage companies should market only their healthiest products to children.
  • The country should invest more in preventing disease to save money on treating it.
  • America’s transportation plans should encourage walking and biking.
  • Everyone should be able to purchase healthy, affordable foods close to home.

To review F as in Fat: How Obesity Threatens America’s Future 2013, go to
http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2013/08/new-report–adult-obesity-rates-hold-steady-but-remain-high.html

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