Obesity Survey Uncovers Striking Clinician 'Knowledge Gap'

Marlene Busko

March 29, 2016

Two-thirds of US clinicians who replied to a new Medscape survey about treating obesity reported that they prescribe weight-loss drugs for about one in four obese patients, and they refer 13% of individuals for bariatric surgery. However, in a somewhat-troubling response, they also said that half of the patients who took weight-loss drugs did not meet their "treatment goals."

The survey, "Are we giving up on obesity? Treatment trends in obesity" garnered responses from almost 1500 US practitioners: 285 family-medicine physicians (19%), 230 internists (16%), 136 endocrinologists (10%), 281 ob/gyns (20%), 280 nurse practitioners (18%), and 282 physician assistants (18%).

Five experts contacted by Medscape Medical News said a better title for the survey could be "Frustrations in treating obesity," pointing out that the results indicate a critical lack of awareness about the new medications that have been approved fairly recently by the US Food and Drug Administration (FDA) to treat obesity.

As Dr Samuel Klein, William H Danforth Professor of Medicine, Nutritional Science Diabetes Research Center, Washington University, St Louis, MO, told Medscape Medical News, "To me, the most striking observation from the survey is that it demonstrates a considerable knowledge gap in the indications, efficacy, and safety of currently FDA-approved drugs for obesity that affect prescribing these medications."

Nevertheless, "Believe it or not this is improvement and appears to indicate more healthcare providers are treating obesity," added Dr Ken Fujioka, Scripps Clinic Del Mar, San Diego, California.

"I know it looks [sort of] dismal, but things are moving in the right direction," Dr Fujioka said.

The survey replies suggest that "clinicians are trying to help their patients manage [their] weight, but they are frustrated because their patients are struggling with lifestyle change," Dr Donna H Ryan, professor emerita, Louisiana State University's Pennington Biomedical Research Center, Baton Rouge, noted.

Similarly, Dr George Bray, professor emeritus, Pennington Biomedical Research Center, agrees that rather than "giving up on obesity," the report shows that clinicians are "frustrated by the challenges."

And Dr Caroline M Apovian, director, Nutrition and Weight Management Center, Boston Medical Center, Massachusetts, and vice president of the Obesity Society, cut to the chase, stating: "Let's start treating obesity!"

"Good News": More Physicians Addressing Obesity

The surveyed practitioners reported that they typically treated about 80 obese patients and 110 overweight patients a month, and about 30% to 60% of these patients had type 2 diabetes, hypertension, or other obesity-related conditions.

Overall, 59% of the respondents (ranging from 40% of the ob/gyns to 65% of family-medicine physicians to 85% of the endocrinologists) prescribed weight-loss medications.

"The good news is that there seems to be some movement in physicians' knowledge, attitudes, and behaviors around obesity," said Dr Ryan.

The fact that 85% of endocrinologists and 65% of primary-care providers are prescribing drugs for weight management "is a huge change" from what would have been seen 5 years ago.

"That's a good thing — but we have a long way to go," she stressed.

Most practitioners used a diet-modification approach (85% of respondents) or exercise (80%) to treat their overweight or obese patients, but far fewer used behavior therapy (40%) or weight-loss medicines (about 20%).

The low use of behavioral-therapy strategies indicates that clinicians still need to improve their "coaching" skills, to help patients make changes in diet and physical-activity habits, Dr Ryan pointed out.

"Not Treating to the Right Goal"

Strikingly, the surveyed clinicians reported that only half of patients taking prescription drugs fully met weight-loss goals, while about 35% partially met them and 15% failed altogether — highlighting another shortcoming of current obesity treatment.

"This must be a major reason that patients and doctors both become frustrated," Dr Bray observed.

However, the explanation may be a lot to do with expectation, Dr Apovian noted. "Patients want to lose 100 pounds, and these drugs will help you lose 10%" of your weight," she explained. Rather, if a patient wants to lose 100 pounds, he or she may be a candidate for bariatric surgery.

"This all falls on a lack of education," she added.

"If the respondents are saying patients are not meeting goals, this means they are not treating to the right goal," stressed Dr Ryan. Success should be defined as improvements in health targets, not a number on a scale, and patients can achieve this with a 5% to 15% weight loss, she observed.

And obesity, like other chronic diseases, may require more than one medication to provide effective weight loss, Dr Bray pointed out.

"At present, the maximal average weight loss is not much more than 10%, if that high, and this is not high enough to satisfy most patients," he said. Moreover, even patients who respond well to a particular treatment will have a "plateau" in their weight loss, so they may believe they have been cured and no longer need medications, but if medications are stopped, weight is often regained.

Lack of Awareness of Clinical-Trial Evidence, Guidelines

In the survey, the most commonly prescribed weight-loss drugs were:

  • Generic phentermine (68% of prescribers).

  • Generic bupropion (53%).

  • Lorcaserin (Belviq, Arena Pharmaceuticals) (48%).

  • Phentermine/topiramate (Qsymia, Vivus) (46%).

  • Bupropion/naltrexone (Contrave, Orexigen) (40%).

  • Generic topiramate (39%).

  • Branded topiramate (Topamax, Janssen) (37%).

  • Orlistat (Xenical, Genentech) (33%).

  • Liraglutide (Saxenda, Novo Nordisk) (31%).

  • Generic naltrexone (13%).

Clinicians who did not prescribe weight-loss drugs said that the main reason for this was that they preferred to focus on diet/exercise and/or behavioral therapy (67% of respondents).

However, many listed concerns about safety (56%) or side effects (45%) or not knowing enough about the medications (39%).

About one in four respondents said they didn't want patients relying on drugs or they don't believe that the medications work.

"Would you say that about diabetes or hypertension?" Dr Apovian asked rhetorically.

Nonprescribers said they would be more inclined to prescribe weight-loss drugs to appropriate patients if there were: clinical trials showing that the drugs are effective and safe (65% of the nonprescribers); and guidelines about prescribing (58%), managing risk factors and side effects (57%), and identifying appropriate patients (53%).

But in fact these drugs were approved by the FDA because clinical trials have shown that they are effective and safe, Dr Apovian stressed, and indeed there are recent guidelines that cover all these prescribing issues, she emphasized.

Moreover, although only 19% of clinicians identified cost and a similar number identified lack of Medicare or Medicaid coverage as deterrents to prescribing weight-loss drugs, Dr Apovian believes that cost is a major barrier.

"The biggest problem is that medications that we have approved for obesity are not covered by insurance," she said. Thus, not surprisingly, the least expensive medication, phentermine, which costs $11 a month, is the most widely used.

Unmet Obesity-Treatment Needs, Urgent Need for Clinician Education

Asked to identify the number-one unmet need in obesity treatment, most respondents said it was "patient willingness to follow weight-loss plan" (36% of respondents).

Others cited "effective treatment options" (24%), "inadequate reimbursement for treating obesity" (16%), "patient education about health effects of obesity" (9%), "more MDs recognizing and treating disease" (7%), and "improved guidelines on whom and how to treat" (6%).

However, "we know the biologic and physiologic challenges that patients face in adhering to the lifestyle plan; it is not a matter of 'willingness,' and that doctors single this trait out as the leading issue means that we have an educational challenge with our providers," said Dr Ryan.

Education about treating obesity needs to start in medical and nursing schools and eventually be part of lifelong continuing professional education, she stressed.

"Providers who think that the patient's obesity is merely the result of a series of personal choices, that appetite can be controlled by willpower alone, that we only need educate patients and prescribe a healthy diet and physical-activity pattern, that patients who are struggling only need to try with more resolve — well, those providers are doomed to frustration," she explained.

Dr Klein agrees that many clinicians are not equipped to treat obesity because they have not received training in the management of this disease.

It is difficult for a busy clinician to take the extra time needed to manage obesity by supporting lifestyle-therapy options and using medications, and this effort is often not reimbursed by insurance, he acknowledged.

The survey shows that "obesity needs to be considered a chronic disease." Although "remission" is often not possible with current treatment approaches, a moderate, 5% weight loss has considerable health benefits and should be considered a reasonable treatment goal for many patients, and many will be able to achieve this type of weight loss with lifestyle therapy with or without obesity medications, he noted.

"It takes an educated clinician to be effective, but more clinicians are gaining the skills needed to help patients succeed over the long term," Dr Ryan concluded.

Dr Apovian was lead author of the obesity treatment guidelines issued last year, "Pharmacological management of obesity: An Endocrine Clinical Society clinical-practice guideline." Dr Apovian serves on advisory boards for Amylin, Merck, Johnson & Johnson, Arena, Nutrisystem, Zafgen, Sanofi, Orexigen, and Enteromedics. She has received research funding from Lilly, Amylin, Aspire Bariatrics, GI Dynamics, Pfizer, Sanofi, Orexigen, MetaProteomics, and the Dr Robert C and Veronica Atkins Foundation. Drs Bray, Klein, and Ryan were coauthors of "Advances in the science, treatment, and prevention of the disease of obesity: Reflections from a Diabetes Care editors' expert forum." Dr Bray is a speakers' bureau member for Eisai, Novo Nordisk, and Takeda/VIVUS and is a consultant to Herbalife and Medifast. Dr Fujioka has served as a consultant for Orexigen Therapeutics, Allergan, Novo Nordisk, Enteromedics, Zafgen, NPS Pharmaceuticals, Arena Pharmaceuticals, and Jenny Craig. He has served as a speaker for Abbott Laboratories and Merck and has received research grants from Orexigen Therapeutics, Novo Nordisk, Enteromedics, Amylin Pharmaceuticals, NPS Pharmaceuticals, Arena Pharmaceuticals, Jenny Craig, and Weight Watchers. Dr Klein is a shareholder in Aspire Bariatrics, Human Longevity, and MetroMidwest Biotech and sits on advisory boards for or serves as a consultant to Aspire Bariatrics, DanoneYakult, Novo Nordisk, NuSi, and Takeda. Dr Ryan has served on advisory panels or as a speaker for Medscape, Novo Nordisk, Pfizer, Real Appeal, Takeda, and VIVUS and as a consultant to Novo Nordisk and Scientific Intake. She is a shareholder in Scientific Intake and Tulip Medical.

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