Hanging in the Balance: Reports Aim to Propel Obesity Care Forward

Marlene Busko

July 04, 2019

Two brief "cutting edge reports" in the July issue of Obesity propose training competencies for medical students and care standards for practitioners for treating patients with obesity, which one expert hopes will help drive the field forward.

"Hopefully, the prescribed standards of care and training competencies in this issue of Obesity will result in reformation of our systems for obesity healthcare delivery and medical education," W. Timothy Garvey, MD, professor of medicine, Department of Nutrition Sciences, University of Alabama at Birmingham, writes in a commentary that accompanies the two reports.

The first report outlines a set of 32 obesity-focused competencies to be taught and assessed in medical education programs for graduate and undergraduate medical students and for advanced practice nurses and physician assistants.

The second report is a proposed standard of obesity care for all providers and payors.

The two articles, says Garvey, "constitute landmarks that will impel the evolution of healthcare for patients with obesity."

32 Obesity Care Competencies to Be Taught in Medical School

The first article is by Robert F. Kushner, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, and colleagues, on behalf of the Obesity Medicine Education Collaborative (OMEC) — an intersociety initiative spearheaded by three societies, The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), and OMA, involving 15 medical societies* overall and endorsed by 20 societies.**

OMEC's aim is to develop obesity-focused competencies and benchmarks for medical education programs.

A task force of representatives from the 15 medical societies developed 32 competencies in obesity care, internally reviewed them, adjusted them after a consensus-building process, and then sent them for external review and feedback from 16 other societies.  

The competencies were developed to "standardize the process of evaluating obesity-related competencies across medical school, residency, fellowship, advanced practice nursing, and [physician assistant] training programs," according to Kushner and colleagues.

There is a need for such a document because "a major challenge facing medical educators today is adequately training current and future healthcare providers in the prevention and treatment of obesity," said Kushner, past president of TOS, in a statement from the organization.

The competencies, he said, "provide the framework to improve provider education and thus also improve patient care in the treatment of obesity."

The 32 competencies cover six areas: practice-based learning and improvement (5 competencies), patient care and procedural skills (5), system-based practice (4), medical knowledge (13), interpersonal and communication skills (3), and professionalism (2).

Examples of competencies that students need to master are:

  • "Elicits comprehensive obesity-focused medical history."

  • "Applies knowledge of obesity treatment guidelines to the development of comprehensive, personalized obesity management care plan."

  • "Uses appropriate language...that is nonbiased, nonjudgmental, respectful, and empathetic when communicating with patients with obesity."

Charting a Course for the Training of Healthcare Professionals

Ethan Lazarus, MD, FOMA, a weight loss physician at the Clinical Nutrition Center, Denver, Colorado, and vice president of the OMA, says a 2016 American Medical Association report showed obesity training is neither consistent nor comprehensive.

"OMEC represents a big step forward in filling these significant educational gaps and is provided as a free tool*** that can be used at all levels of medical education," he notes in a statement from OMA.

Wendy Scinta, MD, FOMA, OMA president, agrees, noting: "For years, obesity has been misunderstood,"

"The goal of our multidisciplinary and multisociety effort is to remove bias and ensure obesity is appropriately understood as a disease by healthcare professionals in medical school, residencies, fellowships, and beyond. These competencies set the bar for obesity education and will immensely benefit patients with obesity and their providers," she emphasizes.

Garvey writes in his commentary that the OMEC's "groundwork provides a formidable stimulus" and "charts a course for the training of physicians, physician assistants, and advanced practice nurses in obesity medicine" that is "much needed."

And although these competencies are aimed at MDs, doctors of osteopathy, nurse practitioners, and physician assistants, "this structure could readily be adopted in the training of other important professional members of the obesity care team including dietitians, educators and behavioralists, exercise therapists, and clinical psychologists," he adds.

He also notes that the reader is referred to a website for access to the proposed evaluation scheme for all stated competencies.

STOP: Proposed Standards of Obesity Care Represent "Quantum Leap"

The second article is by William H. Dietz, MD, PhD, and Christine Gallagher of the Milken Institute School of Public Health, George Washington University, Washington, DC, representing the Strategies to Overcome and Prevent (STOP) Obesity Alliance, which aims to provide health professionals, payors, community organizations, policymakers, and those affected by obesity with guidance on foundational components of evidence-based obesity care.

STOP has members from business, consumer, government, advocacy, and health organizations. It held three roundtable meetings to develop the standards of care for treating adults with obesity in the community and in a clinical setting.  

"Our goal," Dietz said in the TOS statement, "was to develop a practical, tangible, measurable, and simple standard of care for the treatment of adult obesity across care settings and representing practices that positively impact the health of people impacted by obesity."

The standards are intended to augment published guidelines developed for obesity care providers, according to Dietz and Gallagher, and "to be implementable and acceptable to payors."

"The core principles...include shared decision-making," which includes the involvement of patients in developing treatment plans, and help on "when to use adjunctive therapies and when to move patients to higher intensity treatments, as well as providing assurance that patients have access to appropriate levels of care, regardless of when they enter the healthcare system."

The standards further state, "Obesity should be treated as a chronic disease" and providers "should be sensitive to bias and language" and "be trained to initiate the conversation about weight."

Dietz and Gallagher add that clinical providers should recommend an evidence-based dietary strategy and appropriate levels of physical activity for patients with obesity, minimize the use of medications that may cause weight gain, and when appropriate, discuss and/or prescribe obesity medications and/or refer to bariatric surgery.

Garvey does find some fault with the proposed standards.

"For one thing, [they] do not address obesity prevention. Secondly, they seem to exclude patients with overweight (BMI 25-29.9 kg/m2) from the treatment paradigm," he observes.

Thirdly, in treating obesity as a disease, "there could be more explicit integration of the presence and severity of obesity-related complications into therapeutic decisions, so risk stratification can serve as a strategy to target more intensive interventions to those at highest risk."

Nevertheless, "the recommended standards represent a quantum leap forwarding in guiding the formulation of high-quality and evidence-based care of patients with obesity," he stresses.

Critical First Steps: "Much Hangs in the Balance"

Garvey summarizes in his commentary, "At the heart of this issue is the bias that obesity is a lifestyle choice and not a chronic disease that merits the full force of a medical model for prevention and treatment."

"This bias is in abject contradistinction to scientific evidence but, nevertheless, is prevalent among the lay public, many healthcare professionals, and regulators. The result is a lack of access by patients to evidence-based therapies in our healthcare systems."

Taken together, "the two papers do not even begin to address what will be necessary to promote the prepared patient, nor efforts needed for obesity prevention requiring changes in the built environment, food supply, and messaging for a healthier lifestyle."

Nevertheless, "these are critical [first] steps in the evolution of a comprehensive care model for obesity treatment and prevention."

"Much hangs in the balance," he concludes.

*American Association of Clinical Endocrinologists (AACE), American College of Obstetricians and Gynecologists, American Association of Nurse Practitioners (AANP), American Academy of Physician Assistants (AAPA), American College of Lifestyle Medicine, American College of Preventive Medicine, American Osteopathic Association, American Association of Colleges of Osteopathic Medicine, American Society for Nutrition, Endocrine Society, Society of Behavioral Medicine, and Society of General Internal Medicine.

**The obesity competencies for medical education were endorsed by the AAPA, AACE, AANP, American Board of Obesity Medicine, ASMBS, American College of Surgeons, Association for Bariatric Endoscopy, American Medical Woman's Association, AND, American College of Osteopathic Pediatricians, American Society for Gastrointestinal Endoscopy, Endocrine Society, Obesity Action Coalition, OMA, Society of General Internal Medicine, Society of Behavioral Medicine, Society of Teachers of Family Medicine, TOS, World Obesity Federation, and Obesity Canada.   

***More information about adopting OMEC competencies can be obtained by contacting: omec@obesitymedicine.org

The authors of the report on "obesity competencies for medical education" have no relevant financial disclosures. The report on the "proposed standard of obesity care for all providers and payors" was funded through a research grant from Novo Nordisk. Dietz has reported serving on the scientific board for Weight Watchers. Gallagher has reported no relevant financial relationships. Garvey has reported receiving personal fees from Sanofi, Novo Nordisk, Amgen, American Medical Group Association, BOYDSense, and Gilead, and grants from Merck, Pfizer, Novo Nordisk, Astra Zeneca, and Sanofi outside the submitted work

Obesity. 2019;27:1045-1047, 1059-1062, 1063-1067. Report 1, Report 2Commentary

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