Joining the dots for the management of clinically severe obesity

Perceptions about the cause, prevention and management of obesity need to change

At its annual meeting in June 2013, the American Medical Association (AMA) adopted a policy that recognised obesity as “a disease requiring a range of medical interventions to advance … prevention and management”.1 On the first anniversary of this decision, with the firm support of relevant colleges and associations, the AMA went further by adopting a policy that supported patient access to the full spectrum of evidence-based obesity interventions, including behavioural, pharmaceutical, psychosocial, nutritional, pharmacological and surgical options.2 The next steps in delivering better integrated care in the United States will not be easy, as they will not only require a transformational change to health services, but also that community perceptions of obesity be confronted. These steps will need to recognise and manage clinically severe obesity (ie, significant health impairment, including comorbid conditions and functional status directly related to excess weight, regardless of whether body mass index [BMI] exceeds 35 kg/m2) as a chronic disease.3 We have already seen that incremental changes in health care service delivery, chronic disease models of care, and the widespread use of effective interventions have delivered markedly improved outcomes for people with type 2 diabetes in many countries.4 This experience provides a template for delivering better health outcomes for those with clinically severe obesity.

Health service delivery for obesity is undergoing major change in England, with several important initiatives instigated by the 2013 Royal College of Physicians report, Action on obesity: comprehensive care for all.5 The objective is to commission an integrated chronic disease model of care for patients with clinically severe obesity by providing specialised, multidisciplinary assessment and management services (tier 3 interventions) that are conceptually located between community and public health (tier 1) and primary care lifestyle interventions (tier 2) on the one hand, and bariatric surgical services (tier 4) on the other.6 This process of developing tier 3 interventions, initiated by the British Obesity and Metabolic Surgery Society and the Royal College of Surgeons, fills a logical gap in delivering integrated comprehensive care in the context of chronic disease management, irrespective of whether surgery may be an option. The National Health Service England and Public Health England also initiated a working group to examine urgent problems in the delivery of obesity care and recently published their consensus report, Joining up clinical pathways for obesity.7

Making informed treatment options

It is difficult to imagine how oncological, cardiac, endocrine or neurological interventions could be delivered effectively without the integration of specialised medical and surgical services, and it is no different for severe clinical obesity.

Delivery of anything more intensive than lifestyle and behavioural interventions requires three elements — that appropriate interventions are both available and understood by patients and physicians; that the range of options suitable for a particular individual are identified; and that a treatment plan is developed in a timely manner. However, the process of patient selection for many interventions currently lacks evidence-based clarity, and relies more on the preferences of the physician and on the BMI of the patient than on a more sophisticated risk–benefit evaluation of the individual's condition. In providing appropriate treatment for clinically severe obesity, the benefits of planned weight loss need to be balanced against the potential mental, physical and metabolic complications and risks, as well as considering the patient's age and BMI. Health outcomes beyond the degree of intended weight loss must be considered, with a focus on improving health-related psychosocial and physical functions and quality of life, avoiding end-organ damage, and reducing morbidity and mortality.

There are also fundamental but contentious concerns about planned weight loss that need careful analysis. Apart from weight loss after bariatric surgery in patients with clinically severe obesity and a BMI of at least 35 kg/m2, there is little evidence that intentional weight loss reduces mortality, despite improvements in cardiovascular risk factors.8,9 It is increasingly apparent that there is no single ideal BMI range; an optimal BMI depends on factors such as ethnicity, age and current state of health. In addition, the relationships between the degree of weight loss and improvements in health and function are not necessarily linear; indeed, much of the benefit may come with a modest 5%–15% reduction in weight. Attaining a BMI between 18.5 and 25 kg/m2 is therefore unlikely to be an appropriate target for patients with clinically severe obesity — whether we are discussing realistic expectations or achieving optimal health outcomes. Understanding the benefits and risks to each individual of more intensive weight loss interventions will allow resources to be better directed to those in need and help avoid unnecessary risk to those who are unlikely to benefit.

Integrated care is the key to effective treatment

Over the next century, Australian health care resources will be increasingly directed to treating the disorders associated with ageing and obesity. The inertia in delivering effective treatment options for clinically severe obesity is based on numerous factors, and manifested in several ways. The most notable include the systematic social stigmatisation of obesity (perceptions of failed willpower and compliance), including by health professionals;10 the frustration associated with difficulties in achieving and sustaining weight reduction; the poor uptake of bariatric surgery; barriers to gaining access to care; and the currently poor track record of medical systems in providing safe and effective pharmacotherapy.

“Failure” is a term that is often heard in this situation, but using it in the context of chronic disease management is unacceptable. It implies systemic failure in providing “care for all”, failure to engage the individual patient in the process of managing chronic disease, and failure to deliver improved health outcomes. We have learned that improving health outcomes in type 2 diabetes involves more than simply controlling glucose levels, and we expect a similar relationship will exist between treating clinically severe obesity and weight reduction strategies.

All effective evidence-based options, including intensive dietary approaches, pharmacotherapies, bariatric surgery, gastrointestinal devices and emerging surgical and endoluminal interventions, can be integrated with core behavioural and lifestyle therapies. The emphasis on particular approaches and combinations of treatments can be adjusted as required. Bariatric medicine — as a key evidence-based health care discipline — needs to mature, expand and develop a transdisciplinary approach over the next decade.

As with any chronic disease, all therapies — not only surgery — require indefinite follow-up, management of comorbid conditions, nutritional support, assessment for complications, and strategies to attenuate any long-term downside to therapy. This will ideally be performed in a primary care setting with support from a multidisciplinary bariatric team.

Medical practitioners and allied health professionals who provide effective interventions with improved health outcomes should not apologise for the appropriate medicalisation of obesity. Engaging patients in understanding their condition, empowering them with options for care, and providing enduring support is the very definition of quality chronic disease management. The opportunity to make informed evidence-based decisions and the resources to proceed with those decisions should be a pillar of modern health care.

In the US and England, with their contrasting health systems, there has been a clear decision to make a major change toward providing comprehensive care for those with clinically severe obesity. A broader range of effective tools, greater clarity about patient selection based on actual risks and benefits of weight loss interventions, and the establishment of effective clinical pathways are important research translation priorities in delivering comprehensive care for all. As shown in the US and England, this requires that many groups and organisations coordinate their activities to effect change. We should applaud and support these and similar activities in other countries and regions, while realising that problems of pejorative perceptions, stigmatisation and clinical inertia generate challenges that must also be tackled.

Around 1.5 million people in Australia have clinically severe obesity, and a similar number have diabetes.11 Each condition impairs quality of life, generates disability, is linked with serious complications and shortens life expectancy in a similar way — but only for the second of these conditions do we have established clinical pathways, responsibilities and resources. For clinically severe obesity it is time to critically examine our performance, to overcome the barriers to better care and to move forward.

Recommendations

• Clinically severe obesity needs to be recognised and managed as a chronic disease.
• Pervasive stigmatisation of severe obesity by the general public and by health care providers must be countered to enable appropriate treatment pathways to be developed. The AMA policy aims to do this by empowering care providers and patients to jointly manage their chronic condition, not to disempower or victimise them.
• Perceptions about the cause, prevention and management of obesity need to change. Quality health literacy about obesity management needs to be improved in the community and among health professionals.
• Major regional hospitals and health care providers need to develop integrated clinical pathways that include specialised multidisciplinary obesity assessment and management services that equitably deliver clinically effective therapies, including surgery.

Implementing these recommendations will need a broad transformational change to the way clinically severe obesity is assessed and managed. It will also require policy commitment and research, together with community and professional education, enabling the development of effective clinical pathways.