Collaborations between PCPs, community, needed to tackle obesity epidemic
Efforts to help patients who have overweight or obesity — which CDC data suggest affects nearly 40% of adults and 20% of children in the U.S. — need to go beyond doctors and hospitals, two doctors told Healio Family Medicine.
“Frankly, if all we healthcare providers do is think about a tool belt that involves surgeries, treatments and pharmaceutical products, we’re missing the boat on what’s going to create health and wellness,” Amanda Parsons, MD, MBA, and vice president of community and population health at Montefiore Health System in the Bronx, New York, said in an interview and whose article, entitled “How Health Systems Can Promote Healthier Eating,” was recently published in the Annals of Family Medicine.
“Often a patient will come in to see a doctor or nurse practitioner who acknowledges the weight problem, but then says ‘come back and see me in 4 months,’” Oscar F. Lovelace, Jr., MD, told Healio Family Medicine. “Giving weight management counseling three times a year has never been shown to be effective.”
Both Parsons and Lovelace are facilitators of weight-management projects in their communities. Healio Family Medicine asked them to provide details of their projects, as well as provide information on their impact.
Lovelace, a family medicine practitioner in Prosperity, South Carolina, a town of 1,200 residents, said he used the 5As of Intervention in developing a weight-management program: Assess, Ask, Assist, Advise and Arrange.
“For ‘assess,’ we determined a patient’s BMI. For ‘ask,’ we survey attendees on their goals. For ‘assist,’ we offer the class; for ‘advise,’ we answer follow-up questions and for ‘arrange,’ once the patient has lost weight, appointments are scheduled to discuss ways to keep their weight, BP and blood sugar down,” he said.
Lovelace also said he looked for what he called a “champion” on obesity when developing his weight management program for patients with BMIs higher than 30 kg/m2. He said he found that person in a high school coach.
“This coach comes to our hour-long, weekly weight management class and gives a pep talk,” Lovelace explained. “One week it might be about portion size, another week it might be about the importance of combining aerobic and anaerobic exercise.” Other obesity-related topics are reviewed during subsequent weeks, he added.
Lovelace said that a physician or nurse practitioner must facilitate and answer specific medical questions at the end of each weight management class in keeping with the Medicare Guideline. Parsons’ initiative involves working with bodegas and food warehouses in the Bronx to increase the supply of, and demand for, healthier foods to help people who have overweight or obesity. She said the program also lowers the promotion and availability of less-nutritious options through health system leadership and advocacy.
Parsons, who is also a former deputy commissioner with New York City’s department of health and mental hygiene, said PCPs can encourage their health systems to deploy effective community strategies to complement and augment the work of the clinical teams.
“We’re in a borough of more than 1.4 million people. It would be daunting to try to tackle the entire Bronx [obesity] problem all at once. So, we asked ourselves ‘Which neighborhoods or block groups have the most number of obese patients?’”
Using aggregate patient health data, Dr. Parson’s team identifies blocks with the highest prevalence of obesity and then works to engage the bodegas in those hotspots to sell healthier foods. “We talk to the bodega owners about how their business needs align with Montefiore’s goal of having healthy foods available to their patients. The bodega owners are usually receptive to working with us once they understand that healthier items are more profitable, and that we are also going to support them to ensure there is local demand for the new healthy items.”
The initiative also helps teach community members about the danger of excess sugar intake by using inexpensive “Rethink Your Drink” poster boards with empty bottles and plastic bags filled with the amount of sugar these beverages contain. These board displays encourage people to think more about the sugar content in their sports drinks, sodas and other beverages, and to not be misled by advertising.
Montefiore also nurtures its community, by encouraging people to shop at local farmer’s markets, by giving out Health Bucks — printed coupons to help offset the costs of fruits and vegetables.
The AAFP recognizes the need for these kinds of collaborations, publishing a position paper in 2015 that discusses the integration of primary care and public health.
“For successful broad system change, family medicine within the primary care specialties must co-align with the public health sector, two fields with a common interest yet functioning independently for the last century.”
One such partnership between the AAFP and the YMCA of Greater Providence encouraged participation in the YMCA’s weight loss, diabetes prevention, and healthy lifestyle programs. One of the techniques utilized was motivational interviewing, which the Agency for Healthcare Research and Quality defined as a more patient-centered approach to therapy that gets the patient to “explore and resolve their own ambivalence” to lose weight.
Lovelace said his program, conducted in a ‘Stroke Belt’ state with one of the highest obesity rates in the country, produced results of a 6.6 lb weight loss or more within 6 months for slightly more than one out of every four participants. That was not the only advantage he saw from creating the program.
“Medicare reimburses physicians who provide weight management counseling to their obese patients. This policy is based on recommendations from the U.S. Preventive Services Task Force guidelines on treating obesity. These can include hosting a weekly program for 4 weeks, every other week, for the remainder of 6 months,” he said. “If the patient has lost 3 kilograms by the end of the 6 months, the patient can be followed up with monthly for the remainder of the year.”
Lovelace said his practice was reimbursed more than $19,000 from Medicare in the program’s first year.
Parsons said the work Montefiore is doing to tackle obesity is showing small signs of success, - the percent of youth in the Bronx considered overweight — which used to be the second-highest among New York City’s five boroughs — is starting to trend downwards but Bronx obesity rates remain the highest in the city.
“We have gotten one of the bodega’s largest suppliers to give us free reign to mark the items in their warehouse that are healthy and increase the number of healthy items that they sell,” she added. “It’s not health outcomes data in the traditional sense but it is important progress we are making strides towards addressing this important issue.”
A systematic review published in 2015 looked at 24 randomized clinical trials that explored the effectiveness of at motivational interviewing, the technique used in the AHRQ and AAFP program. Nine trials reported significant weight loss at posttreatment assessment for the motivational interviewing condition vs. control groups, and 13 studies reported that the patients undergoing motivational interviewing achieved at least 5% loss of initial body weight.
“There is potential for [motivational interviewing] to help primary care patients lose weight,” Rachel Barnes, PhD, of the department of psychiatry at Yale University School of Medicine, one of the authors of the systematic review, wrote.
Program worth time and effort
Both Lovelace and Parsons acknowledged that there are many medical conditions that warrant a PCP’s attention, but addressing obesity can have multiple, beneficial impacts.
“As a former practicing physician, I can really empathize with how much work the PCPs have to do, and how frustrating it can be to endlessly alter what we’re prescribing, like diabetes medications and hypertension medications. It can feel like we’re trying harder than ever before and not getting anywhere,” Parsons said. “But changing what people eat is far more effective than changing what medications they take, when it comes to things like preventing diabetes, hypertension and obesity. Health systems can support their PCPs by creating and promoting, healthier food environments in the community”
Lovelace said that behavioral therapy for chronic medical conditions like obesity allows PCPs to have a greater personal and community impact.”
“Obesity is the fastest growing epidemic in America. It impacts just about every other chronic medical illness, which is the driver of 75% of the medical costs in the nation,” he added. “If America’s PCPs were to embrace this type of program, they would see a much bigger impact on their patients’ weight management goals.” – by Janel Miller
AAFP Position Paper. “Integration of Primary Care and Public Health.” Available at: https://www.aafp.org/about/policies/all/integprimarycareandpublichealth.html. Accessed Dec. 19, 2017.
Agency for Healthcare Research and Quality. “Community Connections Linking Primary Care Patients to Local Resources for Better Management of Obesity” Available at: https://www.ahrq.gov/sites/default/files/publications/files/obesity-toolkit.pdf. Accessed Dec. 19, 2017.
Barnes RD, Ivezaj V. Obes Rev. 2015;doi:10.1111/obr.12264.
Parsons A, et al. Ann Fam Med. 2017;doi:10.1370/afm.2155.
Disclosure: Neither Parsons nor Lovelace reported any relevant financial disclosures.