Hello from NOLA, where our team has been soaking up sun and smarts at the annual Obesity Week meeting. We are back with more daily coverage from day 3 of the conference. The main event was the unveiling of the results of the long-awaited ACTION study – the first-ever study exploring the factors underlying the barriers to weight management. The study revealed that while most stakeholders – 63% of people with obesity, 80% of healthcare providers, and 62% of employers – agree that obesity is a serious disease, serious gaps exist in obesity care. For instance, only 55% of Americans with obesity have been formally diagnosed, and a startling 95% feel that they bear personal responsibility for their weight. We additionally heard fascinating discussions on engaging pharmacotherapy and behavioral interventions to minimize post-surgical weight regain, calls to action on viewing obesity as a chronic disease, and thoughts on the gut microbiome as a potential therapy to prevent obesity.
Below we share our top five takeaways from this incredible day of learning. In case you missed it, check out our coverage of days #1-2 of the meeting and take a look at our conference preview for a look at what the final day holds.
Top Five Highlights
1. Dr. Lee Kaplan (Massachusetts General Hospital/Harvard Medical School, Boston, MA) presented the results of the Novo Nordisk-sponsored national ACTION study (Awareness, Care, and Treatment in Obesity MaNagement), the first ever study exploring the factors underlying the barriers to weigh management.
2. In a corporate symposium co-sponsored by the Cleveland Clinic and Medtronic, Dr. Bartolome Burguera (Cleveland Clinic, OH) provided a most-welcome “reality-check” – “we treat the comorbidities, but we don’t treat the main problem, which is obesity.”
3. A great deal of discussion focused on healthcare policy and structural barriers to obesity treatment, namely underdiagnosis and perceived lack of insurance coverage for obesity treatment.
4. With incredible enthusiasm, Dr. Anthony Fodor (UNC Charlotte, NC) shared highlights of microbiome research in obesity over the past 10 years, underscoring great progress, despite the lingering questions that remain.
5. Dr. Louis Aronne (Weil Cornell Medical College, New York, NY) examined the impact of obesity pharmacotherapies on body weight in individuals who have experienced either inadequate weight loss or weight regain following bariatric surgery.
Top Five Highlights
1. Dr. Lee Kaplan (Massachusetts General Hospital/Harvard Medical School, Boston, MA) presented the results of the Novo Nordisk-sponsored national ACTION study (Awareness, Care, and Treatment in Obesity MaNagement), the first ever study exploring the factors underlying the barriers to weigh management. The conversation on this groundbreaking study continued at a subsequent Novo Nordisk-sponsored corporate symposium. The ACTION study used a questionnaire to survey the attitudes and perceptions regarding obesity in three groups of participants: people with obesity (n=3,008), healthcare professionals (n=606; 83% primary care providers and 17% weight loss specialists), and employers (n=153). These results were concurrently announced in a Novo Nordisk press release. A previous qualitative version of the ACTION study, based on two-hour focus group sessions as opposed to a quantitative survey, were presented last year at Obesity Week 2015.
- On the patient side, a majority of surveyed individuals with obesity (65%) perceived obesity as a disease, an encouraging sign that public education campaigns have been effective in spreading this message. Paradoxically, however, a huge 95% consider themselves personally responsible for their weight (82% “completely;” 17% “somewhat”). While an encouraging 73% of people with obesity have at some point discussed their weight with a healthcare professional, 36% reported that they did not end up seeking support from this HCP for weight loss and only 16% attended follow-up appointments to specifically discuss their weight. This perhaps underlies the worrisome finding that only 55% of Americans with obesity have received a formal diagnosis. Accordingly, only 51% of people with obesity self-identified themselves as such (48% opted for the perhaps more neutral term “overweight” and 2% described themselves as “normal weight). On average, these individuals have undergone seven serious attempts at weight loss over a lifetime, with only 11% successfully achieving 10% weight loss lasting one year. Frustration over this is reflected in the statistic that 38% of individuals with obesity believe they cannot achieve weight loss “even if they set their mind to it.”
- Providers widely agree (80%) that obesity is a serious chronic disease and 72% report feeling a “responsibility to actively contribute” to their patients’ weight loss efforts. Although the majority of physicians (67%) indicated that they were “very comfortable” or “extremely comfortable” initiating conversations with their patients about obesity management, a substantial proportion also reported deprioritizing such conversations. Not unexpectedly, about half of HCPs reported having deemphasized discussions of weight due to “limited time” (52%) and “more important issues” to address (45%). Rather startlingly, however, many did so because of a belief that the patient was “not motivated” (27%) or “not interested (26%) in losing weight. Dr. Kaplan pointed out that this reveals a troubling disconnect between words and actions: “If providers view obesity as a serious disease, why isn’t it being addressed as such in clinical practice?”
- Employers largely understand obesity as a serious disease (62%) but feel fairly little responsibility for actively supporting individuals’ weight loss efforts (46% none; 37% “somewhat”). During the corporate symposium, Dr. Tom Parry (President and Co-Founder, Integrated Benefits Institute, San Francisco, CA), an esteemed expert on the intersection between health and business, pointed out that the employer’s role in obesity care runs far deeper than simply the provision of health insurance. After all, people spend over 40 hours/week at the workplace; thus, employers have the power to structure their environment to create or alleviate a culture of health. Health conditions impact workplace productivity, not only through costs of medical appointments and prescription drugs (typically the main variables employers focus on) but also through absenteeism and lost productivity. Although obesity is the least costly chronic condition for employers in terms of medical appointments and prescription drugs alone, it becomes the second most expensive (after depression) when absenteeism and lost productivity are also accounted for. Thus employers should view the active promotion of obesity management as a mutually beneficial arrangement that both promotes employee health and makes economic sense. Though many workplaces have wellness programs that 72% of employers and 64% of HCPs find valuable, only 17% of people with obesity agree. This constitutes a resounding call for a restructuring of these programs – and clearly underscores a need for clearer communication between patients and providers on patients’ weight loss intervention progress.
- Together, Dr. Kaplan dichotomized these results as being indicative of (i) barriers to seeking care; and (ii) barriers to receiving care. People with obesity may feel discouraged from seeking care because of the widespread perceptions that weight loss is exclusively the individual’s responsibility, that long-term weight loss is rarely achieved, and that employer wellness programs have limited value. Likewise, barriers to receiving care may exist because, even when weight is discussed, “obesity” is rarely a diagnosis and follow-up care is uncommon.
- These learnings from the aptly-named ACTION study parallel nicely with the call to action issued by The Obesity Society (TOS) for more engaged obesity care. Throughout the conference, in the spirit of National Obesity Care Week, attendees have been encouraged to sign the pledge to treat obesity seriously and “Take 5” – that is, dedicate five minutes out of each appointment to have a productive and empathetic conversation with their patients about weight management. Eye-catching signs adorn the conference hall reading the pledge: “I believe obesity isn’t just a problem. It’s a disease that warrants serious evidence-based treatments – nutritional and physical activity guidance, intensive behavioral counseling, drug therapy, and surgery. I agree to learn more and help more. I treat obesity seriously.”
2. In a corporate symposium co-sponsored by the Cleveland Clinic and Medtronic, Dr. Bartolome Burguera (Cleveland Clinic, OH) provided a most-welcome “reality-check” – “we treat the comorbidities, but we don’t treat the main problem, which is obesity.” He pointed out three problems with our current approach to obesity care that impede directed treatment: (i) Obesity is not widely recognized as a disease, and without formal diagnosis, it can be difficult to implement an intervention; (ii) Only a fraction of people with obesity are referred to bariatric surgery, which Dr. Burguera called the most effective therapy for obesity; and (iii) Cost barriers, safety concerns, and general patient/provider reluctance to talk about obesity as a real disease lead to under-utilization of the therapeutic tools that are available for obesity management. Dr. Burguera spoke boldly about a bias that exists among HCPs, in that they assume people with obesity are difficult to treat. We appreciated his willingness to bring these issues into the limelight, and we hope that with greater education, awareness, and weight management guidelines HCPs are better supported in providing optimal obesity care – this was the theme of Dr. Donna Ryan’s (Pennington Biomedical Research Center, Baton Rouge, LA) keynote address at AADE 2016, which continues to resonate with us. Overall, Dr. Burguera’s talk was a tremendous wake-up call to confront obesity as a disease and to stop missing opportunities to treat it.
3. A great deal of discussion focused on healthcare policy and structural barriers to obesity treatment, namely underdiagnosis and perceived lack of insurance coverage for obesity treatment. A poster by Dr. Bartolome Burguera (Cleveland Clinic, Cleveland, OH) and colleagues underscored the prevalence of obesity underdiagnosis. A review of nearly 325,000 electronic health records from the Cleveland Clinic revealed that only 48% of individuals with obesity (BMI > 30 kg/m2) and 75% of individuals with severe obesity (BMI > 40 kg/m2) had received a formal diagnosis in the form of ICD-9 documentation. Without a formal diagnosis it is difficult to imagine a pathway toward the treatment and multidisciplinary support required for successful weight loss. Furthermore, during an absolutely packed symposium on the subject of policy and obesity treatment access, Mr. Ted Kyle (ConscienHealth, Pittsburgh, PA) presented the results of an online survey measuring consumer perceptions of health insurance coverage for obesity treatment (n=17,565). The majority of respondents (60-70%) indicated that their health insurance would cover the costs of hospital stays, doctor’s appointments, and blood pressure medications, but ≤20% felt confident that their insurance would cover obesity treatment measures such as medical weight management programs, drugs, and bariatric surgery. Regardless of the actual coverage statistics among US insurance plans, this work importantly reveals that consumers do not perceive obesity care as being covered – another potential factor discouraging them from seeking care.
4. With incredible enthusiasm, Dr. Anthony Fodor (UNC Charlotte, NC) shared highlights of microbiome research in obesity over the past 10 years, underscoring great progress, despite the lingering questions that remain. He made special note of the ease of study replicability and the decrease in DNA sequencing costs, both of which have facilitated progress in the field. That transfer of obesity between mice via transplant of the microbiome has been successfully replicated, Dr. Fodor explained, and has established consensus over the role the microbiome plays in obesity development. Similarly, researchers have come to agree that a juvenile diet can impact the later-life microbiome. That said, the impact that different drugs have on the microbiome remains to be fully understood. Dr. Fodor suggested that the microbiome should be carefully tracked when patients are taking different pharmacotherapies in order to elucidate the confounding effects of drugs. We were inspired by Dr. Fodor’s passion for the microbiome (and by his good humor throughout the presentation!). The microbiome is increasingly talked about in diabetes and obesity circles, and we hope to see future progress on the microbiome as a target for therapies, though we understand that much more research and investment may be necessary as a means to this end.
5. Dr. Louis Aronne (Weil Cornell Medical College, New York, NY) examined the impact of obesity pharmacotherapies on body weight in individuals who have experienced either inadequate weight loss or weight regain following bariatric surgery. This session was absolutely p-a-c-k-e-d – there was not a single seat available in the room and attendees lined the walls or even sat on the floor. This level of attendance was clearly indicative of the great concern for suboptimal bariatric surgery outcomes as well as great interest in potential solutions – it is of course a huge disappointment and tragedy for patients and providers when very invasive and expensive bariatric surgery isn’t able to achieve the desired weight loss and metabolic outcomes. Dr. Aronne is well-known for promoting a treatment paradigm that incorporates pharmacotherapy after bariatric surgery, shared some remarkable results from a study that utilized this paradigm. The retrospective, two-center study identified patients who had undergone Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2000-2014. An additional criterion was that the patients had been assigned to postoperative pharmacotherapy due to inadequate weight loss or weight regain. Of 319 qualifying patients (RYGB n=258, SG n=61), 54% of them lost ≥5% of total body weight, and 30% of patients, classified as high responders, lost ≥10% of total body weight. Of the medications given, topiramate was the only one that demonstrated a significant weight loss response when administered to postoperative patients, as it doubled their likelihood of losing ≥10% of body weight (p<0.05). Given these results, Dr. Aronne concluded that the optimal time to implement postoperative pharmacotherapy would be when the patient’s weight loss plateaus. However, he stressed the need for more comprehensive, prospective studies. We’re intrigued by Dr. Aronne’s proposed combination approach to weight loss, which further underscores the multifactorial causes of obesity. We hope Dr. Aronne’s work can help encourage greater use of pharmacotherapies can enhance and maintain the weight loss following bariatric surgery.
--by Abigail Dove, Sam Haque, Jennifer Zhao, Helen Gao, Payal Marathe, and Kelly Close