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Obesity Care Path Guide

Introduction

CLINICAL JUDGMENT

The care path is intended to be broadly applicable, but it is not meant to substitute for clinical judgment. Clinicians and specialists should tailor processes and approaches to align with patient needs, abilities and care goals. This care path guide is based on the most recent available recommendations from the Academy of Nutrition and Dietetics, the American Society of Bariatric and Metabolic Surgery, the Endocrine Society and the Obesity Society.

OBESITY: A BURDEN ON PUBLIC AND PERSONAL HEALTH

Nationally, more than 40% of the United States adult population is affected by obesity, a chronic progressive disease1 linked to many medical conditions, including diabetes, heart disease and certain types of cancer.1 Etiology is multifactorial, including environmental, metabolic, genetic and socioeconomic factors.2,3 The Centers for Disease Control and Prevention (CDC) estimates the medical care costs of obesity at $147 billion per year.1 Obesity costs add up incrementally over time and not only affect insurance costs, but also have an impact on lifetime productivity losses.4 At a personal level, individuals suffering from obesity have an inferior quality of life in terms of physical health, emotional well-being and psychosocial functioning.5

Obesity is associated with more than 40 diseases, including type 2 diabetes and its sequelae, heart disease, stroke, and numerous cancers.2,6,7 Proper management of obesity, whether surgically or nonsurgically, can delay, ameliorate or prevent these complications.

THE CASE FOR A CARE PATH GUIDE

Recent studies have demonstrated that inadequate, unnecessary and inefficient care are responsible for waste in the healthcare system that may account for 35%-–50%8 of the more than $3 trillion the United States spends annually on healthcare.9 With a central goal of reducing unnecessary variability, care path guides can be tools for education, reporting, measurement and continuous improvement. They are designed to standardize care and assure a consistent level of quality for patients across time, venue and provider, combining workflow-friendly, evidence-based practice principles.

THE CHALLENGE OF OBESITY MANAGEMENT

TABLE 1: Defining Obesity: Classification of Overweight and Obesity by body mass index (BMI), obesity class and Associated Disease Risk10

BMI
(kg/m2)

Obesity
Class

Obesity Disease Risk*
(Relative to normal weight and waist circumference)

Underweight

<18.5

–

Normal

18.5–24.9

–

Overweight

25.0–29.9

Increased

Obesity

30.0–34.9

35.0–39.9

I

II

High

Very high

Extreme

Obesity

≥40

III

Extremely high

* Disease risk for type 2 diabetes, hypertension and cardiovascular disease

Obesity has been identified as a metabolic and hormonal disease state11 leading to impaired function, including appetite dysregulation, abnormal energy balance, endocrine dysfunction, and systemic and adipose tissue inflammation. While healthcare providers cannot ameliorate all factors that lead to obesity, they can help manage hormonal and metabolic abnormalities that lead to obesity-related comorbidities. Obesity is a chronic disease that requires lifetime monitoring and may encompass multiple therapies to achieve the desired outcome. Often, therapies are divided into two approaches: medical weight management or weight loss surgery. However, both tools should be considered throughout the disease process and can often be synergistic when used together.

This guide focuses on the management of adults with obesity; pediatric weight loss is outside its scope.

HEALTH STATUS MEASURES AND PATIENT‑REPORTED OUTCOMES

Health status measures in general and patient-reported outcome measures (PROMs) in particular are becoming important standard components of patient care. These measures are validated tools that provide insight into patient-relevant issues, improve patient/clinician communication and guide individual management. They provide a method to objectify outcomes and quality in a manner that can be shared with patients.

These measures require patient participation and have been shown to improve patient engagement in their own healthcare. They are an important component of value-based care and are becoming significant factors in health policy and reimbursement, as well.

 

Sidebar 1

PROMs FOR WEIGHT MANAGEMENT (General)

In weight management, the following PROMs are particularly relevant in helping clinicians evaluate general and behavioral health status that could affect outcomes and guide treatment:

Patient-Reported Outcomes Measurement Information System (PROMIS)

Global-10: A 10-question screening tool designed to assess physical, mental and social health, including pain, fatigue and quality of life.

PHQ-2: A two-question depression screening tool that can provide information about the patient’s mental health status. If the patient has a positive PHQ-2 score of three or higher, they should be further screened for  depression. 12,13

IWQOL: A questionnaire developed to assess the effects of obesity on health-related quality of life.14

PROMS FOR WEIGHT MANAGEMENT (Immediate Pre- and Post-Surgical Only)

WHODAS 2.0: An assessment tool administered as either a 12-item self-report or a more detailed 36-item structured interview used to measure disability and functional impairment in psychiatric disorders.15

QoR-15: A 15-question patient-reported outcome tool measuring quality of recovery after surgery and anesthesia.16

Medical Weight Management

GOAL OF MEDICAL WEIGHT MANAGEMENT

People with a BMI greater than 27kg/m2 who have a weight-related comorbidity or people who have a BMI greater than 30kg/m2 with or without a weight-related comorbidity should be considered for formal weight loss efforts. The primary goal of medical weight management of obesity is achieving a weight reduction of 7%–10%. Secondary goals include improving metabolic outcomes, reducing no-show rates, achieving satisfaction, and limiting or eliminating disease comorbidities. Even a modest, sustained weight loss of 3%–5% can improve clinical outcomes (e.g., reduction in triglycerides, blood glucose and type 2 diabetes risk).17 When a larger volume of weight is lost, there are further reductions in risk factors of cardiovascular disease (CVD) (e.g., low-density and high-density lipoprotein cholesterol and blood pressure) and the need for medication to control previously diagnosed CVD and type 2 diabetes.17 Therefore, a weight loss goal of 5%–10% of total body weight within six months of management is recommended.17

TRIAGE AND ASSESSMENT

Primary Care Initial Screening and Diagnosis (see Algorithm 1)

All adults should be screened annually for obesity using a BMI measurement. Other methods (e.g., bioelectric impedance, air/water displacement plethysmography) to determine adiposity may be used at the clinician’s discretion if BMI results are equivocal or require further evaluation.18 Screening and diagnosis typically occur through primary care providers, who can offer basic weight management treatment options (see tables 2 and 3 for details). It is recommended that the primary care provider offer education sources and tools (see section V) to the patient. Based on obesity status and risk factors, the provider and patient should engage in joint decision-making for medical or surgical management.

  • New patient obesity bloodwork. At minimum, glucose, lipid and endocrine profiles are recommended for every weight-management-program patient.17 If basic labs are available within the last 12 months, bloodwork is at the discretion of the provider.
  • Consultation with a registered dietitian should be also be completed on this visit if possible.

Prompt Initiation of Anti-Obesity Medications

Vanderbilt Health Affiliated Network recommends prompt initiation of anti-obesity medications per The Journal of Clinical Endocrinology & Metabolism guidelines for all patients with a BMI of greater than 27 kg/m2 with comorbidity or BMI greater than 30 kg/m2. Medications are to be used as adjuncts to behavioral modification and reducing food intake.19 Weight loss medications can improve adherence to behavioral changes and may improve physical function so that physical activity is easier in those who cannot initially exercise due to their weight.19

Patients who have been unsuccessful in the past with weight loss and those who meet label indications are candidates for weight loss medication.19

Referral to Medical Nutrition Therapy and Group Therapy

Dietary modifications are an integral part of any successful weight-loss program. Each patient needs an in-depth individualized nutrition plan and should be referred to Medical Nutrition Therapy (MNT) provided by a registered dietitian (RD). MNT is a nutritional diagnostic, therapy and counseling service for the purpose of disease management.20 MNT aims to help patients lose weight, maintain weight loss, and meet goals for blood pressure, cholesterol and glycemic targets. MNT is also often employed to delay or prevent diabetes complications.21 If MNT is unavailable or cannot be achieved, apps or other free resources may provide an option (see section IV, Educational Resources).

Energy Balance

The American Academy of Nutrition and Dietetics recommends both decreasing energy intake and enhancing dietary quality, along with undertaking regular physical activity (150 minutes/week of moderate physical activity or 75 minutes/week of vigorous physical activity, followed by a maintenance routine of more than 250 minutes per week of moderate-to-vigorous physical activity) as essential to initiate and sustain weight loss.17

Evidence-proven dietary interventions to support weight loss include reducing caloric intake—especially of sweetened drinks—monitoring portions, engaging in low-carbohydrate, high-protein eating patterns and following proven eating plans, such as the DASH and Mediterranean plans, in concert with calorie restriction. It is important to note that, without accompanying caloric restriction, diets that restructure macronutrient intake, including the DASH and Mediterranean diets, have not been found to contribute to weight loss.17

The American Academy of Nutrition and Dietetics considers the following recommendations imperative for people who want to achieve sustained weight loss:17

  • Women should be encouraged to aim for between 1,200–1,500 kcal/day, while men should aim for 1,500–1,800 kcal/day; alternatively, people should aim for a deficit of 500–750 kcal/day. Diets should provide adequate nutrition in combination with reduced calorie intake.
  • Patients should be reminded that many healthy diets can help them lose weight, as long as they fall within the calorie-deficit parameters of 500–700 kcal/day.
  • After weight loss, providers should help patients plan an individualized maintenance diet, representing both adequate nutrition and reduced caloric intake to sustain their lower body weight.*
  • Similarly, patients should be reminded that many healthy diets can help them sustain weight loss, as long as they fall within calorie-deficit parameters of 500–700 kcal/day.

*Substantial weight loss through diet and exercise can decrease the initial RMR used for caloric intake calculations. Maintaining weight loss in the maintenance stage may require fewer calories than initially calculated or high levels of physical activity due to this metabolic adaptation.22

Individual and/or Group Exercise Motivation Class

A sedentary lifestyle and obesity are closely linked. People who struggle with obesity may be ashamed to work out on their own due to stigmatization of obese individuals in society. Group exercise classes allow obese patients to exercise without the stigma. Beyond weight loss, participation in group fitness classes has been found to lead to a decrease in perceived stress and an increase in physical, mental and emotional quality of life compared to exercising independently or not engaging in regular physical activity at all.23

Drug-Induced Weight Gain

A thorough medication reconciliation should be completed during the initial consult to identify medications that can contribute to weight gain. Common medication classes that cause weight gain include contraceptives, antidepressants, atypical antipsychotics and some diabetes medications.19 Other medication classes with similar effects include beta blockers and corticosteroids.19 Alternative medications that limit or eliminate weight gain potential should be considered and weighed against patient risk factors for obesity-related health complications.19 Providers must keep this consideration in mind when prescribing first-line therapy or making medication changes.

ONGOING CARE

It is important to have regular, established visits during a medical weight management program to reinforce behavioral and lifestyle changes and monitor progress. The visit pattern is monthly for the first six months, trimonthly for one year, then every 6–12 months.

Surgical Weight-Loss Pathway

Some patients should be considered for bariatric surgery as an initial weight loss therapy based on comorbidity and total weight loss needs. If medical management is not successful or if patients request a conversation about surgery, then they should be referred for consultation for surgical management.

Educational Resources

  • Baritastic is a nutrition and weight-tracking app for people on the bariatric surgery path. It contains numerous self-management, educational and motivational features, such as reminders, recipes, photo timelines and a bite-chewing timer. It also supports integration with a bariatric surgery program for patient monitoring, appointment reminders and communication with providers.
  • Myfitnesspal.com provides free tools for food journaling and logging physical activity. The food journal contains a searchable food database and informs the user of the types and duration of exercise needed to burn consumed calories. It also features community boards and downloadable apps.
  • MyPlate is a free app from choosemyplate.gov that allows users to set goals within food groups and choose and track food goals.
  • American Diabetes Association provides information on the topic of weight management in relationship to diabetes management.
  • American Society for Metabolic and Bariatric Surgery offers an online patient learning center providing information about the disease of obesity, bariatric surgery FAQs and more.
  • The Obesity Society website features a section of patient-friendly downloads on a range of topics, including healthy pregnancy weight gain, the correlation between body weight and cancer risk, and more.
  • Vanderbilt Weight Loss Center features patient stories and helpful information, including a BMI calculator, bariatric nutrition guide, a video with bariatric surgeons answering patients’ most common questions about surgical weight loss, and guidance about what patients need to ask of their health insurance providers.