Practice Management

Ethan A. Lazarus

Adam H. Gilden

CASE STUDY

A 62-year-old male patient with hypertension and obesity has recently retired. He wants to enjoy a better quality of life, but knee osteoarthritis limits his movement. He has struggled with his weight for decades and knows that weight loss would improve his overall health and daily function. Medications include losartan/hydrochlorothiazide 50/12.5 mg and ibuprofen prn. He has a supportive wife who is ready to help. He is not interested in joining a group but would be willing to take a medication if it would help with weight loss. His insurance plan does not include any coverage for weight loss medications. He does not want to have bariatric surgery.

On examination, height is 68 inches, weight 109 kg (240 lb), blood pressure 128/86, heart rate 88, and body mass index (BMI) 37.0 kg/m². Electrocardiogram (ECG) is normal. The remainder of the physical examination and laboratory tests are unremarkable.

CLINICAL SIGNIFICANCE

Treating obesity in clinical practice requires a multidisciplinary approach to achieve clinically significant patient outcomes. However, since primary care physicians have limited time during office visits, and because the treatments used for obesity have variable reimbursement, healthcare professionals (HCPs) who want to provide competent and compassionate obesity care face multiple office-based challenges. This chapter will discuss issues of staffing, office infrastructure, clinical protocols, billing and health insurance, weight bias, and the ethics of incorporating obesity into clinical practice.

STAFFING, EQUIPMENT, AND EDUCATIONAL CONSIDERATIONS TO PROVIDE COMPETENT OBESITY CARE

Professional staff from multiple disciplines are involved directly or indirectly in the treatment of obesity. This includes front office registration staff who provide check-in and check-out services; medical assistants who obtain vital signs (including measurement of weight and height); HCPs (physician, physician assistant, and nurse practitioner) who conduct the medical encounter; other team members (registered dietitian nutritionist [RDN], exercise specialist, social worker, health psychologist) who provide counseling; and “back office” staff who support billing and other office-based business activities. While many HCPs will not have all of these personnel within the office, most will have at least some. These individuals constitute a healthcare team.

Obesity is a complex, multifactorial disease, and as such, treatment is best accomplished by incorporation of a multidisciplinary team. This is consistent with the management of other chronic diseases such as diabetes, depression, and low back pain where certified diabetes educators, mental health counselors, and physical therapists, respectively, are routinely employed. The team approach to obesity care is further discussed in Chapter 13.

For decades, research has shown that multidisciplinary care is more effective than treatment rendered by a single provider. For example, a 12-month randomized trial demonstrated greater weight loss with the combination of intensive lifestyle intervention (ILI), pharmacotherapy, and meal replacements (16.5% loss of initial body weight), compared with medication alone (4.1%) or medication plus ILI (10.8%).¹ Another study found that ILI with a multidisciplinary team resulted in more weight loss than usual care for patients with type 2 diabetes (8.6% vs. 0.7% after 1 year), and
that this weight loss continued to be significant after 8 years.² The value of an interprofessional team lies in its ability to provide expert assistance in multiple aspects of patient care. For example, if the medical assistant is properly trained to obtain anthropometric measurements, i.e., height, weight, waist circumference, and take vital signs, and an RDN is available to provide counseling on the implementation of lifestyle changes, this leaves more time for HCPs to focus on the medical aspects of obesity care.

Provision of care for obesity should ideally include a full array of professional resources. Although primary care practices are not likely to have all team members in the office, they should have a referral process in place to assist in comprehensive care of the patient with obesity. Team members may include:

Medical provider (physician, physician assistant, nurse practitioner)
Metabolic and bariatric surgeon
RDN
Office support staff
Psychologist or other mental health professional (e.g., licensed professional counselor [LPC])
Exercise physiologist/physical therapist

The roles and responsibilities of the team members are displayed in Table 12.1.

Team Members

Medical Provider

Since obesity is recognized as a chronic disease, it is important that a properly trained HCP directs patient care. Most often, this will be a physician. While all providers are able to treat obesity, unfortunately many often feel that they have inadequate training to do so. A recent study found that many providers make recommendations that are not consistent with current medical evidence.³ While there are multiple opportunities to obtain updates and practice tips on obesity care through continued medical education conferences, online training, and journal article reviews, studies show that education around obesity and nutrition continues to be limited.⁴,⁵ The role of the HCP is to have a fundamental understanding of all the aspects of obesity care (e.g., how to take an obesity history, evaluate for comorbid conditions, conduct an obesity-focused physical examination, and discuss treatment options including lifestyle management, pharmacotherapy, and bariatric surgery) and then to direct the patient to the resources most needed. The HCP is also responsible for setting the overall philosophy and direction of the practice. As a specific example of philosophy/direction, some HCPs may personally favor a specific eating plan (e.g., plant-based, low-carbohydrate, Mediterranean) for weight management. However, HCPs who can counsel patients on a wide variety of evidence-based eating plans are more likely to have success in treating obesity.

TABLE 12.1 Clinicians Involved in Treatment of Obesity

STAFF	SERVICE
HCP	Prescribe pharmacotherapy Manage comorbidities Refer to other services—RDN, exercise, behavior, psychologist, surgeon Provide perioperative care for patients who undergo bariatric surgery Arrange follow-up
RDN	Within practice or by referral Perform dietary assessment Review food journals Provide individualized structured food planning, intensive lifestyle intervention Provide dietary and nutritional education
Exercise physiologist/trainer	Typically by referral Assess physical limitations and abilities Develop individualized physical activity program
Psychologist/therapist	Typically by referral Assess psychological stressors and barriers Perform motivational interviewing Provide cognitive behavioral therapy
Bariatric surgeon	Typically by referral Assess patient appropriateness for bariatric procedures Perform procedures and arrange follow-up
HCP, healthcare professional; RDN, registered dietitian nutritionist

Metabolic and Bariatric Surgeon

For some patients, particularly those with a BMI ≥40 kg/m² (or ≥35 kg/m² with a comorbidity such as type 2 diabetes) who have been unsuccessful at achieving and maintaining medically meaningful weight loss through noninvasive means, referral to a properly trained metabolic and bariatric surgeon is indicated. Surgery can improve lifespan, reduce the burden of medical comorbidities, and improve quality of life. Surgery has been
proven to be a powerful tool for obesity treatment. (Like all fields of medicine, these guidelines are constantly changing. Newer surgical guidelines may lower these BMI reference ranges. Often, insurance coverage for treatment lags behind any changes in guidelines.) Although some general surgeons perform bariatric surgery, many choose to specialize in bariatric surgery. In general, it is preferable for the HCP to refer to a surgeon who does only (or at least primarily) bariatric surgery. Many of these surgeons have completed fellowship training in performing bariatric procedures. Ideally, the surgeon should practice in a bariatric “center of excellence,” accredited by the MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program). Patients or HCPs can search the website of the American Society of Metabolic and Bariatric Surgeons to find a provider in their area.⁶ For more information on bariatric surgery, please refer to Chapter 9.

Registered Dietitian Nutritionist

RDNs are certified by the Academy of Nutrition and Dietetics. RDNs must complete a bachelor’s degree at a US regionally accredited university or college and a course work accredited by the Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy of Nutrition and Dietetics. They must further complete an ACEND-accredited supervised practice program consisting of a minimum of 1,200 hours of supervised practice and pass a national examination administered by the Commission on Dietetic Registration (CDR). Once credentials for RDN have been met, the RDN must maintain 75 hours of continuing medical education every 5 years. Where there are legal standards for RDNs, the term “nutritionist” is less standardized and less regulated. A nutritionist can have nutrition training or no nutrition training. Thus, if the HCP is referring a patient for dietary/behavioral treatment, it is preferable to collaborate with an RDN.

RDNs play an important role in assessment and treatment of the patient with obesity. They excel at implementing specific, individualized dietary strategies. The CDR also offers a certificate of training in adult weight management and an Interdisciplinary Specialist Certification in Obesity and Weight Management. The RDN can be helpful in the initial assessment of the patient with obesity by performing a comprehensive nutrition history using a variety of tools that may include a Food Frequency Questionnaire, Diet History Questionnaire, 24-hour dietary recall, or a typical sample food intake day. They can then implement a nutritional intervention that is appropriate for the patient (see Chapter 5).

RDNs also excel at ILI. In a high-intensity weight management program, patients are typically seen every week or every other week. Many of these visits are performed by the RDN. In addition to supervising the food plan, the RDN can work with the patient on specific behavior changes. This can be accomplished during one-on-one visits or in group settings. (In a randomized trial, group intervention has been shown to be at least as effective as one-on-one visits, even when participants expressed a preference for individual treatment.) RDNs can cover topics related to behavior modification (see Chapter 7).

Losing weight and sustaining weight loss is challenging. It is often difficult for patients to remain motivated, engaged, and committed to change. RDNs can help patients maintain a high level of motivation and improve treatment outcomes. The 2013 AHA/ACC/TOS guideline on obesity treatment recommends at least monthly contact to help maintain weight loss; RDNs are well suited to support long-term treatment.

Office Support Staff

As with other chronic diseases, a well-functioning office staff will help improve patient satisfaction and health outcomes. Key personnel include:

Front office staff: check-in, check-out, scheduling, phone calls, billing
Medical assistants and nurses: assess vital signs, weight, blood draws, ECGs. Specific testing for obesity may include body composition or resting metabolic rate (RMR) testing
Administrative staff/office manager: insurance billing, prior authorizations
Patient advocate/case manager

Support staff must ensure a positive patient experience. They should be trained on the topic of weight bias (see Weight Bias section). Patient confidentiality must always be respected. Weight should be checked privately, and staff should be trained to provide encouragement.

Psychologist or Therapist

There are several types of training in psychology. The traditional PhD in psychology is qualified to work in clinical or counseling psychology. They may also choose to teach at the university level, practice at mental health clinics and hospitals, or have a private practice. It takes the typical candidate 4 to 8 years to obtain a PhD in psychology. The PsyD is a more practice-based degree. As a result, this degree requires fewer research and statistics courses and thus takes less time, typically 4 to 6 years. Finally, LPCs must have a master’s degree in a counseling or related field and must have 2 years of supervised clinical experience before becoming credentialed to provide psychotherapy on their own. Thus, LPCs may
include clinical social workers. All of these types of clinicians (PhD, PsyD, LPC) are qualified to treat patients with overlapping weight and mental health concerns, although not all have interest or expertise in this patient population.

Many patients with obesity have coexistent mental health concerns and/or psychosocial treatment barriers. They may have inadequate social support and/or saboteurs, which increases the difficulty of implementing treatment recommendations. There may be a history of verbal, physical, or sexual abuse. Patients may suffer from clinical depression, anxiety disorders, eating disorders including binge eating disorder, or other issues contributing to their obesity. For patients suffering from obesity and coexistent mental health problems, treatment by a psychologist with the proper evidence-based tools will enable improved outcomes. In addition, a psychologist can participate in ILI and address many of the psychological issues common with obesity, including stress management, building support, and increasing assertiveness. Finally, a psychological assessment is typically required before embarking on bariatric surgery (see Chapter 9 for more details).

Exercise Physiologist/Physical Therapist

Reduced calorie diets have been shown to be the most effective approach to achieve initial weight loss. Regular physical activity is key to keeping weight off and to improve fitness and overall health. Many patients with obesity have significant physical limitations. Thus, general recommendations to simply “move more” or begin a vigorous exercise program may lead to injury or further resistance to incorporate physical activity into their daily routine. Rather, the goal is to develop an individualized structured physical activity program, accounting for the patient’s likes, dislikes, and physical limitations.

An exercise physiologist is properly trained to assess a patient’s ability to engage in physical activity. A clinical exercise physiologist is certified by the American College of Sports Medicine (ASCM-CEP) and has either (1) a bachelor’s degree in exercise science or equivalent and 1,200 hours of clinical hands-on experience or (2) a master’s degree in clinical exercise physiology and 600 hours of hands-on clinical experience. The ASCM-CEP can perform body composition analysis, RMR and exercise testing, muscle strength and flexibility testing, and even gait analysis. Working one-on-one with the patient, the exercise physiologist can develop an individualized physical activity program for the patient, including specific goals and metrics. A licensed physical therapist can help carry out the exercise plan developed by the exercise physiologist (or the HCP) (see Chapter 6 for more details).

Office Equipment

Patients with obesity should be able to feel physically and psychologically comfortable in the HCP office. For example, office and examination room chairs should be armless or extra wide (28 inches) to accommodate patients who weigh 300 lb or more. If the office has sofas, they should ideally have firm seats at a higher height to allow patients to get on and off easily. Recommendations for the waiting room include having several sturdy armless chairs (again, to support patients weighing 300 lb or more) with at least 6 to 8 inches of space between them and firm high sofas if possible. Magazines could include those from organizations such as the Obesity Action Coalition (OAC) (obesityaction.org), a national advocacy organization that promotes improved healthcare for persons with obesity. Magazines should not include photographs that depict unrealistic body shape (e.g., supermodels). Measurement of an accurate height and weight is vital to treating patients with obesity. Office scales should be able to accommodate patients with weight up to 600 lb, ideally with a wide base and a handlebar for support, if necessary. A wall-mounted stadiometer is most accurate for measuring height, but a height meter attached to the scale is considered adequate. Office staff should always obtain permission to weigh patients, especially for those with visibly high weight. As stated above, office staff should be trained not to make disparaging comments about patients’ weights.

Examination rooms should have both regular and large gowns available to wear as well as a sturdy step stool to mount the examination tables. Some practices may consider having a bariatric examination room table that is electronically controlled. Equipment for nonobesity care should also include different sizes (e.g., specula for Pap smears). In addition to standard adult blood pressure cuffs, practices should have large adult and thigh size blood pressure cuffs to ensure that blood pressure is correctly measured on patients of all sizes (see Chapter 2 for additional details). Finally, a cloth, vinyl, or metal tape measure should be available for measurement of waist circumference.

Getting Started With Obesity Treatment

HCPs may not have access to all the professionals listed above. In some parts of the country, there may not be an exercise physiologist or a bariatric surgeon. Or, an HCP may work in a small practice and not have access to all the above support personnel. While a multidisciplinary team is ideal, any treatment (if available) is better than no treatment at all. Patients affected by obesity and their HCP can work together using shared decision-making to implement a realistic and practical treatment plan.

For example, an HCP can prescribe medication and monitor weight, BMI, and medication side effects. If the HCP has an RDN in his/her practice or in their health system, the patient can be referred for consultation. If more aggressive lifestyle treatment is indicated, the HCP can refer the patient to an intensive group program. This may include a program based at an academic medical center, the YMCA-based Diabetes Prevention Program, an evidence-based commercial program (such as WW), or a self-directed program that incorporates some of the principles of behavioral treatment (i.e., self-monitoring and feedback), such as Noom. If the patient does have the time or resources to engage in intensive treatment, the HCP can ask the patient to start by self-monitoring diet with a free smartphone application, such as Lose It! or MyFitnessPal.

With physical activity, if the HCP does not have access to an exercise physiologist, the patient could be referred to a skilled personal trainer with experience working with patients with obesity. Physical therapists are typically more accessible in clinical practice compared with exercise physiologists and can create individualized activity plans. For example, a physical therapist can do a teaching visit for patients to use Therabands or Theratubes at home, thus allowing the patient to start an exercise program without the time, cost, or weight stigma barriers of exercising at a gym. Patients can also engage in self-directed physical activities—walking, swimming, or cycling (e.g., stationary bike—easier for patients with obesity as non-weight bearing).

One treatment option for the HCP is to prescribe pharmacotherapy for obesity. As detailed in Chapter 8, patients starting medication should be assessed monthly for the first 3 months and then at least every 3 months thereafter. Patient contacts with the practice between these HCP assessments are likely to be conducted by RDNs or other clinicians. Depending on several factors including patient need, as well as HCP availability/access, assessment after the first 3 months of treatment could take different forms. The assessment may include a 1:1 visit with the HCP or, to reduce patient out-of-pocket cost, could be a nurse visit to evaluate vital signs, with data forwarded to the HCP for prescribing. The HCP must also pay attention to adjusting therapies for weight-related conditions (e.g., diabetes, hypertension), which may need a reduction in dose if patients successfully lose 5% to 10% of initial body weight.

When patients achieve clinically significant weight loss, a significant challenge remains how to help them maintain success. As mentioned above, the 2013 AHA/ACC/TOS guideline recommends at least monthly contact to help patients with weight loss maintenance. The HCP and RDN may provide any schedule of visits that works for the practice, provided that it is intensive enough for the patient to continue practicing the behaviors that led to initial weight loss. Some patients may need more intensive dietary, physical activity, or behavioral support during weight loss maintenance, and some patients may achieve 5% to 10% initial weight loss but not be satisfied with their progress. For patients in the latter category, an office visit with the HCP to determine next steps for treatment intensification may be indicated. An office-based audit for initiation of obesity care is included (Table 12.2).

WEIGHT BIAS

Obesity stigma is a major issue in our society. This type of stigma has negative effects on patients and needs to be addressed and minimized. Weight bias comprises negative attitudes, beliefs, judgments, stereotypes, and discriminatory acts aimed at individuals primarily because of their weight. It can be overt or subtle and can occur in any setting, including employment, healthcare, education, mass media, and relationships with family and friends. It also takes many forms—verbal, written, media, online, and more. For example, a subtle example of weight bias is the common use of photographs that only show the bodies of individuals with obesity (not showing their faces). Weight bias is dehumanizing and damaging; it can cause adverse physical and psychological health outcomes and promotes a social norm that marginalizes people.⁷

Perceptions that obesity is caused by a lack of self-discipline contribute to weight bias. Many people believe that obesity is not a chronic metabolic disease, but instead is caused by willful selection of poor dietary and activity choices. This leads to discriminating treatment in many areas, including work, education, and healthcare. People affected by obesity have more trouble getting hired and promoted and are paid less than their counterparts without obesity. They have lower college acceptance rates and suffer peer victimization and negative attitudes by other students and educators. Furthermore, patients with obesity are viewed by their healthcare providers as being less motivated, honest, compliant, and intelligent, compared to their normal weight counterparts. In one study, 69% of respondents reported that their physicians were a source of weight bias.⁸ These biases can result in adverse health consequences including depression, anxiety, low self-esteem, poor body image, reduced quality of interpersonal relationships, unhealthy weight control practices, binge eating, diminished physical activity, and avoidance of healthcare including routine preventive care.

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