What Do We Need to Do to Get Primary Care Ready to Treat Obesity?

Abstract

In a 2010 commentary titled “Tackling Obesity: Is Primary Care Up to the Challenge?” (1), I asserted that obesity is under-recognized and undertreated in the primary care setting, and that there are few other examples in medicine where significant stigmatization of the patient, feelings of being ill equipped, perceived treatment ineffectiveness, and even reluctance to engage in obesity care prevail as major barriers. In the intervening years there have been significant scientific and therapeutic advancements in the field of obesity. Examples include defining obesity as a disease, further elucidation of its biology and pathophysiology, a deeper understanding of the impact of obesity on health, quality of life, and mortality, and increased availability of evidence-based pharmacological and bariatric surgical options. Yet despite these developments, the assessment and treatment of obesity in primary care remain low. Previous studies have identified numerous practice-, provider-, and patient-based barriers that have not been directly addressed by the achievements in the field (2). Focus on these barriers by multiple stakeholders will need to be implemented in order to change current practice behavior. In the study by Turner et al. (3) in this issue, the authors investigated one potential provider barrier—lack of knowledge. Their aim was to establish baseline information on healthcare professionals' understanding of current evidence-based clinical guidelines for obesity management by surveying a nationally representative sample of 1,003 internists, family practitioners, obstetricians/gynecologists, and nurse practitioners. Knowledge was assessed by asking five obesity-specific multiple-choice questions (MCQ) about the guidelines at a specificity that demands intimate knowledge of details and would be found on a certifying examination. Correct answers varied overall from 49% for knowing the physical activity goals to 15% for knowing the BMI thresholds to prescribe anti-obesity medications. Family practitioners were significantly more likely than internists, nurse practitioners, and obstetricians/gynecologists to identify the correct guidelines for obesity counseling and pharmacotherapy. The authors concluded that most providers lack knowledge and understanding of recommended obesity treatment modalities. The study by Turner et al. (3) provides a snapshot on the ability of primary care providers to correctly answer MCQs that relate to current guidelines. Although interesting, it is difficult to interpret the results as a guide to next steps. Answering these MCQs requires both awareness of the guidelines and basic recall of specific guideline criteria and thresholds. Unfortunately, the study did not distinguish between these two considerations. Furthermore, the full web-based DocStyles panel survey contained 144 questions on attitudes and counseling behaviors on a variety of health issues, of which only 5 items were analyzed for this study. Poor performance on a knowledge-based test may be influenced by many factors, including fatigue, allotment of time, interpretation of the questions, concentration, and importance. Regardless of the study's limitations, the primary outcome suggests that more obesity education is needed among healthcare providers. Knowledge of the guidelines is a reasonable objective but is not sufficient to change practice behavior. Nonadherence to clinical practice guidelines may be due to other factors independent of knowledge, such as lack of self-efficacy, inertia, fragmentation of care, information overload, disagreement between guidelines, and external practice barriers (4, 5). Awareness and familiarity with the guidelines are also dependent upon adequate dissemination in medical journals, conferences, and other continuing education forums. Lastly, the guidelines need to be implemented. Four intervention strategies have been found to be effective for implementation: academic detailing (educating providers in their practice setting), audit and feedback (summary of clinical performance over a specified period of time), provider reminders (prompts for providers to recall information), and provider incentives (financial reward or benefit for doing specific actions) (6). Furthermore, many practices are now being subsumed within large healthcare systems that take a population health approach to obesity. Thus, dissemination and implementation of obesity clinical practice guidelines among healthcare providers will require a deliberate and coordinated effort among multiple stakeholders. Two other educational initiatives are under way that will impact the practice of obesity in the primary care setting. The American Board of Obesity Medicine (ABOM) was created in 2011 to increase the workforce of physicians that care for patients with obesity and to serve as local champions or consultants to primary care providers (7). Sixty-six percent of ABOM Diplomates are internists or family practitioners. And in an effort to better train future healthcare professionals, the Obesity Medicine Education Collaborative (OMEC), a coordinated group of 15 professional organizations, is currently finalizing a set of 32 obesity-specific competencies based on the six Accreditation Council for Graduate Medical Education (ACGME) domains that will be applicable for undergraduate, postgraduate, and fellowship training. Incorporation of obesity-specific competencies along with more rigorous assessment (8) will drive learning. By taking a continual and comprehensive educational approach, we are on our way to get primary care ready to treat obesity.