Key Points Highlighted by Individual Speakers
- Health care providers and patients need education and training in the prevention and treatment of obesity. (Bradley)
- Many health care providers are not prepared to have the delicate and complicated conversations needed to change behaviors in overweight and obese patients. (Solomon)
- The medical care system is just part of a much larger health system, and all parts of this broader system contribute to the prevention and treatment of obesity. (Sanchez)
- Reforms of the reimbursement system could support change in this larger system, along with evidence-based, community-integrated, family-centered interventions. (Sanchez)
Three speakers addressed obesity solutions in the health care setting. Don Bradley, senior vice president for health care and chief medical officer of Blue Cross and Blue Shield of North Carolina (BCBSNC), spoke about the role of the insurance industry. Loel Solomon, vice president for community health at Kaiser Permanente, explored the role of health care providers. Finally, Eduardo Sanchez, deputy chief medical officer for the American Heart Association, talked about the contributions of the broader health system.
It takes a village to prevent and treat obesity, said Bradley, and one member of that village is the insurance industry. Bradley divided the industry’s progress as it relates to obesity into four areas.
The first involves benefits for the treatment of obesity in health care settings. BCBSNC has been offering benefits for physician assessment, referral, and treatment of obesity for about a decade. It also has offered nutritional counseling at no cost during the same period. Particularly helpful have been the synergies created with worksites, said Bradley, because the worksite can direct people to the medical benefits available to them.
The second area of progress encompasses health programs. Hospitals, clinics, primary care physicians, and other health care providers have used a variety of models to work with severely obese patients, although these efforts are still sporadic and expensive. An area in which progress has been good is bariatric surgery, Bradley noted, and BCBSNC has worked with bariatric centers of excellence to reduce complication rates and augment success.
The third area entails community impact. The BCBSNC Foundation has funded a number of activities in this area, such as farm-to-school programs, nutrition education for child care workers, and bicycle commuting programs.
Finally, the insurance industry has provided thought leadership. For example, it has demonstrated that providing benefits for the treatment of obesity is not particularly expensive. BCBSNC covers six nutrition visits a year at no cost, but the average number of visits is only about two. “We will not go broke for two nutrition visits a year,” said Bradley. “It is not a service of abuse.”
Bradley also listed five potential breakthroughs in fighting obesity:
- provider education, training, and teamwork;
- patient engagement;
- addressing obesity throughout life, from breastfeeding to treatment of severe obesity;
- safe environments for physical activity, which is determined by society as much as by the health care system; and
- better nutritional choices.
Providers of care are not just physicians, nurses, nutritionists, and pharmacists, Bradley emphasized. They include parents, grandparents, child care providers, teachers, pharmacists, ministers, insurers, politicians, and policy makers. All need education, training, and engagement. Today, they tend not
to talk with each other, but the example of tobacco control demonstrates what can be done when they collaborate and act as coordinated teams.
With regard to patient engagement, Bradley noted that obesity entails complex behaviors and that developing healthy habits is a complex process. Money and knowledge alone are not enough to explain people’s behaviors. The insurance industry needs to help all the other stakeholders in obesity prevention and treatment think about how to support people in developing healthy habits and apply that knowledge to achieve better outcomes.
Most people engage with their health care providers on only a few days per year, or perhaps for a week or more if they are sick. During the rest of the time, family members, friends, and community members are the caregivers. “People are much more heavily influenced by the places that they live, where they go to school, where they go to work, and so on, than they are by their health care providers,” said Solomon.
Nevertheless, the health sector has important responsibilities, which Solomon described as the “five As”:
- asking patients about their readiness to change,
- assessing their risks,
- advising them on therapeutic alternatives,
- agreeing on treatment plans, and
- assisting with or arranging for the resources necessary for people to take action.
With regard to obesity, much of the health sector has been focusing on assessment, and on measuring body mass index (BMI) in particular, Solomon said. Knowing a person’s BMI is important but is insufficient. In the area of assessment alone, there are other needs, such as assessing what people eat and how much physical activity they engage in. Such assessments can lead to conversations that change behavior.
Health care providers also need to devote more attention to the quality of the advice they provide, Solomon continued. Many providers are not prepared to have the delicate and complex conversations needed with overweight and obese patients. Kaiser Permanente and other organizations have developed online training for providers, including training in brief negotiation and motivational interviewing that can produce quality conversations and support prevention.
Health care providers need to go beyond the idea that a quality encounter is all about motivating people to change. People who are overweight and obese already have plenty of motivation to change, said Solomon. Behav-
ioral scientists have shown that the important opportunities are instead lowering the threshold of activation and creating triggers for behavior change, and identifying optimal defaults that make the healthy choice the easy, convenient, and affordable choice.
More attention also is needed to helping people connect to outside resources, Solomon said. Health care systems are embedded within vast arrays of community-based resources. Integration between clinic and community is critical.
With health care accounting for 18 percent of the nation’s gross domestic product, health care systems have an obligation, as well as the power, to influence community environments. The Patient Protection and Affordable Care Act requires all nonprofit hospitals to conduct community health needs assessments, and these assessments routinely identify problems with physical activity and the food environment. “We need to seize the levers of change,” said Solomon. “We need to model healthy behaviors by [creating] change for our own employees, through our civic leadership responsibilities, and by using our grant money and social influence to change community environments.”
The medical care system is just part of a much larger health system, said Sanchez, and all parts of this broader system contribute to the prevention and treatment of obesity. At the same time, the people and organizations that make up the medical care system play many roles in their communities as part of this broader health system. They are health educators, employers, and sometimes payers (for example, through philanthropy). In these roles, they can be advocates for evidence-based change.
A variety of clinical guidelines exist for the prevention and treatment of obesity, including joint guidelines on obesity treatment from the American College of Cardiology, the American Heart Association, and The Obesity Society; lifestyle modification guidelines from the American Heart Association and the American College of Cardiology; diagnosis, prevention, and treatment guidelines from the American Academy of Pediatrics; and a monograph on how to treat obesity from the American Academy of Family Physicians.
A systems approach is needed to prevent and treat obesity in the clinical setting, said Sanchez. Drawing on a blood pressure initiative undertaken by Kaiser Permanente, he pointed to the essential elements of such an approach:
- assessment and technical assistance for clinical practices;
- a registry of overweight and obese patients;
- clinical guidelines that are relatively simple and easy to follow;
- data metrics and reports from providers and health care systems, including adherence to guidelines;
- expanded health teams that include dietitians, health coaches, social workers, medical assistants, and community health workers; and
- physician training and engagement in advocacy around evidence-based community intervention.
Sanchez also discussed the prospects for reimbursement reform led by Medicare, Medicaid, and other payers. Such reform could help support systems change, although resources would be needed to implement such change. But the initiatives of Kaiser Permanente and others, such as the YMCA’s Diabetes Prevention Program,1 demonstrate the potential for evidence-based, community-integrated, family-centered interventions to achieve even ambitious goals.
Finally, Sanchez stressed that research and evaluation are needed to measure costs, estimate outcomes, and make improvements.