The obesity prevalence among U.S. adults has increased at an alarming rate in the past several decades, reaching 42 percent in 2018 or about 110 million people based on census data. By 2035, the prevalence of obesity in the U.S. is expected to reach 58 percent, with the total economic cost expected to surpass $1.2 trillion annually.

Obesity is a risk factor for increased mortality and has been linked to many chronic conditions. Effective obesity treatment, commonly defined as a clinically meaningful weight loss of greater than 5 percent, can improve chronic conditions such as diabetes, hypertension, and dyslipidemia. Yet despite the clinical and public health significance and implications of obesity, primary care providers have not been well-trained or equipped to evaluate, prevent, and manage this condition. As a result, patients with obesity have been underdiagnosed and undertreated.

The recently FDA-approved Glucagon-like peptide (GLP)-1 and Gastric inhibitory polypeptide (GIP) receptor agonist medications are a significant breakthrough in obesity treatment. Although long-term data is lacking, the availability and acceptance of such effective anti-obesity medications could indicate a significant shift in primary care practice. With more than 110 million U.S. adults meeting the Body Mass Index (BMI) criteria for pharmacologic obesity treatment, health care systems and providers must be equipped and prepared to provide medical treatment of obesity in the primary care setting. BMI does have limitations in estimating adiposity and health risks, and not everyone who meets the BMI criteria for pharmacotherapy truly needs or desires it. This article highlights best practice approaches to incorporate weight management in primary care.

I. Treat obesity as a chronic condition

U.S. life insurance data have shown the link between excess body weight and high mortality risk in the early 20th century. However, it was not until 1998 that the National Institutes of Health (NIH) first recognized obesity as a chronic disease, followed by the American Medical Association (AMA) in 2013. Obesity is defined by the Obesity Medicine Association (OMA) as “a chronic, relapsing, multifactorial, neurobehavioral disease wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.”

It is now well established that obesity is a complex chronic condition that needs long-term management, rather than a simple calorie-in calorie-out phenomenon. Obesity should be addressed as the underlying etiology for many of the chronic conditions primary care providers are trying to prevent and treat. Primary care providers can play a critical role in supporting patients with evidence-based, stepwise obesity treatment approaches ranging from self-directed and provider-guided lifestyle changes to pharmacotherapy and bariatric surgery.

II. Eliminate stigma and weight bias

Unfortunately, people with obesity can experience stigma and bias in all aspects of their lives, including in health care settings. Studies have reported health care providers themselves can be sources of bias and can perceive people with obesity as non-compliant and lacking willpower. This in turn can lead to stress and poor adherence to treatment plans as well as missed or delayed care. It is imperative that providers recognize if they or their colleagues hold any explicit or implicit bias. Medical practices should be set up with appropriate-size chairs, examination tables, gowns, blood pressure cuffs, measuring tapes, scales, and imaging equipment. Diagnostic services should also accommodate patients with obesity.

It is key to communicate to the patient that obesity is not a result of personal fault or lack of willpower but is instead a complex chronic disease with several nonmodifiable risk factors, such as genetics, epigenetics, age, and early life events or exposures. Patients’ efforts and struggles should be acknowledged and validated in order to build a collaborative rapport. Using people-first language, such as “a person with obesity” rather than “an obese person,” can acknowledge that an individual is more than their disease. Stigmatizing words such as “fat” and “morbidly obese” should be avoided and replaced with more neutral terms, such as “unhealthy” or “excess weight.” And providers' communication with patients should focus on changing or optimizing specific behaviors or lifestyles, rather than on blaming individuals.

III. Dedicate time and workflows

A comprehensive assessment and careful communication of a patient-centered plan takes time. During a typical patient appointment, primary care providers often must address a multitude of issues. This can make it challenging to incorporate weight management discussions, as this often comes up at the end of a visit. Addressing obesity and obesity-related conditions deserves dedicated time to do so fully. If there is not adequate time during a visit, scheduling a focused appointment can help avoid frustration for both patients and providers. In order to accommodate patients and improve access, weight management can be provided via shared medical appointments (“group visits”) or virtual visits which may be as effective or more effective than individual office visits. Follow-up appointments should be individualized based on the specific scenario, treatment plan, and progress. A reasonable visit structure for both active weight loss and maintenance phases is as follows:

Individual in-person or virtual visits

• • First 6-9 months: visit every 1-3 months
    – Initial visit 20-40+ minutes
    – Follow-up visits 15-20 minutes
  • Ongoing: visit every 3-6 months

Group visits (60-90 minutes)

• • First 3 months: weekly group visits
  • Ongoing: monthly group visits with individual appointments as needed

Closer follow-ups might be needed and coordinated with support teams, such as nutritionists, nurses, or medical assistants depending on the available resources. Remote patient monitoring of vitals, weights, and progress can also be implemented between visits.

Developing and implementing a workflow—including pre-populated templates for visit notes, order sets, after-visit summaries, and educational materials that can be provided to patients—can help with efficiency. Furthermore, questionnaires for patients to complete before visits either electronically or on paper can be effective.

Reimbursements can vary depending on visit types, services provided, insurance coverage, and payment/fee structure or contracts. It is important to verify insurance coverage and billing requirements in advance along with advocating for patients to have access to medical weight management.

IV. Create patient-centered assessments and plans

One of the major challenges of weight management is the significant variations seen in response to weight loss interventions; there is no simple one-size-fits-all solution. Furthermore, patients’ understanding and preferences can vary greatly. Therefore, a comprehensive individualized assessment and formulation of a patient-centered plan is an essential part of weight management in primary care.

A comprehensive assessment starts with exploring patients’ readiness, motivations, goals, and expectations. It encompasses having a good understanding of prior weight history, weight-loss attempts, treatments, and programs along with timing, duration, and results. Clinicians should thoroughly review current and past medications in addition to medical, surgical, family, and psychiatric history, including specifically screening for untreated/uncontrolled eating disorders and substance use disorders. Furthermore, lifestyle history regarding eating habits, nutrition, physical activity, stress, and sleep should be reviewed in addition to asking about psychosocial factors and social determinants of health.

Comprehensive assessments help to identify and prioritize the major contributing factors affecting each patient’s weight loss efforts and goals to enable the formulation of individualized plans. This is not to say that busy primary care clinicians need to manage or implement every aspect of the plan. However, it is essential for providers to identify and connect patients to available resources within as well as outside of their institutions.

Within institutions, providers can collaborate with behavioral or mental health providers, medical assistants, nurses, pharmacists, nutritionists, physical therapists, health coaches, and social workers on individual or group programs to complement medical management of obesity. For example, referrals to stress management groups may be beneficial for patients struggling with stress- or emotional eating. Various external programs can also be enlisted, such as Jenny Craig and WW (formerly Weight Watchers), as well as the Diabetic Prevention Program (DPP) offered at local YMCAs. Governmental and non-governmental programs may also address social-ecological factors, such as farmers markets to address food insecurity in a health care setting.

Weight management can be done well in primary care

Obesity is a complex chronic disease with a high prevalence rate and significant health and public health consequences. With more treatment options becoming available, primary care providers should be equipped and prepared to address obesity within their practices. This multifactorial disease needs a long-term multifaceted approach. As such, engaging all the relevant stakeholders – including colleagues, ancillary staff, and organizational leadership, as well as community resources – is critical. Careful attention to the entirety of treatment, from the visit format to clinic setup to addressing implicit bias, will allow teams to provide effective, patient-centered obesity treatment in primary care settings.

Clinical resources and patient information for weight management can be found on the Obesity Medicine Association and the Obesity Action Coalition websites.

About the author

Wudeneh Mulugeta, MD, MPH, is a primary care physician board-certified in internal medicine, preventive medicine, and obesity medicine. He is a faculty member at Harvard Medical School and a fellow of the American College of Preventive Medicine and the American College of Physicians.

**Feature photo obtained with a standard license on Shutterstock. 

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