American Society of Clinical Oncology Summit on Addressing Obesity Through Multidisciplinary Provider Collaboration: Key Findings and Recommendations for Action

Abstract

Objective:

Given the increasing evidence that obesity increases the risk of developing and dying from malignancy, the American Society of Clinical Oncology (ASCO) launched an Obesity Initiative in 2013 that was designed to increase awareness among oncology providers and the general public of the relationship between obesity and cancer and to promote research in this area. Recognizing that the type of societal change required to impact the obesity epidemic will require a broad-based effort, ASCO hosted the “Summit on Addressing Obesity through Multidisciplinary Collaboration” in 2016.

Methods:

This meeting was held to review current challenges in addressing obesity within the respective health care provider communities and to identify priorities that would most benefit from a collective and cross-disciplinary approach.

Results:

Efforts focused on four key areas: provider education and training; public education and activation; research; and policy and advocacy. Summit attendees discussed current challenges in addressing obesity within their provider communities and identified priorities that would most benefit from multidisciplinary collaboration.

Conclusions:

A synopsis of recommendations to facilitate future collaboration, as well as examples of ongoing cooperative efforts, provides a blueprint for multidisciplinary provider collaboration focused on obesity prevention and treatment.

Introduction

In its 2012 report Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, the Institute of Medicine recommended an expansion of the role of health care providers in increasing the support structure for achieving better population health and obesity prevention (1). Recognizing that the type of societal change needed to impact the obesity epidemic will require a broad-based effort, health care providers representing various areas of medicine have begun to seek partnership with one another to advance obesity prevention and treatment efforts collectively. In February 2016, 18 medical organizations convened for a Summit on Addressing Obesity through Multidisciplinary Collaboration, hosted by the American Society of Clinical Oncology (see Table 1 for a list of participating organizations). The primary objectives of the Summit were to review current challenges in addressing obesity within the respective health care provider communities and to identify priorities that would most benefit from a collective and cross-disciplinary approach in four key areas: provider education and training; public education and activation; research; and policy and advocacy.

TABLE 1.

Participating organizations

American Society of Clinical Oncology: Catherine Alfano, PhD, MS; Dawn Hershman, MD, MS; Clifford Huddis, MD; Jennifer Ligibel, MD (Convening Organization)	American College of Surgeons: John Magana Morton, MD, MPH, FACS, FASMBS
Academy of Nutrition and Dietetics: Suzanne Dixon, MPH, MS, RDN	American Gastroenterological Association: Sarah Streett, MD
American Academy of Family Physicians: Mark Stephens, MD	American Heart Association: Tiffany Powell-Wiley, MD, MPH, FAHA
American Academy of Pediatrics: Sandra Hassink, MD, FAAP	American Society for Metabolic and Bariatric Surgery: John Magana Morton, MD, MPH, FACS, FASMBS
American Association of Clinical Endocrinologists: Zachary Bloomgarden, MD, MACE	American Society of Preventive Oncology: Karen Basen-Engquist, PhD, MPH
American Cancer Society: Colleen Doyle, MS, RD	Endocrine Society: Amy Rothberg, MD
American College of Cardiology: Tochi Okwousa, DO	National Lipid Association: Robert Wild, MD, PhD, MPH, FACOG
American College of Obstetrics and Gynecology: Robert Wild, MD, PhD, MPH, FACOG	Obesity Medicine Association: Eric Westman, MD, MHS
American College of Physicians: Ronald Williams, MD FAAP FACP	The Obesity Society: Wendy Demark-Wahnefried, PhD, RD
American College of Sports Medicine: John Jakicic, PhD

In advance of the Summit, an environmental scan of participating organizations’ obesity-related activities and resources was conducted in order to identify trends, gaps, and opportunities for collaboration. This assessment showed that many member organizations have been working for years to address obesity as a cause of chronic disease and a risk factor for increased treatment-related complications, while others have begun to integrate a focus on obesity into their activities more recently. Several trends and themes emerged from this scan:

• Several organizations have initiated public education campaigns to raise awareness of the obesity epidemic, with specific focus on prevention, management, and treatment. Efforts have included educating the public on the causal relationship with other chronic diseases including diabetes, cardiovascular disease, and cancer.

• Tailored education has been developed for health care providers to help them understand the specific impact of obesity on the patients for whom they care, as well as methods to help patients move toward the behavior changes necessary to achieve weight loss.

• Several organizations provide research funding through grants and awards focused on research in the area of obesity, and many offer dedicated venues for dissemination of this research.

• Though strategies vary regarding the approach to achieving policy and systems change, most organizations include obesity prevention and treatment in their advocacy platforms.

This paper summarizes the findings and recommendations generated from the Summit for moving forward collectively to address obesity.

Provider Education and Training

Current needs

Many organizations have developed materials to help educate health care providers in a variety of settings about obesity prevention, screening, and treatment. Although some of these materials address the needs of specific provider types, there are many areas of commonality, at times resulting in duplicative work. In some cases, there is a lack of harmonization among clinical recommendations, leading to potential confusion on the part of medical providers. Collaboration has begun through the development of joint guidelines across institutions and through organizations endorsing existing guidelines in some instances instead of creating their own (2–7). These first steps offer an important pathway to disseminate information across provider communities. Additionally, although guidelines and position statements are widely available, many of the available educational resources and continuing medical education course offerings focus on practicing physicians, with less material available for individuals at earlier stages of medical training and for other health professionals such as nurse practitioners and physician assistants. Overall, there is a need for increased education and training of health care providers at all levels to better prevent and treat obesity. Increased coordination across organizations and provider groups is needed in order to avoid duplication of efforts and take advantage of existing resources and areas of expertise.

Recommendations for collaboration

• Establish a core set of competencies for all health care providers related to obesity. The core competencies should address basic skills required for assessing obesity and overweight; screening for comorbidities; recognizing and addressing stigma and bias; and effectively developing health care teams and workflow to address obesity in practice. This training also should educate health care providers on how to compassionately raise the issue of obesity with individuals who may not be aware their weight presents health risks. Once developed, this core set of competencies could serve as a foundation upon which specialty organizations could build, tailoring materials to the learning needs of individual provider types. Efforts such as the Integrated Clinical and Social Systems for the Prevention and Management of Obesity Innovation Collaborative’s Provider Competencies for the Prevention and Management of Obesity (8), released in June 2017, should be encouraged and offer an example of how competencies could be developed to establish a minimum level of education and training required for health care providers.

• Increase obesity education and training for health care providers-in-training. Efforts should focus on assessing the adequacy of education within health care training programs and filling gaps where they exist. Attention also should be placed on education at the college level to reach premedical, nursing, nutrition science, exercise science, and allied health students.

• Ensure guidelines are consistent and translatable to patient care across the medical spectrum. Prior to embarking upon the creation of a new guideline, organizations should consider surveying existing guidelines to determine whether an existing guideline could be endorsed in totality or amended to suit the needs of the providers represented by that organization. Organizations that have developed overlapping guidelines should attempt to harmonize recommendations where possible. Finally, efforts to develop collaborative working groups to construct and update guidelines could be expanded to include a broader range of organizations.

• Extend educational offerings to the whole care team. Advanced practice nurses, physician assistants, and other health care providers are increasingly responsible for care delivery in a variety of health care settings. Ensuring that the entire medical team is actively involved in efforts to support healthy lifestyle change will be an essential part of implementing weight management and physical activity programs in diverse health settings.

Best practice example

The Obesity Medicine Education Collaborative (OMEC) was formed by the Obesity Society, American Society for Metabolic and Bariatric Surgery, and Obesity Medicine Association, with a mission to “promote and disseminate comprehensive obesity medicine education across the continuum spanning undergraduate medical education (UME), graduate medical education (GME), and fellowship training” (9). The Collaborative, which includes 10 partner organizations, is working to develop core competencies, professional activities, learning objectives, and examples of curricular content and design. The OMEC has developed a phased approach to achieving these goals, with the draft of the competencies and entrustable professional activities completed in early 2017, followed by the distribution of these materials for comment and completion of needed revisions by late 2017. The third phase, which will include the dissemination and publication of these deliverables, is slated for completion in 2018.

Public Education and Activation

Current needs

There have been numerous efforts to educate patients and the public about preventing obesity and its related health complications. These include formal public awareness campaigns as well as online tools and resources geared toward specific patient populations and the general public. The shared mission behind these efforts is clear; however, this work has been completed in silos rather than harnessing the collective strength of multiple provider groups. As is the case with provider education, efforts to educate the public and activate individuals to engage in lifestyle efforts to prevent and treat obesity can be strengthened if they are jointly developed and harmonized.

Recommendations for collaboration

• Increase our understanding of optimal messaging to targeted populations. Conduct collaborative studies to understand what will activate people to make healthy behavior change and participate in obesity prevention or treatment programs. Studies of how best to present these messages should engage diverse populations and address family and community-level interventions that can be made to support long-term lifestyle changes.

• Engage in joint messaging to the public. Issue public service announcements and other joint statements that focus on (1) promoting healthy lifestyle and behaviors (not on weight or body mass index levels per se) throughout the life cycle, and especially in high-risk phases such as puberty, pregnancy, etc.; (2) overcoming stigma and shame; and (3) emphasizing that obesity is not a result of laziness or lack of willpower. These announcements should go hand in hand with messages and education for providers about bias. Consider general population-level messages for obesity prevention as well as messages directed to individuals with both obesity and additional chronic diseases.

• Jointly develop better methods of connecting patients to available resources. Identify strategies to help better connect individuals to existing resources that are most likely to meet their needs. This may involve surveying provider specialty organizations to find out what resources they provide, gathering data on what is most helpful to whom, and creating a resource exchange of effective programs and where these are located nationwide.

Best practice example

The American Heart Association (AHA) has worked to target obesity in the context of cardiovascular health by designing community programs across the life course of the population. Since 2010, the AHA has launched several public activation campaigns, including Teaching Gardens, Voices for Healthy Kids, the NFL Play60 Challenge, Go Red for Women, and EmPOWERED to Serve. These initiatives offer examples of successful partnerships with nontraditional organizations that could be modeled and scaled up to reach a broader audience or larger populations. For example, in Voices for Healthy Kids, AHA works with the Robert Wood Johnson Foundation (RWJF) to engage young people in improving their dietary intake and increasing physical activity. This program leverages the grant-funding expertise of both the AHA and RWJF with the existing network of local and regional AHA affiliates to identify and fund projects that promote the improvement of nutrition and access to physical activity for children around the country. This partnership between RWJF and AHA provides an expansive reach for health promotion to reduce childhood obesity; in 2015, Voices for Healthy Kids worked toward the passage of 14 state and local policies, potentially impacting the cardiovascular health of almost 36 million Americans (10). In other examples of novel partnerships, AHA collaborates with national professional organizations such as the American Council on Exercise, faith-based organizations such as The Balm of Gilead, Inc., and national sororities and fraternities in EmPOWERED to Serve to promote obesity and cardiovascular disease prevention within diverse communities. These partnerships capitalize on the established trust of these organizations in multiethnic communities to reach at-risk populations.

Research

Current needs

Research investigating the etiology of obesity, obesity prevention and treatment strategies, and impact of obesity treatment on disease risk and outcomes will be critical in mitigating the obesity epidemic. Interest in and funding for research in obesity has increased in the past decade, with provider organizations directly supporting this work as well as helping to shape research agendas and disseminate research findings (11). Additionally, large databases are emerging that may provide important information regarding the predictors of and outcomes related to obesity. However, the time and effort to conduct the type of large-scale trials needed to explore the best ways to prevent and treat obesity limit the number of these efforts that move forward. There is often little communication among different specialties working to prevent and treat obesity, hampering the development of cross-disciplinary trials and the joint development of databases to explore a variety of obesity-related endpoints.

Involving a transdisciplinary group of investigators in trial design is essential to ensuring that large studies are designed to explore the impact of obesity treatment and prevention interventions on as many endpoints as is feasible in a given setting. Awareness is also needed to harness the role of research networks and big data to expedite research into obesity predictors and effects, recognizing the challenges that exist in setting up the data-sharing agreements and partnerships for multiple entities to join these systems and share data.

Provider organizations can play a key role in promoting greater collaboration among disparate researcher groups in the area of obesity prevention and treatment. Efforts are needed so that studies are designed and implemented to share multiple endpoints of interest and focus on a set of unanswered research questions.

Recommendations for collaboration

• Evaluate existing studies and data resources across organizations for the potential to answer additional research questions. Identify resources available for secondary data analyses and categorize cohorts in terms of availability of samples, patient characteristics, and outcome measures of large prospective studies. Consider developing a compendium of research studies and investigators from each specialty to facilitate collaborations and promote cross-fertilization. Additionally, develop standard operating procedures to facilitate sharing of established data registries, such as the American Society for Metabolic and Bariatric Surgery registry, which contains more than 350,000 patients and provides a longitudinal assessment of various endpoints in patients undergoing bariatric surgery over 7 years.

• Capitalize on current funding opportunities by promoting the development of ancillary substudies by multidisciplinary research teams. Identifying important subquestions early in the study development process will allow for collection of additional outcomes and/or samples.

• Identify and promote alternative funding structures to help assist with secondary research. Consider an initiative to pool organizational funds to create Requests for Applications that encourage team science and networking. This type of effort would require the development of a collaborative governance structure to denote roles and responsibilities and to oversee the disbursement of funds.

• Encourage junior-level investigators to work in this field through the creation of Requests for Applications for early career investigators and through funding for post- and pre-doctoral students as a part of large obesity prevention and treatment studies.

Best practice example

Recognizing the relationship between obesity and poor outcomes in early breast cancer, breast cancer researchers several years ago began to develop concepts for clinical trials to test the impact of weight loss on breast cancer recurrence and survival. To determine if sufficient evidence existed to warrant the development of a breast cancer weight loss study and discuss the optimal study methods, the National Cancer Institute (NCI) convened a Clinical Trials Planning Meeting in 2014 to bring together a diverse group of experts from within and outside of oncology, including researchers with expertise in breast cancer, nutrition, physical activity, behavior change, weight loss, and biostatistics. Meeting participants ultimately concluded that the evidence linking obesity to poor outcomes in breast cancer was compelling, and that prior work had sufficiently demonstrated the feasibility of large-scale weight loss interventions in breast cancer populations. Participants also used evidence from weight loss trials outside of cancer to outline some of the details of how to design and field the breast cancer study. The meeting led to the formation of a concept development committee, which included both individuals with experience in oncology trial design, and researchers who had helped to design and implement large-scale weight loss trials in other populations, such as individuals with and at risk for diabetes.

Funding for the project represented an additional challenge. Once approved, the trial would be conducted through the National Clinical Trials Network and NCI Community Oncology Research Program infrastructure; however, funding for behavioral interventions is not available through this mechanism. Funding ultimately was assembled through a joint effort of three NCI groups—the Division of Cancer Prevention, the Division of Cancer Control and Population Sciences, and the Cancer Therapy Evaluation Program—with additional support from the Susan G. Komen Foundation, the American Cancer Society, and in-kind product donation to support the lifestyle intervention from corporate sponsors such as Fitbit and Nestlé Health Sciences.

Policy and Advocacy

Current needs

Obesity is a complex disease with multifactorial etiology that involves epigenetic, behavioral, environmental, and societal contributing factors that span our lifestyles, schools, families, and communities. Reducing the proportion of US adults who have obesity will require engagement in a broad set of policy issues including coverage and reimbursement, research promotion, and policies to effect change through schools and communities. Many of the organizations participating in this Summit are already engaged in this work, employing a variety of strategies such as directly advocating at the state and federal levels, partnering with federal agencies to ensure obesity prevention remains a priority in public health initiatives, and training members and volunteers to be advocates for change within their practices and communities. Effecting true societal change is an endeavor that will require a broad-based, coordinated effort on the part of many organizations.

To effect meaningful and long-lasting change in preventing and treating obesity, greater coordination is needed among provider organizations to send a strong, consistent message about priorities in this area, working to advance policy change through a collective voice.

Recommendations for collaboration

• Collaborate to support increased funding for obesity research at the national level. Provider organizations should advocate for increased funding for the National Institutes of Health as well as the Patient-Centered Outcomes Research Institute to expedite our understanding of obesity prevention and treatment.

• Advocate for adequate coverage and reimbursement for nutrition and physical activity services and access to physical activity support services. Consider developing an agreed-upon set of obesity treatment services that should be provided to patients and reimbursed by payers. Organize collective advocacy to ensure consistent coverage and reimbursement for these services.

• Consider the establishment of “centers of excellence” accreditation for centers that have the skills and personnel necessary to deliver optimal obesity care and could serve as a resource to smaller community-based practices. Accreditation of this type could be modeled after NCI accreditation of cancer centers.

• Support the efforts of existing obesity coalitions. Consider joint participation in an Obesity Day on Capitol Hill timed with National Weigh-in Day; include patient advocate groups in this effort. Approach legislators with a unified voice.

• Leverage the collective voices of professional organizations to advocate for large systemic changes to the known environmental contributors to obesity. This should include advocating for a focus on the built environment (e.g., access to safe outdoor spaces and sidewalks) and changes to food and agricultural policies that distort the economics around food, such that healthy foods are more expensive than calorie-rich, micronutrient-poor, highly processed foods.

Best practice example

Recognizing the need for and strength of a unified voice from the treatment community, the Obesity Care Continuum (OCC) was established in 2011 and currently includes The Obesity Society, Obesity Action Coalition, Academy of Nutrition and Dietetics, American Society for Metabolic and Bariatric Surgery, and the Obesity Medicine Association. The OCC represents a combined membership of more than 125,000 health care professionals, researchers, educators, and patient advocates and is dedicated to ensuring access to and coverage of the continuum of care for the treatment of over-weight and obesity.

The OCC, through the Access to Care Campaign, is working to achieve coverage of the full spectrum of evidence-based obesity treatments. This includes ensuring coverage through every state health exchange plan and working at the federal level to provide guidance to policy makers.

Conclusion and Next Steps

Increasing rates of obesity in the United States and beyond have broad implications for patients, health care providers, and society as a whole. In order to institute the type of societal changes needed to address the obesity epidemic, organizations must work together on broad-based initiatives focused on building awareness of the consequences of obesity, activating patients and the public to make the behavioral changes needed to achieve and maintain a healthy body weight, and advocating for access to services designed to promote a healthy lifestyle.

There is a need for increased education and training of health care providers at all levels to better prevent and treat obesity. Increased coordination across organizations and provider groups can help to avoid duplication of efforts and ensure dissemination of high-quality educational materials and programming. Coordinated efforts are also needed to educate the public regarding the adverse sequelae of obesity and to activate individuals to engage in lifestyle efforts to prevent and treat obesity. Providing outreach to patient and public groups through a variety of distribution channels will extend the reach of current public service campaigns and build awareness of the importance of lifestyle factors in maintaining health, including awareness of the benefits of physical activity, even in the absence of weight loss.

Provider organizations can also play a key role in promoting greater collaboration among groups of researchers focused on obesity prevention and treatment. Efforts are needed so that studies are designed to explore the impact of obesity treatment and prevention interventions on as many endpoints as is feasible in a given setting. Joint educational efforts also will help assure research findings are disseminated broadly, which in turn will help to inform other research questions and spur collaboration based upon existing research resources.

Finally, to effect broad and long-lasting change in preventing and treating obesity, efforts are needed at the policy and advocacy level to ensure access to proven strategies to help treat and prevent obesity. Coordination is needed among provider organizations to send a strong message, working to advance policy change through a collective voice.

It is hoped that the recommendations generated through this Summit, summarized here, can serve as a blueprint for multidisciplinary provider collaboration in the area of obesity prevention and treatment moving forward.