Forty two percent of U.S adults have obesity defined as a body mass index (BMI) ≥ 30 kg/m2. Obesity has purportedly been recognized as a disease that should be treated aggressively because of its relentless sequelae, both anatomic and metabolic, leading to increased morbidity and mortality compared to those with a normal BMI (1).
Yet despite clear evidence that obesity cannot be managed solely by lifestyle modification (2,3), and that safe and effective medical and surgical treatments are available (4), a large number of patients with this disease are not receiving adequate treatment. There are many factors that contribute to this disparity. To begin with, familiarity with the pathophysiology of obesity and metabolic dysfunction remains subpar in comparison to other diseases among practicing physicians. Few physicians and health care professionals address obesity in their practices, let alone treat it.
Complex societal and cultural factors continue to stigmatize obesity as a behavioral condition leading to failure to diagnose and treat it as a disease akin to the manner in which HIV/AIDS was handled in the 1980s and early 1990s.
In this issue of Obesity, Clemins and colleagues report on their observational study of nearly 700,000 patients with obesity at 15 health systems to examine the relationship between documentation of an obesity diagnosis and obesity treatment as measured by weight loss. Not surprisingly, it was found that of patients with obesity, less than half had an obesity diagnosis on a claim or on their problem list. The manuscript focuses on the finding that of those with a diagnosis of obesity documented in the electronic health record (EHR), 19.7% were able to lose at least 5% of their initial body weight over the subsequent 9–15 months, and 7.7% were able to lose at least 10%. However, of those patients with obesity without a diagnosis in the EHR, 16.9% were able to lose at least 5% of their initial body weight and 5.9% were able to lose at least 10%. The authors go on to conclude that documenting obesity in the patients’ medical records is important to engage patients to lose weight.
An alternative interpretation of these data is that patients who are motivated to lose weight are more likely to communicate their concerns about their body weight to their providers. Even though both the comparisons between those with a diagnosis and those without a diagnosis were significant, the percentages of those presumably getting treatment and losing weight are still quite similar and dismally small and suggest that the diagnosis of obesity in the EHR is relatively invisible to the health care system.
In our opinion, the important conclusion that this study offers is that even with a diagnosis of obesity in the EHR, a health care provider is not compelled to treat it and the health care system and payors are not engaged to support the treatment. Even when there is a diagnosis of obesity in the chart, only 19.7% of patients lose at least 5% of their body weight. At least 80.3% of the patients fail to achieve improvement and remain prone to gaining more weight. Furthermore, even when a physician is compelled to add the diagnosis of obesity in the EHR, there is no oversight or programming in the health care system to ensure that treatment is given and is effective, as is the case for other diseases such as type 2 diabetes, hypertension and coronary heart disease. The diagnosis of obesity in the EHR is invisible.
It is tantalizing to ponder that the obesity pandemic continues unabated with at least 42.4% of adults in the U.S. affected by this stigmatized condition. Despite medical and surgical treatment, being well within the reach of primary care providers, only 1–2% of those with obesity receive any of these effective treatments (5,6). If we compare obesity to type 2 diabetes or coronary heart disease and only this fraction were being treated, we would call that medical negligence or global malpractice.
The call for urgent action requires more than a mere documentation of the diagnosis in the patients’ medical records. Only when medical providers realize that failure to diagnose and treat obesity represent a true medical negligence, as it is for other chronic diseases, that we are likely to start witnessing a real positive change in the course of this relentless pandemic of metabolic dysfunction.
FUNDING:
This work was supported in part by the National Institutes of Health (P30DK046200). The funder had no role in the collection, management, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
DISCLOSURE:
Dr. Apovian has participated on advisory boards for Orexigen, Gelesis, Allergan, Abbott Nutrition, EnteroMedics, Zafgen, Real Appeal, Nutrisystem, Novo Nordisk, Scientific Intake, Bariatrix Nutrition, SetPoint Health, Xeno Biosciences, Rhythm, Janssen, Tivity Health, Roman Health Ventures, and Jazz Pharmaceuticals. Dr. Apovian has received research funding from Gelesis and Novo Nordisk. No other disclosures were reported.
References:
- 1.Garvey WT, Mechanick JI, Brett EM, Garber AJ, Hurley DL, Jastreboff AM, Nadolsky K, Pessah-Pollack R, Plodkowski R, Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract 2016. July;22 Suppl 3:1–203. [DOI] [PubMed] [Google Scholar]
- 2.Kruetzer C, Peters S, Schulte DM, Fangmann D, Turk K, Wolff S, van Eimeren T, Ahrens M, Beckmann J, Schafmayer C, Becker T, Kerby T, Rohr A, Riedel C, Heinsen FA, Degenhardt F, Franke A, Rosenstiel P, Zubek N, Henning C, Freitag-Wolf S, Dempfle A, Psilopanagioti A, Petrou-Papadaki H, Lenk L, Jansen O, Schreiber S, Laudes M. Hypothalamic inflammation in human obesity is mediated by environmental and genetic factors. Diabetes 2017. September; 66(9): 2407–2415. [DOI] [PubMed] [Google Scholar]
- 3.Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011. October 27;365(17):1597–604. [DOI] [PubMed] [Google Scholar]
- 4.Heymsfield SB, Wadden TA. Mechanisms, pathophysiology, and management of obesity. N Engl J Med. 2017;376: 254–266. [DOI] [PubMed] [Google Scholar]
- 5.Thomas CE, Mauer EA, Shukla AP, Rathi S, Aronne LJ. Low adoption of weight loss medications: a comparison of prescribing patterns of antiobesity pharmacotherapies and SGLTs. Obesity (Silver Spring). 2016. September; 24(9):1955–1961. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.English WJ, DeMaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018. March; 14(3): 259–263. [DOI] [PubMed] [Google Scholar]