Elsevier

The Lancet

Volume 385, Issue 9986, 20–26 June 2015, Pages 2521-2533
The Lancet

Series
Management of obesity: improvement of health-care training and systems for prevention and care

https://doi.org/10.1016/S0140-6736(14)61748-7Get rights and content

Summary

Although the caloric deficits achieved by increased awareness, policy, and environmental approaches have begun to achieve reductions in the prevalence of obesity in some countries, these approaches are insufficient to achieve weight loss in patients with severe obesity. Because the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed. Nonetheless, health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity. Modalities available for the treatment of adult obesity include clinical counselling focused on diet, physical activity, and behaviour change, pharmacotherapy, and bariatric surgery. Few options, few published reports of treatment, and no large randomised trials are available for paediatric patients. Improved care for patients with obesity will need alignment of the intensity of therapy with the severity of disease and integration of therapy with environmental changes that reinforce clinical strategies. New treatment strategies, such as the use of technology and innovative means of health-care delivery that rely on health professionals other than physicians, represent promising options, particularly for patients with overweight and patients with mild to moderate obesity. The co-occurrence of undernutrition and obesity in low-income and middle-income countries poses unique challenges that might not be amenable to the same strategies as those that can be used in high-income countries.

Introduction

The relatively small caloric gap necessary to return the mean body-mass index (BMI) of children and adolescents to 1970s levels1 can be readily achieved by the policy initiatives described by other authors of this Series. Environmental changes that bridge the calorie gap will have a substantial effect on prevention, but will not immediately reduce the morbidities and costs associated with obesity. Far greater caloric deficits than those achieved by environmental changes will be necessary to achieve weight reduction in those patients who already have obesity.2

The increases in the prevalence of obesity and its complications in low-income and high-income countries3 emphasise the global need for improved strategies for obesity prevention and control. Current clinical care delivery systems were well suited for the acute diseases that accounted for much of the morbidity and mortality in the early 1900s, but these systems are poorly suited for the prevention and control of chronic conditions, such as obesity, that account for much of the world population's poor health today.4, 5 A combination of effective clinical services to treat obesity and policies, systems, and environmental changes that prevent obesity and sustain weight loss are needed to reduce obesity worldwide. Success will depend on changes in health professional education, attitudes, and practices. The prevalence and complexity of obesity also needs changes in health-care delivery, including the engagement of interdisciplinary treatment teams.6 Hospitals, as model employers, can foster changes in social norms through their institutional and community practices. The USA and UK7, 8 have emphasised the need for improved clinical training and clinical–community partnerships.

Key messages

  • Health professionals are poorly prepared to treat obesity

  • Policy and environmental changes are unlikely to achieve substantial weight loss in patients with severe obesity

  • Training of health-care providers to treat obesity needs to address their biases about patients with obesity, ability to employ behaviour change strategies, and ability to work collaboratively with interprofessional teams

  • Multiple therapeutic modalities, including behavioural therapy, pharmacotherapy, and bariatric surgery, can be used in the treatment of adult obesity; fewer options are available for paediatric patients

  • Alignment of the intensity of therapy with the severity of the disease is necessary to improve care for obesity

  • Integration of clinical and community approaches is necessary for sustained weight loss

  • The co-occurrence of obesity and undernutrition in low-income and middle-income countries poses unique challenges

Section snippets

Education of health professionals

A 2010 Lancet Commission article9 stressed the urgent need for a so-called third generation of educational reforms to address chronic disease management. Existing shortcomings of current health-service delivery include poor teamwork, a mismatch of competencies to the needs of patients and populations, episodic rather than continuous care, and hyperspecialisation. The authors proposed several educational reforms, including the adoption of flexible, competency-based curricula and the promotion of

Weight bias in medical education

Weight bias by preclinical and medical students includes attitudes that patients with obesity are lazy, non-compliant with treatment, less responsive to counselling, responsible for their condition, have no willpower, and deserve to be targets of derogatory humour, even in the clinical-care environment.19, 20 These biases can also lead to views that obesity treatment is futile21 and feelings of discomfort, which students report as a barrier to discussing weight with patients,22 both of which

Weight bias in medical settings

Widespread explicit and implicit negative weight biases have been shown in large samples of physicians, even in health professionals who specialise in the treatment of obesity.25 Negative stereotypes expressed by health professionals parallel those by medical students and residents.26

Weight biases by health-care professionals can impair the quality of health-care delivery. Providers spend less time in appointments,27 provide less education about health,28 and are more reluctant to do some

Management of adult obesity

The figure provides an algorithm for the management of adult obesity. In adults, both BMI and waist circumference are used to assess the risks of cardiovascular disease, including hypertension, stroke, dyslipidaemia, non-alcoholic fatty liver disease, and type 2 diabetes. The Edmonton obesity staging system (EOSS) has been used to provide additional guidance for therapeutic interventions in individual patients (table 1).34 EOSS provides a practical method to address the treatment paradigm. In

A stratified system for obesity management: the interventional approach

The chronic and relapsing nature of obesity and its related diseases argues for comprehensive management approaches to achieve long-term weight reduction. Sound evidence supports an intensive lifestyle intervention characterised by dietary restriction, increased physical activity, and behavioural management as the first line of therapy.37 A comprehensive management plan includes specific treatment of comorbidities, such as hypertension, dyslipidaemia, type 2 diabetes, and sleep apnoea. Table 2

Strategies for weight maintenance in adults

Almost 25% of adults with obesity achieve 5% or greater weight loss annually.69 People who successfully maintain weight loss engage regularly in around 1 hour of daily physical activity, consume a low-calorie and low-fat diet, eat breakfast regularly, self-monitor weight, and maintain a consistent eating pattern across weekdays and weekends.41 If successfully maintaining lost weight for 2–5 years, long-term success greatly increases.70 Continued adherence to diet and exercise strategies, low

Pharmacological treatment of obesity

In the past decade, the withdrawal of three major anti-obesity agents (fenfluramine, sibutramine, and rimonabant) from clinical practice due to safety concerns has made medical practitioners and regulatory agencies cautious about the use of drugs. Drug treatment in general leads to 5–10% weight loss, and should only be considered by both patient and physician as an adjunct to lifestyle change requiring long-term follow-up. A major gap in the use of drug therapy is the absence of clinical trials

Surgical treatment of obesity

Bariatric surgery achieves greater and more sustained weight loss than non-surgical management in patients with severe obesity. Irrespective of the type, surgery improves comorbidities such as diabetes, hypertension, and health-related quality of life.72, 73 For example, the results of a recent study51 of patients with obesity and type 2 diabetes confirmed that the combination of 12 months of medical therapy and bariatric surgery achieved glycaemic control in significantly more patients than

Management of paediatric obesity

Recent American and Scottish guidelines provide recommendations for the assessment, prevention, and management of childhood obesity.78, 79 The recommendations provide guidance to clinicians on how to structure care delivery and emphasise the need for both primary and tertiary care approaches to managing paediatric obesity in children aged 2–17 years.

Recommendations for primary care include assessment of BMI, nutrition, and physical activity counselling to promote maintenance of healthy weight,

Shortcomings in paediatric obesity assessment

Since 1998, when the first American recommendations on the assessment and treatment of childhood obesity were released, paediatric health professionals have often failed to diagnose childhood obesity and only inconsistently use BMI84 or provide nutrition and physical activity counselling.85 Recent trends confirm that whereas more parents reported having been told that their child was overweight or obese in 2007–08 than in 1999–2000, only a quarter of parents of overweight children were told

Innovative strategies for delivery and management of obesity care in children and adults

US federal funding has supported the use of information technology to improve the diagnosis, counselling, and referral of children with obesity.88 To improve diagnosis and counselling in primary care, the American Government has collaborated with the American Academy of Pediatrics in the Let's Move in the Clinic initiative to give health professionals internet-based resources for BMI, diet, and activity screening in primary care in addition to counselling and advocacy methods.89 Innovations in

Technological innovations in obesity care and management

Innovative uses of health information technology, such as electronic health records, can accelerate improvement of adult and childhood obesity management.99, 100 Although many medical practices do not have fully functional electronic health records, they are likely to become widely used in the next decade, and innovative strategies that take advantage of this new technology can assess and improve quality of care. In management of paediatric obesity, rates of documented counselling approached

Hospitals and health professionals as role models

As with social norms related to tobacco, physicians and hospitals could play a major part in changing social norms related to nutrition, physical activity, and obesity. The decision of physicians to stop smoking and that of hospitals to discontinue the sales of cigarettes in vending machines and gift shops sent an important message to patients and the public, and probably contributed to the change in social norms related to smoking. Just as physicians who smoke are less likely to counsel about

Institutions and community partnerships

Environmental changes will probably not achieve the caloric deficits necessary to treat severe obesity, but they will help to sustain weight loss after it occurs. Therefore, both public health and clinical strategies need to become mutually reinforcing, beginning with interprofessional education and extending to integrated partnerships between the clinic and community. Although the primary-care setting provides an important site for obesity intervention and prevention, maximum effectiveness

Challenges in low-income and middle-income countries

The approach to obesity in low-income and middle-income countries is complicated by major nutritional transitions in the past several decades.116 In these environments, stunting of child growth persists, but obesity has become the most prevalent form of undernutrition. Moreover, both stunting and obesity constitute a double burden that can affect the same population and the same individual. The double burden is characterised by undernourished infants who do not develop their full height but

Conclusion

Therapy for obesity will need changes in the clinical delivery system to accommodate the prevalence of the disease and improvement of training to equip health-care providers with the skills necessary for treatment. Efforts to train professionals with behavioural skills, ability to work in teams, and to link clinical and community resources have just begun. Strategies to reduce the health professional bias that impairs care have not been widely disseminated. The most elemental skills, such as

Search strategy and selection criteria

We conducted a systematic review of the published literature on obesity management in adults and children through December, 2013, using “obesity”, “treatment”, “prevention”, “body weight and BMI” and combinations of “medical education”, “health professional education”, “education”, “training”, “nurse education” to identify relevant studies. Databases searched included Medline (PubMed), PsycINFO, RePort, ERIC, NHS EED, the Cochrane Database of Systematic Reviews, and the Cochrane Register of

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