No matter how large or how specialised your centre, it will serve you well to establish clear standards and procedures. Topics that need to be defined and agreed upon would include not only what patients get accepted into the clinic but also treatment pathways, standards of care, sequencing of care, measuring outcomes, and ensuring on-going quality improvement.
The particulars of these topics will of course vary according to the nature, scope, and funding of the clinic, but certain aspects will be common to any kind of centre. Thus, ideally, any respectable obesity centre would likely need to adhere to the accepted obesity treatment guidelines in that country. Where there are no clear standards set up by a national professional organization, you may have to look to other countries for guidance. Obviously, some of the guidance found in such guidelines may not translate directly to the situation in your own country or region (e.g. access to medications, surgery, psychological interventions, etc.), but adhering to them as closely as possible is probably a good idea. In any case, disregarding evidence-based standards would require clear acknowledgement and justification.
Most obesity guidelines provide at least an outline of an assessment and treatment pathway or algorithm. Virtually all recommend a multi-disciplinary multi-modal approach that covers the five elements of obesity management: nutrition, physical activity, psychological intervention, medications, and surgery. Although most guidelines recommend a hierarchical approach to using these interventions (if one “fails”, move to the next), this may not be the most efficient or even most cost-effective approach.
Thus, for example, spending a lot of time and effort on trying to help someone with Class III EOSS Stage 2 obesity to try to “conquer” their obesity with diet and exercise alone, when overwhelming evidence points to the general futility of such an approach (anecdotal exceptions are just that, anecdotal exceptions!), can eat up a lot of staff time (never mind the patient’s efforts), and lead absolutely nowhere. In fact, it can make things a lot worse, as in the long run this will only lead to demotivation and learned helplessness (never mind any detrimental effects on metabolism).
In practice it may be better to think of these five approaches as complementary rather than as distinct therapeutic pathways. Patients start at different stages of motivation, knowledge, past experience, expectations, and socioeconomic circumstances. Furthermore, patients present with varying levels of complications and impairments, necessitating varying intensity and urgency of intervention. Trying to squeeze all patients into a set pathway may appear more “efficient” at first glance but also results in spending time and resources where they are either not effective or not needed. Thus, I am always wary of approaches where “all patients” have do certain things (no exceptions!) to fit into the program. Even worse, when those who drop out or are labeled as “less motivated” are quickly deemed “failures”, when it is not they who failed the program but rather the program that failed them.
It is of course one thing to recommend individualized tailored approaches, another to actually offer them to each patient, and yet another to then scale them up for efficiency and cost-effectiveness. While a small program can treat each patient as an individual and a large program can afford to divide patients into various subgroups to include more homogeneous subsets of patients, mid-size programs will likely struggle to find a workable sweet spot that does justice to all-comers. These programs will have to be particularly clear about patient selection, recognizing that they may not be the best choice for all patients.
Obviously, this will depend on the setting, the personnel, the infrastructure, the funding model (public or private) and a host of other considerations.
For example at a surgical centre, one will not only have to decide what procedures are to be performed but also just how much pre-surgical workup and management and what post-surgical follow-up will be provided. At our centre, which is a publicly funded joint medical and surgical centre staffed by family doctors, internists, dietitians, psychologists, nurses, and surgeons, we can offer extensive pre-surgical work up as well as extended post-surgical follow-up (generally up to two years). In addition, we have a robust roster of consultants, who provide a wide range of support.
It is however, also increasingly common to find surgical centres that work closely with referring physicians, who perform much of the patient selection and pre-surgical workup as well as post-surgical follow-up. In this scenario, the surgeon only sees the patient a few times prior to surgery and rarely post-surgery, unless there are specific surgical issues that may arise.
Irrespective of which model you chose, it is essential that much attention is paid to patient selection, education, work-up and preparation for surgery. The notion that patients may be chosen based on a single visit or even just a phone call is laughable, if this was indeed a laughing matter.
Similarly, I strongly feel that the surgeon is obliged to ensure that competent post-surgical management is in place and I would consider it ethically challenging to perform bariatric surgery, where there are significant doubts regarding the post-surgical long-term follow-up. Indeed, ensuring that patients fully understand and appreciate the need for long-term (lifelong) follow up is only part of the obligation. Patients may be so eager to get surgery that they do not give much consideration to the need for post-surgical care. Futhermore, in many places, there simply is no post-surgical care outside of surgical centres, so that patients who run into problems will likely find themselves left to fend for themselves.
But also the medical programs need to define their scope of practice and think about what services will be offered. Given the complexity and heterogeneity of obesity, centres that offer a limited number of treatment options (e.g. one dietary approach, such as a ketogenic or formula diet), will necessarily not be able to help all-comers. In fact, it may well be that this very treatment option is contraindicated in some patients, something the centre needs to be very clear about. Furthermore, in my opinion, any obesity centre that does not also address the common psychological or psychiatric issues present in this patient population, cannot claim to provide a holistic approach to this complex chronic disease.
Another issue related to scope, is deciding how much effort is to be put into managing comorbidities or other health issues present in the patient that may be the direct consequence of excess weight or otherwise complicate obesity treatment. A broad definition of obesity or bariatric medicine would in fact cover all areas of medicine relevant to the care of the patient with obesity (in the same way that geriatric medicine would seek to address the spectrum of care for the elderly patient). However, given the wide range of problems, it is highly unlikely that any obesity centre can provide all of these services to its patients. Rather, it is likely that the patient needs to be in the care of other physicians, especially their family doctors. In such cases, being clear about what will be managed at the obesity centre and what will need to be managed elsewhere, is of considerable importance.
Obviously, no centre can be everything to everybody – but being very clear about exactly what services will be provided and which services may need to be sought elsewhere is not only honest but in the interest of patients trying their best to live with this chronic disease.
Irrespective of what services you can integrate into your obesity clinic, there will always be issues that require consultation with other specialists or require diagnostic procedures outside your clinic. Or, as I learnt early in my medical practice, the two most important skills of being a good doctor are knowing when to consult a colleague and knowing who to consult.
Areas in which any obesity clinic will most likely need regular consult services include psychiatry, sleep medicine, gastrointestinal medicine and hepatology, thrombosis, uro-gynaecology, respiratory medicine, cardiology, orthopaedic surgery, plastic surgery and a few others. Common diagnostic requirements will include ultrasounds, cardiac testing, CTs, MRIs, etc.
In all cases, you will find colleagues who are happy to see patients with obesity and those who are not. You will also find that certain diagnostic procedures have technical or weight limitations for patients with obesity.
Ideally you would be able to identify at least one colleague in each of these disciplines who will welcome patients with obesity into their clinics and are willing to work closely with you in helping your patients deal with these issues.
Be aware that it may take time for colleagues to recognise and adapt to the special needs of this population. Not everyone is comfortable practicing bariatric psychiatry, bariatric cardiology, or bariatric plastic surgery. Over time, hopefully, these colleagues will come to appreciate the issues specific to patients with obesity.
A good source of determining whether or not your patients with obesity are welcomed and well treated are your patients themselves. Sometimes patients will complain about a specific consultant or practice and in my experience it is often worthwhile bringing this to their attention, as they may be unaware of how their attitude or statements are being received. Sometimes the complaints may not be about the colleagues themselves but rather about their clinic personnel or even just about the ambience and infrastructure. Many colleagues will thank you for this feedback and many will change their practice. In cases where patients continue to complain, you may be better off looking for a new consultant for that specific issue.
One important reason for having competent consultants at hand is, because patients presenting at an obesity centre may often have problems that need to be dealt with before you can have any hope of helping them manage their obesity. This includes patients with unmanaged or uncontrolled psychiatric issues like depression, anxiety, or ADHD, unmanaged sleep apnea, chronic pain, unmanaged reflux disease, and many more, where these conditions can be significant barriers to obesity management.
Thus, as you set up your obesity centre be prepared to proactively create and cultivate your own network of consultants, without which you will find managing obesity even more challenging than it already is.
Once we have identified the appropriate medical or surgical leadership for our program, we turn to the issue of staffing.
Obviously, we need appropriate administrative support staff to man the front desk and take care of scheduling, record keeping, stocking and all of the other secretarial tasks that are so essential to running a smooth clinic. Obviously, they need not only be good at their work but also have undergone sensitivity training and generally work towards creating a welcoming, supportive, and empathic atmosphere for patients.
That said, the models for obesity programs vary widely. Whilst everyone probably agrees that most patients will need both dietary and psychological support, whether or not these can be directly integrated into the clinic or will be provided outside the clinic (but in close collaboration) may depend on the local circumstances and funding models. In our clinic in Edmonton, we are fortunate to have both dietitians and clinical psychologists as an integral part of our clinic. In addition, we have registered nurses, who take on the important role of “case managers” and guide the patients through the whole process. From time to time, we have also had occupational therapists, physiotherapists and exercise physiologists as valued partners in our team, but for various reasons, these have not become a fixed feature of our program.
Irrespective of the discipline, in my experience most dietitians, psychologists, nurses or other allied health professionals (similar to most doctors) have generally not had specific training in obesity management prior to joining the program. Thus, while they bring important generic tools of their trade to the team, learning to work with patients presenting with obesity, according to the prevailing “philosophy” of the clinic, generally demands a steep learning curve.
This is of particular relevance when patients need to be supported in medical and/or surgical treatments for obesity. Thus, for example, patients undergoing bariatric surgery have very specific psychological and nutritional challenges to deal with that may go well beyond the expertise of a psychologist or dietitian who has not worked in this setting before. Fortunately, there are now an increasing number of educational resources offered to allied health professionals entering this field.
One such example is the Certified Bariatric Educator program offered by Obesity Canada, which is open to all licensed allied health professionals (this program is currently being updated to line up with the new Canadian Clinical Practice Guidelines and should be relaunched shortly).
Given the complexity of the field, I am not surprised to have seen a broad range of allied health professionals work in obesity programs – physician assistants, social workers, recreational therapists, pharmacists and even unlicensed “health coaches” (often with bachelor degrees in health-sciences or related fields). All of these models can work, as long as the overall concepts and ability to work in a team are sound.
Importantly, as the field is in rapid flux, ability to train and retrain, adopt new concepts as they emerge, revise and reframe approaches and expectations is the rule rather than the exception. This is where networking and sharing experience with colleagues working in other obesity centres is most helpful.
Now that we’ve looked at some of the issues around gathering administrative support for setting up an obesity program, we must turn our attention to the next key step, i.e. finding personnel to staff the program.
This of course starts with finding appropriate leadership for the program – be it medical or surgical.
Today, thanks to the proliferation of bariatric surgery, finding surgical leadership for a bariatric program is in many ways far less challenging than finding medical leadership. Indeed no one would today consider hiring a bariatric surgeon who has never performed such operations to run a program. Bariatric procedures are now increasingly listed in many licensing catalogues for general abdominal surgery. There are also an increasing number of surgical bariatric centres, which regularly train residents and fellows. Thus, finding a trained bariatric surgeon to establish and lead a bariatric surgery program is rather straightforward.
In contrast, finding experienced and qualified medical leadership for an obesity centre is far more challenging. For one, while you would require a surgeon to have performed a certain number of bariatric procedures (hopefully in the hundreds) before claiming expertise in the area, no such requirements exist for other health professionals. Thus, there is currently no accepted pathway or minimal requirement that would stop any medical professional who takes an interest in this field from setting up their own “weight-management” program.
As in my case, when I embarked on running my first obesity clinic two decades ago, I had no specific training or experience in obesity medicine – in fact the term “obesity medicine” was not even around yet. All I had was a bunch of, what I then thought were, good ideas, an interest in the field, and strong administrative support to do something in this area.
My story is by no means unusual. Most of my colleagues in this field had little, if any, formal training in obesity medicine and had little more than good intentions and a lot of hope and determination when they set out to work in this area. Many were guided by their own personal “weight-loss-success” stories, their strong interest in “preventive medicine”, or simply their fascination with healthy eating and/or exercise. Few had ever worked in an actual obesity program. Even fewer had completed a formal fellowship or had any kind of training or certification in this field.
Given that there is no accepted pathway to obesity medicine, it should be no surprise that doctors enter this field from a wide range of backgrounds. We have family doctors, general internists, endocrinologists, diabetologists, gastroenterologists, preventive cardiologists, pulmonologists, nephrologists (e.g. myself) and even gynaecologists leading obesity programs. I have also seen obesity programs led by dietitians, psychologists, exercise physiologists, nurses and even pharmacists.
In my personal experience, given the complexity and heterogeneity of the patient population, generalists (e.g. family doctors or general internists) may be far better suited to run an obesity clinic than specialists. While patients with obesity present with a wide range of health problems affecting both mental and physical health (virtually every organ system can be involved), specialists tend to pay inordinate attention to their area of expertise. Thus, I have seen endocrinologists reduce obesity to a thyroid or diabetes problem, while ignoring musculoskeletal pain or depression. I have seen gastroenterologists focus on fatty livers and reflux disease, while showing less enthusiasm for PTSD or urinary incontinence. I have seen preventive cardiologists micromanage blood pressure and lipid profiles, whilst ignoring binge eating disorder or chronic pain. But I have also seen dietitians turn obesity into simply a nutrition problem and exercise physiologists largely focus on getting people to be more active whilst paying little attention to their actual mental or physical health.
While all of these problems exist and obviously will need to be dealt with, I tend to see family docs and general internists do a far better job of taking a holistic view of the problem than most specialists. Thus, for instance, while my colleagues from family medicine have few qualms about starting a patient on medications for their depression or ADHD or helping them deal with their anxiety, insomnia or chronic pain, I often find my specialist colleagues obsess about optimising blood pressure or glucose control while largely ignoring the “real” issues.
Fortunately, we now have an increasing number of educational and certification programs dealing with the breadth and scope of obesity medicine. Examples include the American Board of Obesity Medicine Diplomate Program (open to all doctors who have completed residency training in the US or Canada) or the World Obesity Federations SCOPE Program, open to all health professionals. Moreover, we are starting to see a number of new obesity fellowship programs pop up around the globe, which I am sure will, over time, increase the number of trained and qualified obesity personnel with true leadership potential.
In the meantime, I can only celebrate the fact that more and more younger colleagues are deciding to dedicate themselves to this exciting and fast developing field of medicine. Recently, I was truly delighted to hear that well over 1400 doctors are currently poised to sit for the next round of ABOM exams. There are now thousands of health professionals who have taken the SCOPE seminars. This bodes well for the field and should go a long way towards making it easier and easier to find qualified medical personnel to lead obesity programs in the future.
A final word on gaining administrative support for setting up an obesity program relates to the issue of managing expectations and ensuring support from colleagues in other disciplines.
As much as I have seen administrators get enthusiastic about setting up an obesity program, I have also seen them get overly optimistic about the outcomes, both in terms of health impacts and earnings (private) or savings (public). The reality is that our current obesity treatments, although much better than doing nothing, are far from “magical”. Like everyone else, administrators’ expectations have often been anchored to the rather unrealistic anecdotal before-and-after pictures touted by the commercial weight-loss industry or the overly-hyped “success” stories that are regularly celebrated in public media. This problem is even more serious, in cases, where an administrator has apparently “conquered” their own obesity and believes to have found the “cure”. Convincing them that these anecdotal outcome are not typical and can generally not be achieved in serious obesity programs can prove quite challenging.
Many find it hard to believe that, based on the best evidence we have, the average more or less “sustainable” weight loss that can be achieved in lifestyle or behavioural programs focussing on diet and exercise (even with good psychological support) is roughly in the 3-5% range. Thus, a 200 lb patient who ends up at 190 lbs at 2-5 years after entering the program, is pretty much exactly where you’d expect them to be! While even this rather modest change in body weight can have important health benefits (e.g. reducing the risk for diabetes by about 75% in people with pre-diabetes), it is not very impressive when you are expecting to see people lose 50 or even 100s of pounds. Even with the addition of medications (where available), average sustainable (with continued treatment) weight loss is only in the 5-15% range (bringing your 200 lb patient down to perhaps 180 lbs). In fact, even with bariatric surgery, the average long-term weight loss is in the 20-30% range (still leaving your patient at around 150 lbs). If administrators, like most patients are hoping for a 50% weight loss, they are likely to be deeply disappointed.
This is not to pooh-pooh the benefits of an obesity program – indeed, even with just a “lifestyle” program, you may well achieve significant improvements in health despite rather modest change in body weight (if any). Indeed, even just preventing on-going weight gain with an improvement in overall health could be deemed a success. But to appreciate these benefits, you need to look beyond weight loss as your main outcome (more on this in future posts).
When administrators set up programs with unrealistic expectations, they may soon lose their initial enthusiasm. This is particularly true of administrators higher up the food chain, who hope that setting up such a program will have a noticeable impact on the “burden” of obesity in a given region. Frankly, when the number of eligible patients in a jurisdiction is in the 100s of thousands and the program can only cater to perhaps a few thousand patients a year (all of who will need ongoing follow-up), it will be difficult to demonstrate any benefit at the population level (despite the significant impact on the health of participants in the program). Thus, hoping for significant savings within the health system as a result of decreased demand in other areas (e.g. knee replacements or diabetes clinics) is usually quite unrealistic.
The issue of expectations is also important in the context of collegial support for the program. Often, you will find colleagues from other disciplines with little knowledge or appreciation of obesity medicine in leadership positions within the administration. These colleagues may have strong opinions and beliefs about people living with obesity and the need or value of providing obesity treatments within the system, especially, when such a program would require space or other resources currently held or sought after by other programs. In my experience, getting the buy-in from these colleagues may on occasion prove even more challenging than getting support from management.
In summary, there are large number of administrative issues that need to be considered in setting up an obesity program and managing all of these together with tempering overly optimistic expectations would be well worth the effort, not just initially but on an ongoing basis (particularly, as administrators tend to often move about in the system, as a result of which administrative enthusiasm and support may disappear from one day to the next).
In my experience, administrators tend to often underestimate the amount of outpatient space needed to run an obesity clinic. Given the larger size of these patients, there is need for larger seating, larger scales, larger exam tables, and wider doorways (not to mention the critical importance of floor-mounted toilets!). This means larger waiting rooms, larger exam rooms, larger changing booths, larger rooms for group sessions, etc. Add to this, the additional time needs for patients to dress and undress and move between rooms, it should be no surprise that an obesity clinic will take up at least 50% more space than a regular clinic to see the same number of patients per unit time.
And while we’re on the topic of space, let us consider the physical location of the clinic in terms of accessibility including distance from parking or public transportation. Having to walk a few hundred metres, navigating ramps, long hallways, or even stairs may prove physically exhausting or almost impossible for patients with severe obesity and mobility issues.
At this point it may be appropriate to put in a plug for an exciting project on designing a bariatric-friendly hospital, championed by my colleague Mary Forhan in a partnership between Alberta Health Services and Obesity Canada at the Medicine Hat regional hospital in Alberta.
Key findings from this project, that would make an in-hospital encounter far more safe, efficient, and pleasant for both patients and staff include mandatory education of all staff on weight-bias and respectful interactions, better understanding of the unique needs of people living with obesity, access to and knowledge in the use of bariatric equipment and supplies, and the need to respectfully communicate patients’ needs to other departments (e.g. diagnostics, wards, etc.). As a learning from this project, Obesity Canada is currently working on finalizing a simple labelling system that would readily indicate the weight capacity of all hospital or clinic furniture and equipment.
Finally, when it comes to naming the program, I recommend avoiding the use of the word “weight” (as in “Weight-Loss Clinic”, “Clinic for Healthy Weights”, “Weight Wise”, etc.), as a key tenet of obesity management is to improve the overall health of the patient and not just focus on changing numbers on the scale. This is why I much prefer the terms “Obesity”, “Metabolic”, or even “Bariatric”, as used in a clinical context. These terms will also help differentiate your centre from commercial “weight-loss” programs that are solely focussed on helping patients lose weight rather than on practicing obesity medicine or providing bariatric care.
Thus, even the most enthusiastic administrators may require some education around the specific needs of this patient population, which will hopefully not dampen their enthusiasm too much. It is far better to anticipate these needs than to try to meet them once the program is up and running.
While we’re on the topic of harnessing the enthusiastic support from administrators for an obesity program, it is important to consider that administrators, like most people, have little experience in thinking of obesity as a chronic disease nor fully appreciate the complexity of its causes or the need for multi-modal treatment pathways.
While, given the clear unmet need, one may well succeed in convincing administrators of the need for setting up an obesity program, they may not be thinking beyond “educational” interventions focussed on promoting “healthy lifestyles”. In fact, their idea of an obesity program may be limited to providing dietary or exercise counselling, whether to individuals or groups, in the hope that this will be enough to help patients reduce their weight.
At the other end of the spectrum, administrators may be gung ho about bariatric surgery (perhaps hoping for a new income stream), little recognising that such a program requires far more than simply hiring surgeons and giving them sufficient OR time. They may in fact be surprised that such a program involves medical management, psychologists, dietitians, and nurses, not to mention the considerable space and infrastructure required for intake, pre-surgical assessment and management as well as extended follow-up. In addition, there is almost never consideration or plan for post-surgical abdominoplasties or body contouring surgery.
Lately, with the increasing availability of effective anti-obesity medications, the boundaries between “medical” and “surgical” programs is fast eroding, as these medications, and thus medical management, is proving to be an integral part of pre- and post-surgical care. Thus, today, obesity programs must plan to integrate both conservative medical as well as pre- and post-surgical management of patients (even if the actual surgery may be performed elsewhere).
Thus, a key step in gaining administrative support for setting up an obesity program, is ensuring that they fully understand the nature of obesity and the complex needs of these patients, so that they plan for the provision of what is required. Simply hiring a dietitian and an exercise specialist does not constitute an obesity program, nor does simply performing a few bariatric surgeries on anyone willing to pay for them.