Now that I have discussed some of the “Big Picture” barriers that need to be considered when thinking about setting up an obesity program, it is time to take a deeper dive into the challenge of harnessing administrative enthusiasm and support.
Obviously, for folks in the private sector, who are their own bosses and can pretty much do whatever they want, this topic is not of relevance. However, for those of us working in health systems, public or private, where funders, governing boards, administrators, business managers, and accountants have their say in what services are to be delivered, obesity programs are not an easy sell.
Although everyone is by now aware of the rising prevalence of obesity and its impact on health, most administrators (like most people) have little understanding of the complexity of the field. Indeed, many still don’t consider obesity a chronic disease or see the need for programs that go beyond providing some education and encouragement to eat a healthier diet and to be more physically active. Given that there is always a shortage of funding in health systems, weighing investments into this new area of medicine against investments in other, more established disease areas (all of which have their demands), is anything but straightforward.
One approach to getting interest from administrators may require making a case for obesity care that either promises a new revenue stream or cost-savings in other areas. However, in my experience, neither attractive revenue streams nor significant savings within the health system are easily demonstrable, especially over shorter time frames (e.g. 3-5 years). This is because setting up and running a high-quality and effective obesity program will require significant up-front investments in space and ongoing expenditures in personnel, with little immediate return on investment other than hopefully improving the health of patients living with obesity. Thus, trying to “sell” obesity programs to administrators using financial arguments is generally a difficult prospect.
There are of course exceptions. Thus, for example, in public systems, when governments make separate streams of targeted funding available for obesity programs, hospital administrators may sense an additional source of revenue. For e.g. a few years ago, when the Ontario Ministry of Health announced a separate funding envelope for creating bariatric surgical programs, several hospitals in Ontario (almost overnight) developed a keen interest in setting up such programs. Indeed, even in the private sector, bariatric surgery programs, in contrast to medical programs, can open new profitable revenue streams, which may explain the proliferation of private surgical programs at least in some jurisdictions.
Rather than presenting obesity programs as a new “profit centre”, I have had some success with administrators, when I got them to buy into the human cost of obesity and recognise that these patients need medical care in their own right, similar to patients presenting with any other health problem. Once I can get administrators to appreciate the unmet need presented by this patient population, I have, on occasion, sensed a more supportive attitude to the notion of setting up an obesity program. Indeed, I have even seen administrators become enthusiastic champions for setting up obesity programs, not because they anticipate additional revenue or cost-savings, but simply because they are convinced that this underserved patient populations needs access to such services.
There is absolutely no doubt that having enthusiastic administrative support goes a long way in easing the path to setting up an obesity program – in contrast, without at least some level of administrative buy-in, setting up a viable program is virtually impossible and will probably not prove rewarding professionally or otherwise.
Thus, as a first step for anyone considering setting up an obesity program, it is essential to gauge high-level administrative interest and support for such an endeavour before investing too much time and effort in an enterprise that may lead nowhere.
Put simply, one of the biggest barriers to setting up an obesity program is that most clinicians have little or no formal training in obesity assessment and management. Indeed, in most jurisdictions, there is currently no established or recognised pathway to becoming an obesity doctor (with rare exceptions for e.g. the ABOM certification), let alone any incentive to specialise in this area. Furthermore, as established centres are rare and far between, most clinicians will never have worked at such a centre or even seen one in action and will have to figure out most aspects of their programs for themselves.
Thus, although one may see the need for, have the interest in, and be enthusiastic and dedicated to creating a program for patients living with obesity, the lack of formal training and expertise in obesity medicine may be the first barrier to overcome (we’ll come back to pursuing training in this field in later posts).
Given that there is currently no universally accepted standard of expertise or criteria for an obesity clinic, pretty much anyone with an interest in this area can set up shop and claim to be running an obesity program. Indeed, we often see physicians or other health professionals from diverse backgrounds and with various motivations setting up “weight-loss” clinics based on a wide range of ideas and personal philosophies. While some may well take an evidence-based approach built on the understanding that obesity is a complex and heterogeneous chronic disease requiring multi-modal approaches to management that must include behavioural, medical and even surgical treatments, this is, by far, not the most common approach.
Rather, we often see obesity programs built around a single or dominant treatment that is offered to most (if not all) patients at that clinic. Although the programs may describe themselves as being comprehensive and holistic, they are often limited in the treatments they offer. Thus, for example, surgical obesity programs are built around surgery, formula-diet programs are built around the use of formula-diets, low-carb or keto-program are built around low-carbs and ketogenic diets, “lifestyle” programs are built around addressing “lifestyle”, psychological programs are built around psychological interventions, etc. This segmented approach to obesity care is obviously confusing to patients, who have no way of knowing whether the recommended treatment at a given centre is really the one likely to serve them best, or rather, just happens to be the one available at that centre.
This selective (and sometimes dogmatic) approach to obesity management can also be a barrier to recognition and respect from professional colleagues, as it appears arbitrary and simplistic. No doubt, this state of affairs is partly responsible for the criticism and apprehension from colleagues, who often do not look at running a “weight-loss clinic” as practicing “real” medicine. Indeed, even bariatric surgeons, despite the considerable evidence supporting the positive impact of surgery on morbidity and mortality, have had to (and continue to) fight for legitimacy and respect from many of their non-bariatric surgical colleagues.
Finally, as in any field, there are folks with strong opinions and beliefs about what obesity treatment should or should not look like. Thus, there are champions of keto diets or exercise programs, who not only don’t “believe” in the need for medication or surgery, but actively advocate against their use. Even within the conservative field, we find colleagues arguing about which dietary approach is most effective, not dissimilar from surgeons passionately arguing about which operation or endoscopic procedure is best. As an interesting quirk, we have in the field of obesity medicine, those who focus on weight loss as the primary outcome and those who sternly discourage their patients from even weighing themselves and rather embrace “non-scale victories”. While such controversy should be embraced and respected as it helps drive the field forward, it can also be perceived by policy makers, funders, patients, and colleagues as a state of chaos and uncertainty, thereby discrediting the entire field.
Thus, anyone considering setting up an obesity program must be aware of their own limitations in knowledge and experience as well as the challenges and barriers arising from within their own professions.
In yesterday’s post I discussed some of the policy barriers one must consider when setting up an obesity program. As important, are barriers that arise from the beliefs and misconceptions as well as the shame and internalised stigma commonly present in people living with obesity.
For one, research (e.g. the ACTION Study) shows that although most people living with obesity are well aware of the potential health implications of excess weight and are largely open to the notion that obesity is a chronic disease, they generally do not seek professional help from their doctors or other health care providers, as they would for other health conditions (e.g. hypertension or diabetes). Rather, they tend to try to tackle the problem on their own, often turning to fad diets or weight-loss programs and products offered by the commercial weight-loss industry. Although most people living with obesity state that they know what to do (namely, eat-less-move-more) and believe weight to be under their control, they rarely experience long-term success in maintaining weight loss.
There are several factors that explain this behaviour. For one, the message that the root cause of obesity is simply eating too much and not moving enough is so pervasive, that trying to manage weight simply by eat less and exercising more appears to be the obvious solution. This message is of course amplified both by public health messages and by the commercial weight-loss industry that directly benefits from this simplistic notion of what causes obesity and how to manage it. The commercial weight-loss industry spends millions of marketing dollars to reinforce this message with their anecdotal “before-and-after” success stories and promises of simple and ever-lasting weight-loss whilst promoting unrealistic weight-loss expectations by anchoring the magnitude of weight loss to outliers (results not typical!) rather than the average client (never mind the lack of prospective long-term RCTs or ITT analyses).
Perhaps an even more important factor is the shame and self-blame together with internalised weight bias that prevents people with obesity from reaching out to health professionals. After all, if I am convinced that I only have myself to blame, know what to do (just eat-less-move-more), and simply seem to lack the motivation or will-power to do what is necessary, why would I expect my doctor to be of much help. Indeed, what is my health professional going to tell me that I don’t already know? So I’d much rather avoid the embarrassment of even bringing up this topic in my doctor’s office.
Unfortunately, in the instances, where people living with obesity have indeed reached out to their doctors or other health professionals, their experience has often not been a positive one. If anything, they are likely to come away with little more than the recommendation to try even harder and not give up. This of course lies in the fact that the vast majority of health professionals have little more than a layman’s understanding of obesity and the complex biology of body-weight regulation and have never been trained in obesity assessment or management. These past negative experiences can thus be a major barrier in patients seeking help from an obesity clinic.
However, even when patients manage to locate a health professional who understands and has experience in evidence-based obesity management, they may not be happy with what they hear. Thus, they may well go to an obesity clinic expecting sophisticated endocrinological or other medical assessments to get to the root of the problem and may be disappointed to learn that such tests rarely reveal treatable medical conditions that account for their weight gain. Or they may simply be looking for diet and exercise plans and are surprised that their doctor would rather talk about their mental health, relationship issues, or even past-trauma. There are many who may not fully appreciate any suggestion that they could perhaps benefit from obesity treatments such as anti-obesity medications or surgery, which carries apprehension and stigma of their own (in addition to not having access to such treatments due to lack of coverage). Many patients are also deeply disappointed and often disillusioned when they are told that their weight-loss expectations may be highly unrealistic in the long-term and that we don’t really have a “cure” for their condition.
Lastly, we cannot ignore that there may well be a perceived stigma of going to an obesity clinic – this is not something you would wish to share even with your closest friends or colleagues. Somehow, going to a gym or following the next fad diet appears far more socially acceptable than seeking obesity treatment from a medical professional.
All of these “patient” barriers need to be considered when setting up a program in order to anticipate why patients may or may not flock to a program, or give it a poor rating, even when it is offered and provided with the best of intentions and based on the best evidence.
Before we get into the nuts and bolts of setting up an obesity program, it is perhaps worthwhile to look at some of the “big picture” barriers to obesity care.
These can be broadly divided into policy barriers, patient barriers, and professional barriers.
When we look at health policy barriers in general, much revolves around the failure to fully recognise and accept obesity as a chronic disease in its own right. Thus, the widely persisting notion that obesity is simply a matter of personal responsibility and that patients need to take control of their body weight and shed those excess pounds by changing their “lifestyles” and that failure to do so is simply due to lack of knowledge, motivation, or will-power, feeds into the justification for not funding or establishing obesity programs.
Thus, it would be fair to say that the main reason why obesity treatment programs are largely unavailable, under-funded, and under-valued, is that policy makers have not fully bought into the idea that obesity is a complex chronic relapsing disease that needs to be resourced as any other chronic disease (e.g. diabetes or heart disease). Indeed, by refusing to recognise obesity as a chronic disease in its own right, and by continuing to lay the blame on the people living with obesity for their excess weight, health systems can apparently get away with not addressing the needs of these patients just by declaring it “not our problem”.
Even in cases where policy makers and funders recognise obesity as a chronic disease, their reluctance to fund such programs may reflect the fact that conventional approaches to obesity management, largely based on the “eat-less-move-more” philosophy, have demonstrated only marginal long-term results, lack long-term outcome data with “hard endpoints”, and are hardly cost-effective (effective and sustained behavioural intervention is far more expensive than most people think!). Thus, as the available evidence clearly shows, weight-loss achieved with conventional approaches (eat-less-move-more) are generally modest, difficult to sustain, and not easily scalable. To be fair, other than for bariatric surgery, behavioural and medical treatments for obesity have yet to demonstrate their positive long-term impact on reducing morbidity and mortality. Thus, anyone looking for funding of an obesity program, has the onus of convincing policy makers that such a program can indeed deliver clinically meaningful outcomes, other than short-term weight loss.
Obviously, there are other factors, not least the staggering size of the problem. Thus, it is only natural that policy makers and payers baulk at the idea that a full quarter of the population may need long-term treatment for a chronic disease, which in the face of funding shortfalls in other (more “established”) areas of medicine, is simply not fundable.
Depending on jurisdictions, there may be other, specific restrictions on funding or providing obesity treatments. Thus, in some countries, evidence-based obesity treatments like medications or surgery, even when clearly endorsed by guidelines, remain excluded from coverage or reimbursement (e.g. Germany’s existing statutory ban of coverage for anti-obesity medications by health insurance plans).
Finally, even when obesity care is accepted, reimbursements for health professionals working in this area may be challenging or non-existent. Thus, for e.g., in public or insurance-based health systems, health professional may find that there are no appropriate billing codes that would allow them to bill for obesity related counselling or interventions.
In summary, anyone planning to set up an obesity program, especially in countries that have public or insurance-based healthcare systems, needs to be fully aware of these policy level barriers to obesity care, which may ultimately determine whether or not such a program is at all financially viable and thus worth pursuing.
Over the past months, (despite or perhaps even in light of the pandemic), I have received a number of invitations to speak and advise on setting up obesity programs, both nationally and globally. As I prepared for these talks, I realised that my own trials, failures and successes over the past decades add up to a rather deep knowledge and experience in a field that I would still consider in its infancy.
The more I tried to condense this experience and information into a 20 minute presentation, the more I realised just how complex this issue really is and how many factors (most of which, in hindsight, may seem obvious) are really crucial to establishing a successful program.
Thus, in planning a program, it is important to give consideration to a host of issues that include understanding the existing and arising policy barriers to obesity care, harnessing administrative enthusiasm and support, considering space and personnel requirements, creating a consultant network, establishing standards and procedures, defining referral, transition and discharge pathways, ensuring ongoing quality control, education and training, integration of community support, and, perhaps most important of all, managing stakeholder expectations.
Looking back at the numerous obesity programs that I have helped set up, formally reviewed, consulted on, mentored, and have seen both nationally and around the world, I could not help but see important commonalities, most of which cross jurisdictions and “markets”.
No doubt, each of these topics and sub-topics presents its own challenges and opportunities and there is much to say about each of them – definitely more than enough for a whole series of posts on this issue, which I hope readers will not only find helpful as they consider setting up or expanding their own programs but will also encourage them to share their many experiences and challenges.
So, stay tuned as I work my way through these topics over the coming days and weeks.
It’s probably fair to say that this year did not quite unfold the way anyone expected. As many have rightly pointed out, the pandemic turned a magnifying glass on many issues that existed before but got a lot worse as a result of the virus (e.g. old-folks homes and meat-packing plants, just to mention two). While some businesses saw opportunity (e.g. on-line retail and home-delivery takeout), others experienced catastrophic misfortune (e.g. hospitality and the performing arts). Not just medical practice, but countless other businesses changed their operations seemingly overnight – suddenly working virtually became a virtue!
The epidemic also magnified the fissures in our societies, some of which appear to have grown to the size of the Grand Canyon. One could not help but note interesting paradoxes. For one, the same crowd that generally calls for “law and order”, meaning that people need to follow the laws, which in turn need to be enforced, suddenly discovered the rather unlawful notion of civil disobedience by openly refusing to wear masks. The same people, who did not appear to value science or scientists, suddenly turned to science to provide the vaccine that would save the day. The same folks who support virtually unlimited budgets for arms and the military (to keep us safe-lol) – found their arsenals empty and their governments unprepared for dealing with an actual danger that scientists had long predicted and was by far more likely to occur than WW III. Interestingly, the most passionate religious and ideological “believers” discovered that it was rather easy to extend their “beliefs” to even the most unlikely conspiracy theories. I could go on, but you get the point.
On a more personal note, the year certainly turned out quite differently from what I had planned but with some interesting unexpected positive spins. Thus, although all of my heavily booked travel itinerary got cancelled, I ended up (thanks to virtual platforms) speaking to far more and far larger audiences globally than I would have, had I needed to physically travel to each event. Although I spent most of the year more or less in lockdown or in quarantine, I connected and reconnected (virtually) with more colleagues around the world than in any other year – in fact, for most of the year, my daily walk-and-talk routine was the most enjoyable part of my day. Although the many planned live events related to the (rather spectacular) launch of the Canadian Obesity Clinical Practice Guidelines were cancelled, I thoroughly enjoyed the weekly virtual COVID-19 and Get Real Series that I had the privilege to host, again reaching a far greater audience that we would have had with in-person events.
Ultimately, thanks to the pandemic, I have also had to reassess both my professional and personal future and I very much look forward to some significant changes in 2021 (stay tuned).
All in all, it’s been a most unusual year and, as we enter 2021, it will be interesting to see what aspects of the B.C. era (“before Corona”) will return and which will forever remain changed.
Wishing all my readers a peaceful, happy, and healthy New Year – stay safe!