Setting up an Obesity Centre: Standards and Procedures

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. 

@DrSharma
Berlin, D