Administration: Managing Expectations and Collegial SupportWednesday, January 20, 2021
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).