Policy Barriers to Obesity CareTuesday, January 12, 2021
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.