ACP Announces 'Ambitious' Effort to Improve Access to Obesity Care

SAN DIEGO -- During its annual meeting, the American College of Physicians (ACP) announced an "ambitious" new initiative to promote equitable access to obesity care.

Because most medical schools do not prepare internists on how to treat obesity, and because pharmaceutical, surgical, and behavioral strategies have rapidly evolved, the ACP plans to develop guidelines for treating obesity and update training materials with its obesity management learning hub.

"Although some medical schools are doing a wonderful job of this, most medical schools are challenged by it with the fairly limited time they have to devote to education around nutrition and diet," said Davoren Chick, MD, chief learning officer for the ACP and an adjunct professor at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

Caring for patients with obesity means you have to "meet patients where they are" in a way that's ethnically and culturally sensitive, and medical school and residency programs don't always provide that, she said. "The diversity of clinical experiences requires education."

The ACP already has a well-stocked educational series on obesity management covering fundamentals of diet, exercise, lifestyle, medications, and bariatric surgery, along with some communication skills, so doctors can avoid potentially stigmatizing the patient in clinical discussions, Chick said. "But we want to do more ... we need to maintain it" and update it, and develop practical and point-of-care information, all with a lens that focuses on health equity.

Christina Wee, MD, vice president of the annals division of the ACP and senior deputy editor of the Annals of Internal Medicine, noted that "to be honest, the availability of these newer, very effective pharmacotherapies has prompted even more physicians to feel they need to get training, so there's been a renewed interest."

ACP president Ryan D. Mire, MD, an internist in Nashville, Tennessee, said the issue is increasingly important, with the U.S. prevalence of obesity reaching 42% in 2017 to March 2020, "with higher prevalence among some racial and ethnic groups, and those who are socially and economically disadvantaged."

He added that people with obesity "often suffer from stigma and negative bias, in large part because obesity has erroneously been viewed as a problem brought on primarily by the lack of willpower. These dangerous perceptions further perpetuate health inequities, which disproportionately affect communities of color."

The initiative will also help doctors address misinformation about the causes of obesity.

Part of the education the ACP hopes to provide involves advice on how internists can set up their physical offices appropriately to see patients with obesity, Mire said. For example, they should make sure chairs are of different sizes to accommodate patients of different weights and offer exam room gowns of different sizes.

Physical organization of the practice is important too, he noted, such as "making sure that our scales are not just in the middle of the hallway but are placed in a more private area."

Wee also highlighted the challenges doctors face in trying to counsel their patients. "We are now a population exposed to an overabundance of cheap, nutrient-poor yet calorie-dense foods, particularly sugar-sweetened beverages, while at the same time, there's a lack of affordable, nutritious food alternatives and options in many parts of the country," she said.

Furthermore, there is a lot of "mixed messaging and conflicting research on what actually constitutes a healthy diet, which adds to the confusion," she added.

How internists should proactively address this confusion to help their patients is one focus of the initiative.

Chick and Wee said that it may take some time and a lot of resources, but ACP plans on issuing formal obesity clinical guidelines that will make recommendations on treatment -- medical, behavioral, and surgical -- as well as suggest language doctors can use to avoid offending or stigmatizing patients.

Another key effort involves internal medicine payment reform to compensate for the time doctors must spend discussing these issues with their patients.

"We all know, finally, our payment system needs fixing," said Wee. It "currently makes it very difficult for clinicians to do a good job and effectively manage obesity," and that's also true for patients with limited means and no access to appropriate care.

The Annals of Internal Medicine's collection of studies on obesity is now available in one place online, and includes podcasts and materials doctors can print out for their patients.

Asked how doctors should manage a patient who, for whatever reasons, thinks being overweight is okay, or none of the doctor's business, which seems to be an emerging cultural trend, Chick replied that such patient attitudes are simply responses to the patient feeling stigma, of being treated as "other, and no one wants to feel othered."

Internal medicine needs to develop ways to remove stigma, so doctors can have conversations and get permission to discuss a patient's weight. "That's yet another one of the educational needs that we need to meet," Chick said.

Mire added that weight is not always the measure of a patient's health. Doctors need to ask, "what can we do to be more healthy, not necessarily what can we do to get your weight down," he said, an approach that opens up the discussion and allows patients who are feeling anxious to relax.

The ACP's initiative is also working to influence governmental public policy, for example, reducing food insecurity and healthy food deserts, and encouraging the development of communities where patients can walk and exercise safely.

The urgency is real, Chick said. "This is not a single patient problem and this is not a cosmetic problem. This is a fundamental problem for our country that is [even] affecting our military."

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