Addressing the obesity challenge: A model for personalized management in primary care

Abstract

Primary care practitioners (PCPs) play a critical role in the management of persons living with obesity (PwOs). PCPs are often involved in all phases of the PwO's journey, from diagnosis to follow-up. There are constraints that preclude PwOs from deriving maximum benefits from their interaction with PCPs: time paucity, disalignment, lack of communication, stigma. Strategies to place PwOs at the center of value-based care should contribute to overcoming these drawbacks. Specific recommendations are detailed to guide PCPs in their daily practice and a roadmap is outlined to guide the journey of PwOs while in the primary care setting. The model is inspired by Obesity Canada's 5As of Obesity Management, which helped us to design a well-arranged visitation plan. PwOs’ opinion is always considered. Decisions regarding lifestyle and pharmacological treatment are jointly shared. These recommendations could lead to a better use of the resources available to PCPs while increasing PwOs’ well-being.

Resumen

Los especialistas en atención primaria (EAPs) juegan un papel fundamental en el manejo de las personas que viven con obesidad (PcOs), acompañándolas en su “viaje” desde el diagnóstico hasta el seguimiento. Sin embargo, existen limitaciones que impiden al PcO extraer el máximo beneficio de su interacción con el EAP: falta de tiempo, desalineación, incomunicación, estigma. El diseño de estrategias para colocar al PcO en el centro de una medicina basada en el valor contribuiría a sortear estos obstáculos. Este trabajo proporciona recomendaciones específicas para guiar el viaje del PcO. Inspirados por Obesity Canada's 5As of Obesity Management, hemos diseñado un plan de consultas pormenorizado que incluye un árbol de decisión. La opinión del PcO es relevante, por lo que las decisiones acerca de estilo de vida y medicación se adoptan consensuadamente. Estas recomendaciones podrían contribuir al mejor aprovechamiento de los recursos de la atención primaria y al bienestar del PcO.

Introduction

Obesity is a chronic disease caused by an accrual of fat mass subsequent to an imbalance between intake and energy expenditure. Obesity increases the risk of morbimortality associated with more than 20 diseases, especially cancer and cardiovascular disorders (CVDs). Etiology is associated with physiological, behavioral, sociocultural, environmental and/or polygenic abnormalities. Dysfunctional adiposity causes low-grade systemic inflammation. Excess lipids and sugars alter the adipokine profile. The microenvironment promotes the amplification of the inflammatory response, which results in damage of several organs.¹

New therapies have made it possible to raise weight loss (WL) goals that heretofore could only be achieved by surgery.² However, long-term maintenance of WL remains a challenge. Several studies report regains of 70% of the weight lost 5 years earlier. Regain is also observed in those patients who have undergone bariatric surgery. There are mechanisms beyond the control of the will that contribute to this finding. Metabolic rate becomes slower. Homeostatic and hedonic pathways regulate energy balance and increase the desire for high-fat/sugar foods.³ Therefore, closely accompanying PwOs throughout their journey is mandatory. To accomplish this purpose, primary care practitioners (PCPs) should be familiar with the singularities of the obesity scenario, since they play a paramount role as the PwO's gateway to medical care and referral to other specialists and, frequently, as responsible for PwO diagnosis, treatment and follow-up.⁴

Initial assessment of PwOs in primary care (PC) settings: current limitations

There are constraints that preclude PwOs from profiting from their interaction with PCPs. The paucity of time during consultation does not propitiate the generation of a confident atmosphere, which is essential for PCP to uncover the individual PwO's circumstances. Without this information, establishing personalized behavioral or therapeutic guidelines is challenging. The disalignment between PCPs and PwOs regarding essential topics such as perception of obesity as a disease, attitudes to adopt or barriers to overcome, enlarges the communication gap.⁵

Aims

This study has a dual purpose:

• •

  PCP-focused

On the basis of a patient-centered approach, to make easy practical guidelines available to PCPs to optimally manage PwOs even when little time is available during visits.

• •

  PwO-focused

To provide personalized management to PwOs while empowering them to better control their condition in the long-term, thereby gaining self-confidence.

Methods

Expert meetings to design the model

A panel comprising four PCPs and one endocrinologist with wide experience in the management of obesity convened across virtual meetings with the aim of reaching consensus guidelines to improve the management of PwOs in the PC setting, from diagnosis to follow-up or referral to other specialists. The guiding thread was the Obesity Canada's 5As of Obesity Management, where concerns and preferences of PwOs are primary targets. The model is intended to guide the relationship between healthcare professionals and patients through five sequential steps, whose goals are achievable regardless of available time and resources: ask; assess; advise; agree; assist. A sixth “A”, arrange, allows specialists to plan the follow-up strategy.^6,7 The authors also performed an updated literature review to look for other authors’ proposals. The first meeting paved the way to build the proposal and draft the decision-tree and the main recommendations. Nevertheless, two more consultation rounds were required to achieve full consensus among all authors.

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our proposal.

Recommendations

Decision tree model to guide the PCP throughout the PwO's journey

A decision-tree was developed to guide the timing and contents of the medical visits according to the PwO's clinical condition and, importantly, their views and opinions (Fig. 1). The model is intended to provide PCPs with a practical tool for their daily practice at any moment of the PwO's journey. Infographics envisaging the relationship between PCP and PwO at each stage are included (online supplemental Fig. S1).

Figure 1.

Decision tree to guide actions to accomplish in each visit while in alignment with the PwO's priorities. V0. Ordinary – Ask – Destigmatize – Boarding gate. V1. Programmed – Assess – Comprehensive assessment. V2. Programmed – Advise, agree – Inform – Making a deal. V3. Programmed – Assist – Choosing together. V4, 5. Programmed – Arrange – Follow-up. *All required explorations and analytics will be programmed. ^†Results will be available to PCP before V2. OU, obesity unit; PwO, person living with obesity; PCP, primary care practitioner; V, visit.

Source: Developed by the authors on the basis of the scenario pictured by Fitzpatrick et al.⁶.

Rationale for using 5As of Obesity Management as guiding thread

The 5As of Obesity Management program identified a series of evidence-based realities that warrant the approach presented here (online supplemental Table S1).⁸ Using the 5As as cornerstones to conduct visits increases the doctor's self-confidence to manage PwOs,⁹ improves communication,^10,11 and exerts advantageous effects on WL.¹² The Spanish GIRO guide stresses the requirement to put the PwO at the center of the whole process.¹³

Phases of the journey

• 1.

  Ask

Aim

To establish fluent communication with the PwO in a judgment-free, stigma-free environment that enables participants to build a fruitful interaction in the short and long-term.

The level of empathy shown by the PCP during the first contact with the PwO will influence the success of the journey. The PCP should prepare a specific structure to guide the dialogue. There is literature that provides advice on how to conduct a constructive conversation while addressing all mandatory topics.¹⁴

Recommendations regarding “Aim”

• •

  Request permission

The main goal when preparing the first contact with PwOs (or the contact where obesity will be addressed for the first time) must be to tell them that they have a disease that is chronic in nature (online supplemental Fig. S2). PCP should start by requesting the PwO's permission to have a conversation about their obesity, offering the option to provide counseling and suggest changes in lifestyle habits and/or treatment options. The practitioner should not be surprised if the first response is negative, since some PwOs are not ready to speak openly about their condition.¹⁵

• •

  Listening

The initial question should be raised in a confident, bias-free environment. PCP should let the PwO explain themselves loosely and calmly. There will be patients who may feel that, for the first time, somebody is taking an interest in their condition from a constructive perspective. Naturalness should allow the PwO to reveal details that are essential for the PCP to build a comprehensive picture of their circumstances.¹⁶

• •

  Summarize

Once the PwO has finished self-explaining, the practitioner will regain control over the conversation, by summarizing the most relevant issues raised by the former. By doing this, the PCP can ensure that the information conveyed by the patient has been correctly assimilated, which will help to avoid disalignments. The PwO will feel understood, and will perceive the PCP as a partner.

• •

  Informing and suggesting

In the last step of the first conversation (online supplemental Fig. S2), the PCP will provide the PwO with a first picture of their condition and will describe the main milestones of the progress made in the obesity field, underscoring the fact that there are mechanisms that are not dependent on the PwO's will that can prevent WL or induce a regain of the lost weight.¹⁷ This knowledge should contribute to alleviating the PwO's sense of guilt. Likewise, the PCP will explain that WL prevents obesity-associated complications, and that there are tools to manage obesity effectively that rely on three cornerstones: behavioral therapy, pharmacological therapy and surgery.

Finally, the PCP will raise specific recommendations, which

• ∘

  will be formulated respectfully.

• ∘

  will not involve unilateral judgment.

• ∘

  will admit negative responses, leaving open the possibility of reconsideration.

• ∘

  will not be simplistic.

• ∘

  (in the cases where obesity was not the main reason of the visit) will include the option to arrange a visit to address specifically the condition of obesity.

• 2.

  Assess

Aim

To collect enough information regarding the PwO's condition to allow an accurate diagnosis of obesity and, importantly, of the risk of obesity-associated comorbidities.

Recommendations regarding “Assess”

• •

  Milestones to accomplish to achieve the aim

The PCP should try to:

• ∘

  confirm the diagnosis of obesity.

• ∘

  identify triggers responsible for weight gain.

• ∘

  assess the severity of the condition and foresee physical and mental outcomes.

• •

  Procedures to carry out

The PCP should:

• ∘

  review the PwO's medical history to assess the risk of concomitant comorbidities.

• ∘

  analyze body weight history, for which questions regarding weight at other life stages, dietary habits and physical activity should be prepared (suggestions regarding how to approach this conversation are available).¹⁸

• ∘

  gather information about the PwO's psychosocial, family and labor sphere to assess the influence of these environments on their clinical condition.

• ∘

  carry out a physical exam to assess the condition of obesity (Table 1).¹⁴

  Table 1.

  Physical exam and analytical assessments for an integrated diagnosis.

  Global and specific exams

  Vital signs

  Blood pressure, heart rate

  Anthropometric measurements

  Weight, height

  Head and neck

  Neck circumference; Mallampati score; thyroid exam; Cushing; PCOS

  Cardiorespiratory system

  Heart rate and rhythm; symptoms of heart failure

  Gastrointestinal system

  Incisional or umbilical hernias; hepatomegaly assessment, CLD

  Musculoskeletal system

  Osteoarthritis; gout; range of motion

  Skin tissue

  Candida, intertrigo, ringworm, papilloma, psoriasis, acanthosis nigricans, nutritional deficiencies, abdominal stretch marks

  Lower limbs

  Lymphedema, lipedema, venous insufficiency, ulcers, stasis, thrombophlebitis

  Analytical variables

  Indispensable

  Fasting glucose (DM risk)

  Lipid profile (cardiometabolic risk)

  ALT, AST, GGT (liver function, NAFLD risk)

  Creatinine (kidney function)

  Complementary

  HbA1c (DM risk)

  hsCRP, ferritin (inflammatory status)

  Uric acid (kidney function)

  TSH (thyroid function)

  ⇓

  The information collected will be analyzed in the context of EOSS criteria

  Results can lead to requesting additional studies to further explore liver or cardiovascular function, sleep apnea or endocrine disorders.

  ALT, alanine aminotransferase; AST, aspartate aminotransferase; CLD, chronic liver disease; DM, diabetes mellitus; EOSS, Edmonton Obesity Staging System; GGT, gamma-glutamyl transferase; HbA1c, glycosylated hemoglobin; hsCRP, high sensitivity C-reactive protein; NAFLD, non-alcoholic fatty liver disease; PCOS, polycystic ovary syndrome; PwO, person living with obesity; TSH, thyroid-stimulating hormone.

  Adapted from Wharton et al.⁷
• ∘

  arrange mandatory analytical tests (Table 1).⁷

For diagnosis purposes, the PCP should not be limited to using the body mass index (BMI), but should also consider the Edmonton Obesity Staging System (EOSS) criteria (online supplemental Table S2).¹⁹ The information provided by the BMI is incomplete. BMI relies on height and weight only, and does not consider variables such as muscle mass, bone density or body composition. As a result, its ability to predict complications and mortality is far from ideal.²⁰ The EOSS provides a better picture than BMI since the presence of risk factors, comorbidities and functional limitations are also contemplated. EOSS is being increasingly used because it provides easy guidance towards personalized treatments.¹⁹

Accordingly, in those PwOs whose BMIs range between 25 and 35 kg/m², assessment of waist circumference and waist-to-height ratio is recommended.²¹ These variables allow drawing a picture of central adiposity and thus contribute to the identification of those PwOs at cardiometabolic risk who would otherwise not have been detected.²² At mid-term, an increased use of nutritional ultrasound, which is a non-invasive method for morphofunctional analysis that may be available in the PC setting, may be envisaged. This tool could help the PCP to determine accurately the PwO's obesity stage since it provides body composition information, including data regarding the proportion of fat mass and lean mass in muscle and abdomen.²³

An early and accurate diagnosis in PC will enable planning strategies to reduce obesity and will contribute to success in the goal of achieving health gain by lowering body weight.²⁴

• 3.

  Advise

Aim

To provide the PwO with concrete, specific advice regarding steps to undertake to manage their condition (importantly) always sharing decisions and reaching consensus; to suggest addressing obesity in a future visit in the event that the PwO was reluctant to discuss their condition.

Recommendations regarding “Advise”

In this phase, dynamics is defined by the sequence of issues to address with the PwO.

• •

  More detailed picture

Firstly, after having studied the analytics, carried out the physical exam and reviewed the medical history, the PCP should provide the PwO with a simple but accurate picture of their medical condition. The description must be more detailed than that given in the first visit.

• •

  Health benefit derived from the improvement of obesity

Secondly, the PCP should explain the benefits associated with WL in terms of prevention of comorbidities. It must be underscored that a modest WL of not more than 5% returns visible benefits.²⁵ The PwO has to comprehend the notion of “the long-term” when planning strategies aimed to avoid the regain of WL.⁷

• •

  Types of treatment

Next, the PCP will let the PwO know the treatments that fit with their individual condition, avoiding raising unrealistic expectations in order to prevent disappointment that could compromise adherence or compliance. Not only the pros but also the cons of each therapy have to be conveyed. In order to build an easy communication plan, therapeutic options may be grouped into blocks (Fig. 2).^7,26

• •

  Discussion

Figure 2.

A guide to explain to PwOs what the currently available treatment options are. Therapeutic options have been categorized into five blocks. The basic foundations of each one of them that should be explained to the PwO are outlined. BMI, body mass index; PwO, person living with obesity.

Adapted from Fitzpatrick et al.⁶.

Finally, the PCP will invite the PwO to hold a constructive discussion to identify the most suitable therapeutic option, but never before ascertaining that the latter has understood all details of their condition. The next phase can be launched provided that the answer is affirmative. Otherwise, the PwO will be invited to address their condition in a future visit.

• 4.

  Agree

Aim

To attain the target that the PwO, freely and pressure-free, claims to be ready to address their condition with the PCP, while being motivated enough to consider the use of therapeutic tools.

Recommendations regarding “Agree”

The start of the conversation should focus on the PwO's concerns. Once these have been revealed, the PCP will reassure the PwO using realistic information, which should be conveyed according to the PwO's literacy level. By doing this, reaching agreements that satisfy both sides regarding the issues outlined below will be easier.

• •

  Agree that setting goals is positive per se

Goals have to be realistic in the mid and long-term. They should focus on changing lifestyle habits and promoting personal fulfilment associated with health gain rather than on the amount of WL. Goals have to be “smart”: specific; measurable; achievable; rewarding; timely.⁸ It is important to insist on the “a”: achievable. Experience recommends tempering expectations, which should never pursue WLs above 0.5–1 kg each week or above 5–10% of baseline weight in the long-term. Reaching a plateau is not uncommon even although patients remain on treatment.³ The PCP should insist on conveying the notion that WL is not a goal per se but rather the bridge towards a more healthy, active life, which should be the final goal.

The suitability of the “smart” goals is supported by studies that have demonstrated the effectiveness of this strategy.²⁷ Nevertheless, the unique characteristics of each PwO may influence the “smart” approach. There are goals whose description could be enough to encourage some PwOs but may not convince others. Flexibility to reformulate the target is recommended.¹⁵

• •

  Agree to acknowledge the need for a therapeutic approach to improve the condition of obesity

In order to enter next phase, the PwO should show willingness to comply with a specific treatment strategy. The PCP has to design a therapy that considers the PwO's unique hallmarks (medical needs, triggers, preferences, work, resources).

• •

  Referral

In the event that the PCP believes that treatment should be provided by another specialist, the PwO will be referred to the appropriate practitioner. Referral will be carried out according to specific criteria (Fig. 3), and, importantly, only if the PwO agrees. There is evidence to recommend an interdisciplinary approach to obesity. According to unique PwO's needs, other specialists, dieticians, psychologists, physical therapists or social workers may be involved.^13,14

Figure 3.

Criteria for referral of PwOs from primary care to other specialties. Referral will be carried out as long as the PwO agrees. *Examples: T2DM, OSA with no tolerance to CPAP treatment, arterial hypertension (even when combining ≥3 drugs), PCOS that prevents gestational desire, steatohepatitis with suspicion of stage 3–4 fibrosis, severe osteoarthrosis in load-bearing joints in patients <60 years. ^†In order to have the possibility to accomplish clinical procedures such as joint prosthesis implantation or entering a transplant list. ^‡PwO will continue in the primary care setting under the care of healthcare providers with training in obesity, but will be referred to the proper specialist. Examples: department of endocrinology and nutrition if T2DM; department of pneumolgy if OSA; department of gynecology if infertility. ^§In order to achieve accurate diagnosis and, where appropriate, start specific treatment. Examples: Cushing's syndrome, acromegaly, others. ^¶Obesity having started in childhood, association with hypogonadism, exaggerated hyperphagia, malformations in other organs, others. ^#Referral to department of psychiatry or unit for eating disorders. BS, bariatric surgery; CPAP, continuous positive airway pressure; OSA, obstructive sleep apnea; PCOS, polycystic ovary syndrome; T2DM, type 2 diabetes mellitus.

Adapted from Pearson ES.²⁷.

Finally, treatment success should not be assessed according to the amount of WL achieved but rather to the impact of such WL on everyday life, which could be measured by collecting variables such as blood pressure, mobility, wellness feeling, and others.⁷

• 5.

  Assist

Aim

To let the PwO share feelings on how they are adapting to treatment, and provide assistance if barriers that can compromise compliance are detected.

Recommendations regarding “Assist”

The PCP will be especially available to provide support to the PwO in several settings, all of them important to warrant success.

• •

  Adaptation to treatment

The therapeutic strategy should be adaptable enough to admit variants when discussed with the PwO, if treatment does not fit to personal preferences as initially perceived, or any barriers arise.

• •

  Identification of triggers

By this stage, the environment of confidence should have allowed the PCP to find out the triggers that led to the PwO's obesity. One of the goals of the therapy should be aimed at getting rid of such stimuli.²

• •

  Education

Further attempts to improve education to better acknowledge therapy's pros and cons are welcome, since this will permit to achieve shared decisions aligned with the PwO's needs and preferences.²⁸

• 6.

  Arrange

The sixth “A” addresses follow-up at long-term, once the PwO has started customized therapy. This stage addresses the main challenge in obesity management: avoiding regain of lost weight. Despite evidence demonstrating the complexity of this goal,^3,17 there is a paucity of consensus recommendations about how to approach this phase. However, an interdisciplinary follow-up plan to provide close monitoring and support is warranted.

Aim

To arrange care and follow-up of the PwO at mid and long-term.

Recommendations regarding “Arrange”

Obesity is a chronic disease subject to relapse. Therefore, a long-term strategy is mandatory. One specialist should be responsible for the coordination of this program, even although some of the actions might belong to another area of expertise. When follow-up is not organized in the hospital setting, the PCP must take control.

• •

  The PwO's education is essential

The PwO should accept that a period with remarkable WL achievement may be followed by a period of stagnation or weight regain subsequent to treatment suspension. When this occurs, it is important that PwOs do not blame themselves, in order to maintain motivation to comply with treatment and/or healthy lifestyle habits.^3,17

• •

  Fluent communication should be maintained between PCP and PwO

When the PCP organizes follow-up, regular check-up visits should be arranged to reassure that the PwO realizes that they can regain part of the lost weight and that wellbeing should not be exclusively dependent on body weight figures. The PCP should be open-minded regarding long-term programmed procedures, in that these may be modified according to the PwO's clinical and psychological condition.⁸ Digital means may streamline communication.²⁹

Discussion

Obesity Canada's 5As introduced a paradigm shift in obesity management in that the PwO is now at the center of care. Prioritizing a PwO-centered approach brings benefits (online supplemental Fig. S3).³⁰ Taking the 5 As model as the guiding thread, specific recommendations are issued for the PwO's journey under the care of PC providers:

• •

  for PCPs to count on a practical tool (decision tree) to be consulted in day-to-day practice.

• •

  for PwOs to live a rewarding and empowering experience.

The PCP is now a partner rather than a judge, and can make a better use of the limited time to manage PwOs. This proposal places PC at the cornerstone of short, mid and long-term management of obesity.

Conclusions

This study presents a series of recommendations of a distinctly practical nature. We believe that their implementation could transform everyday clinical practice in the field of PC and, ultimately, contribute effectively to the fight against a disease recognized as a global pandemic that affects more than one billion people and is expected to continue increasing dramatically in the coming years. Indeed, the use of this model in the PC setting could lead to a more effective use of the often limited resources available to PCPs, better management of obesity comorbidities, and increase PwOs’ well-being.

Contributorship

The corresponding author warrants that all authors contributed equally to the writing and final critical review of the manuscript. Andreu Altés contributed iconography that was used to design the decision tree and infographies.

Ethical approval

This modality of specialised care was conducted in accordance with the ethical principles of the Declaration of Helsinki. This article describes a medical procedure consisting of a model of collaborative and integrative approach in obesity care. The Clinical Research Ethics Committee of authors’ centers approved the program discussed here for management of obesity.

Funding

This article was funded by Novo Nordisk. The funder was not involved in the preparation of this article or the decision to publish.

Declaration of competing interests

Gabriel Cuatrecasas declares speaking honoraria from Novo Nordisk, Eli Lilly and Novartis; has served as a member of scientific advisory board for Eli Lilly; unpaid position in leadership Obesity Group CAMFIC (Catalan Family Medicine Society).

Cristóbal Morales declares the following: clinical trials with Novonordisk, Sanofi, Astra Zeneca, Pzifer, Lilly, Merck, Lexicon, FPS, Hanmi, Janssen Boehringer, Takeda, Roche, Theracos, LeeGanz; advisory boards with Novonordisk, Lilly, MSD, Boehringuer, Astra, Sanofi, Abbot; speaker for Sanofi, Novonordisk, Astra Zeneca, Roche, Lilly, Boehringher, MSD, Ferrer, Janssen, Abbot.

Andreu Altes, Igotz Aranbarri and Juan Luis Alonso-Jerez declare no conflict of interest.

Data availability

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.