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      The Most Undertreated Chronic Disease: Addressing Obesity in Primary Care Settings

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          Abstract

          Purpose of Review

          While obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings.

          Recent Findings

          We now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings.

          Summary

          Clinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.

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          Most cited references108

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          Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies

          Prospective Studies Collaboration, George Davey Smith (2009)
          Summary Background The main associations of body-mass index (BMI) with overall and cause-specific mortality can best be assessed by long-term prospective follow-up of large numbers of people. The Prospective Studies Collaboration aimed to investigate these associations by sharing data from many studies. Methods Collaborative analyses were undertaken of baseline BMI versus mortality in 57 prospective studies with 894 576 participants, mostly in western Europe and North America (61% [n=541 452] male, mean recruitment age 46 [SD 11] years, median recruitment year 1979 [IQR 1975–85], mean BMI 25 [SD 4] kg/m2). The analyses were adjusted for age, sex, smoking status, and study. To limit reverse causality, the first 5 years of follow-up were excluded, leaving 66 552 deaths of known cause during a mean of 8 (SD 6) further years of follow-up (mean age at death 67 [SD 10] years): 30 416 vascular; 2070 diabetic, renal or hepatic; 22 592 neoplastic; 3770 respiratory; 7704 other. Findings In both sexes, mortality was lowest at about 22·5–25 kg/m2. Above this range, positive associations were recorded for several specific causes and inverse associations for none, the absolute excess risks for higher BMI and smoking were roughly additive, and each 5 kg/m2 higher BMI was on average associated with about 30% higher overall mortality (hazard ratio per 5 kg/m2 [HR] 1·29 [95% CI 1·27–1·32]): 40% for vascular mortality (HR 1·41 [1·37–1·45]); 60–120% for diabetic, renal, and hepatic mortality (HRs 2·16 [1·89–2·46], 1·59 [1·27–1·99], and 1·82 [1·59–2·09], respectively); 10% for neoplastic mortality (HR 1·10 [1·06–1·15]); and 20% for respiratory and for all other mortality (HRs 1·20 [1·07–1·34] and 1·20 [1·16–1·25], respectively). Below the range 22·5–25 kg/m2, BMI was associated inversely with overall mortality, mainly because of strong inverse associations with respiratory disease and lung cancer. These inverse associations were much stronger for smokers than for non-smokers, despite cigarette consumption per smoker varying little with BMI. Interpretation Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well add extra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22·5–25 kg/m2. The progressive excess mortality above this range is due mainly to vascular disease and is probably largely causal. At 30–35 kg/m2, median survival is reduced by 2–4 years; at 40–45 kg/m2, it is reduced by 8–10 years (which is comparable with the effects of smoking). The definite excess mortality below 22·5 kg/m2 is due mainly to smoking-related diseases, and is not fully explained. Funding UK Medical Research Council, British Heart Foundation, Cancer Research UK, EU BIOMED programme, US National Institute on Aging, and Clinical Trial Service Unit (Oxford, UK).
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            Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis.

            Katherine Flegal, Brian Kit, Heather Orpana … (2013)
            Estimates of the relative mortality risks associated with normal weight, overweight, and obesity may help to inform decision making in the clinical setting. To perform a systematic review of reported hazard ratios (HRs) of all-cause mortality for overweight and obesity relative to normal weight in the general population. PubMed and EMBASE electronic databases were searched through September 30, 2012, without language restrictions. Articles that reported HRs for all-cause mortality using standard body mass index (BMI) categories from prospective studies of general populations of adults were selected by consensus among multiple reviewers. Studies were excluded that used nonstandard categories or that were limited to adolescents or to those with specific medical conditions or to those undergoing specific procedures. PubMed searches yielded 7034 articles, of which 141 (2.0%) were eligible. An EMBASE search yielded 2 additional articles. After eliminating overlap, 97 studies were retained for analysis, providing a combined sample size of more than 2.88 million individuals and more than 270,000 deaths. Data were extracted by 1 reviewer and then reviewed by 3 independent reviewers. We selected the most complex model available for the full sample and used a variety of sensitivity analyses to address issues of possible overadjustment (adjusted for factors in causal pathway) or underadjustment (not adjusted for at least age, sex, and smoking). Random-effects summary all-cause mortality HRs for overweight (BMI of 25-<30), obesity (BMI of ≥30), grade 1 obesity (BMI of 30-<35), and grades 2 and 3 obesity (BMI of ≥35) were calculated relative to normal weight (BMI of 18.5-<25). The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity. These findings persisted when limited to studies with measured weight and height that were considered to be adequately adjusted. The HRs tended to be higher when weight and height were self-reported rather than measured. Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality. The use of predefined standard BMI groupings can facilitate between-study comparisons.
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              Weight Loss Through Lifestyle Modification Significantly Reduces Features of Nonalcoholic Steatohepatitis.

              Eduardo Vilar-Gomez, Yadina Martinez-Perez, Luis Calzadilla-Bertot … (2015)
              It is not clear how weight loss affects histologic features of liver in patients with nonalcoholic steatohepatitis (NASH). We examined the association between the magnitude of weight loss through lifestyle modifications and changes in histologic features of NASH.
              Article 0 comments Cited 571 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Melanie Jay:
                ORCID: http://orcid.org/0000-0001-7343-3120
                melanie.jay@nyulangone.org
                Journal
                Journal ID (nlm-ta): Curr Obes Rep
                Journal ID (iso-abbrev): Curr Obes Rep
                Title: Current Obesity Reports
                Publisher: Springer US (New York )
                ISSN (Electronic): 2162-4968
                Publication date (Electronic): 23 July 2021
                Pages: 1-13
                Affiliations
                [1 ]GRID grid.137628.9, ISNI 0000 0004 1936 8753, Department of Medicine, , NYU Grossman School of Medicine, ; New York, NY USA
                [2 ]GRID grid.17635.36, ISNI 0000000419368657, Division of General Internal Medicine, , University of Minnesota Medical School, ; Minneapolis, MN USA
                [3 ]GRID grid.17635.36, ISNI 0000000419368657, Center for Pediatric Obesity Medicine, , University of Minnesota Medical School, ; Minneapolis, MN USA
                [4 ]GRID grid.223827.e, ISNI 0000 0001 2193 0096, University of Utah School of Medicine, ; Salt Lake City, UT USA
                [5 ]GRID grid.38142.3c, ISNI 000000041936754X, Departments of Medicine and Surgery, Massachusetts General Hospital Weight Center, , Harvard Medical School, ; Boston, MA USA
                [6 ]GRID grid.280062.e, ISNI 0000 0000 9957 7758, Kaiser Permanente Colorado, ; Denver, CO USA
                [7 ]GRID grid.430503.1, ISNI 0000 0001 0703 675X, University of Colorado School of Medicine, ; Aurora, CO USA
                [8 ]GRID grid.137628.9, ISNI 0000 0004 1936 8753, Departments of Medicine and Population Health, , NYU Grossman School of Medicine, ; New York, NY USA
                [9 ]New York Harbor Veterans Affairs, New York, NY USA
                Author information
                http://orcid.org/0000-0001-7343-3120
                Article
                Publisher ID: 444
                DOI: 10.1007/s13679-021-00444-y
                PMC ID: 8300078
                PubMed ID: 34297343
                SO-VID: 54dda42c-0e90-4684-aa02-5d5deb2760cb
                Copyright © © This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2021
                License:

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                Date accepted : 22 June 2021
                Categories
                Subject: Obesity Treatment (D Bessesen, Section Editor)

                ScienceOpen disciplines: Health & Social care
                Keywords: obesity,weight management,primary care,challenges/barriers,shared decision making
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: obesity, weight management, primary care, challenges/barriers, shared decision making

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