Vogt, MD, MPH, and Victor Stevens, PhD, discuss the need to treat obesity
as a chronic disease
Thomas M Vogt, MD, MPH; Victor J Stevens, PhD
Obesity Research: Winning the Battle, Losing the War |
and obesity have increased dramatically in the United States during
the past quarter century and are having a profound, negative impact
on morbidity, mortality, quality of life, and cost of medical care.
New research confirms that diabetes can be prevented or delayed through
aggressive weight management. After years of discouraging reports on
the failure of weight management programs to produce sustained weight
loss, several approaches are now known to contribute to long-term weight
control. However, despite this good news, most weight control programs--those
housed within medical care systems--are of low quality, have inadequate
resources, and are not accountable for their results. Moreover, most
of these programs are not covered benefits and are instead treated as
optional public relations services instead of as integral parts of medical
care. Most clinical advice and counseling about weight and diet is delivered
to patients sporadically, briefly, inexpertly, and only after clinically
significant morbidity is already present. Ironically, assessment of
weight occurs almost to the point of obsession but with little meaningful
follow-up. Given the magnitude of the problem as well as the new, encouraging
research findings, programs--those housed within medical care systems
generally and in Kaiser Permanente (KP) must become as proactive in
treating obesity as the organization already is in treating hypertension
and heart failure: We must treat obesity as a chronic disease. To reduce
morbidity and mortality and to improve quality of life for patients
with obesity, health care practitioners must correctly apply effective,
available remedies for this chronic disease.
States is undergoing an epidemic of diabetes and obesity with profound
consequences on our health and on health care costs.1-3 This
epidemic cannot be addressed without involving patients and health care
systems in an effective, integrated approach to managing the lifestyle
behavior that leads to the problem.4 The exciting findings
of the Diabetes Prevention Study5 and of the Diabetes Prevention
Program6 make clear that Type II diabetes is a preventable
disease and that--after many years of disappointing efforts--we have at
last begun to identify components of effective obesity maintenance intervention.7,8
Identification of approaches that lead to sustained, long-term weight
loss is a wakeup call to health care systems that have generally neglected
weight management, particularly for their patients who are not already
ill with obesity-related conditions such as diabetes, cardiovascular,
and musculoskeletal diseases. KP members incur an enormous burden from
obesity-related morbidity and mortality as well as from the enormous cost
of treating the resulting preventable diseases.
Consequences of Obesity
has not been treated systematically in medical care systems, although
treating its comorbid conditions without preventing and treating the obesity
itself could be considered unethical.9 Nonetheless, treatment
of obesity is the cornerstone of both diabetes care9 and diabetes
prevention.5,6 Two of every three diabetic patients are overweight,10
and obesity is increasing rapidly throughout the United States.11-13
Weight loss reduces medical costs; improves control of glycemia, lipoproteinemia,
and blood pressure;14 and reduces mortality risk among patients
with diabetes.15 The economic burden of obesity may exceed
$100 billion per year.16 Weight management requires a lifelong
commitment to healthy eating practices as well as to daily physical activity.17
Regaining weight after successful completion of a drug with
diet and exercise program is common, mainly because of the scarcity of
adequate programs for maintaining weight loss.18
Disparate Racial and Ethnic
Distribution of Obesity and Diabetes
of Hawaii is one of the world's most ethnically diverse and includes whites
(21.8%), Japanese (19.1%), Native Hawaiians/part-Hawaiians (19.4%), Filipinos
(12.6%), Chinese (3.9%), Other (8.3%), and mixed (15.0%).19
About two thirds of Hawaii's Native Hawaiians, Filipinos, and Japanese--and
about half of Hawaii's whites--maintain a sedentary lifestyle.20
In Hawaii, 46% of Native Hawaiians are obese compared with 24% of the
general population of Hawaii.20 In Hawaii, diabetes among people
aged 36 to 64 years is more than twice as prevalent among Native Hawaiians
as in non-Hawaiian residents, and diabetes among people older than 65
years is about one-and-one-half times as prevalent in Native Hawaiians
as in non-Hawaiian residents.20 Native Hawaiians are the only
US ethnic group with a life expectancy below 70 years (68 years),20
and obesity and diabetes are the primary reason. Filipinos and Japanese
in Hawaii also have high rates of diabetes.20 Among KP members
in Hawaii, excellent health is self-reported by 27% of whites, by only
17% of Japanese and Filipinos, and by only 13% of Native Hawaiians. Poor
health is self-reported by 11% of whites, 18% of Hawaiians, 19% of Japanese,
and 21% of Filipinos. If this disparity among ethnic groups in Hawaii
and among similar groups in other parts of the United States is to be
effectively addressed, health care systems must pay attention to race,
culture, and personal habits of patients.
Weight Control Programs
Can be Cost-effective for Health Care Systems
of losing a kilogram of weight in an intensive, long-term, very-low-calorie
diet program has been estimated at $630.21 Despite strong evidence
of benefit from sustained weight loss,22,23 few data balance
the cost against medical care utilization rates. Research is needed to
estimate the impact of various weight management programs and their cost
against change in medical care utilization levels.
the program and whatever its cost, one fact remains: Ineffective programs
and half-hearted interventions are the most costly of all because they
don't produce change. In a one-year pilot program for weight loss among
200 obese patients whose body mass index (BMI) ranged from 30 to 56, 72%
remained in contact and at least partially complied with recommended lifestyle
changes after 12 months. Medical care savings per patient equaled $380
for the year.24 Despite the cost of these programs, obese and
diabetic patients use about three to four times more medical care resources
than the average Health Plan member. Thus, even expensive interventions
are cost-effective if they help patients to lose weight and to maintain
this weight loss.
Weight Control Interventions
that Lead to Sustained Weight Loss
barriers are encountered by health systems attempting to implement effective
weight management programs: 1) the myth that no program is effective in
the long term; and 2) failure to integrate lifestyle issues into our medical
care paradigm. We talk about lifestyle but are not accountable for addressing
it in the way that we are accountable for treating hypertension. Consequently,
assistance with weight management is not standard medical practice. Table
14,7,8,21,25-52 shows obesity intervention components that
have been associated with sustained weight loss. If included in serious,
high-quality, appropriately funded programs, these effective interventions
could reduce the number of morbid and mortal outcomes from obesity.
Exercise clearly improves outcome of behavioral weight management programs.
One third of deaths from cardiovascular disease and diabetes may result
from physical inactivity.53,54 Sedentary lifestyle is also
an important risk factor for cancer.55-57 In
the United States, about 60% of adults are inadequately physically active,
and one quarter report engaging in no physical activity at all.58
The Surgeon General's Report on Physical Activity and Health58
makes clear the importance of physical activity in reducing morbidity
and identifies promising strategies for intervention. Health care systems
have a critical role in promoting physical activity and disease management
strategies needed to foster physical activity among diabetic patients.25
Prevention Program clearly showed the importance of exercise in diabetes
prevention.26 Physical activity counseling by physicians affects
patient exercise levels,59-62 but more research is needed on
how to incorporate exercise counseling into the medical setting.63
The Physician-based Assessment and Counseling for Exercise (PACE) Program63,64
trained physicians to counsel patients about diet, weight, and physical
activity, but physicians have little time to add behavioral counseling.
Physical activity counseling is as effective as structured exercise programs
for increasing physical activity.65 Medical systems need effective
system support programs endorsed by physicians but delivered by nonphysician
support staff who are specifically trained for the task.
effective weight loss programs include exercise as an integral part of
their approach.28,66-69 One very-low-calorie diet program21
showed that four-and-a-half years after treatment, continuing exercisers
had 7.4 times as much weight loss (mean loss of 21 lb [9.53 kg]) as those
who did not exercise (mean loss of 2.9 lb [1.3 kg]). Blair et al70,71
developed a lifestyle approach to increasing physical activity based on
the Stages of Motivational Readiness Model72 and on the Social
Cognitive Theory Model.73 A similar approach has been widely
used by Stevens et al66-68,74 in research programs. Barriers
to engaging in physical activity have been widely studied, as have interventions
designed and tested to overcome those barriers.75-79 Successful
approaches to adopting a physically active lifestyle assure that the individual
1) perceives a net benefit; 2) chooses an enjoyable activity; 3) feels
competent in doing the activity; 4) can easily access the activity on
a regular basis; 5) can fit the activity into the daily routine; 6) perceives
no major financial or social cost to the activity; 7) experiences few
negative consequences (eg, injury or ridicule) from the activity; and
8) can successfully resolve any competing time demands.29
physicians have been encouraged to counsel their patients on exercise,
physicians are less likely to counsel patients about exercise than about
smoking and other health behaviors.60,80,81 Ethnicity may influence
whether advice and counseling are provided. In the KP Hawaii Region, Filipinos
are less likely to
be counseled by their physicians about physical activity than are other
ethnic groups.33 The PACE program64 assisted clinicians
in counseling their patients to overcome barriers to exercise. The INSURE
Project on Lifecycle Preventive Health Services was effective for promoting
adoption of high levels of exercise 12 months after intervention59
and showed that brief advice sessions in the medical office (similar to
effective smoking intervention in the medical office) increases patients'
total weekly minutes of exercise.
Very-Low-Calorie Diet (VLCD)
Behavioral and cognitive intervention approaches combined with a very-low-calorie
diet (VLCD) and a chronic disease case management model may be the most
effective strategy for helping patients to lose weight and maintain that
weight loss. Contrary to the pessimism of many clinicians and researchers,
effective long-term weight loss can be achieved,7 and the components
of successful maintenance programs are gradually emerging. The VLCD approach
is associated with greater initial weight loss and maintenance of weight
loss than are low-energy, balanced diets and may be associated with better
sustained weight loss.8 Participants in the wellness program
in the KP Southern California Region, Positive Choice, achieved a mean
weight loss of 57 lbs (25.9 kg) during a six-month intervention.34
Walsh and Flynn21 reported a mean initial weight loss of 59.8
lbs (27.1 kg) for men and 42.4 lbs (19.2 kg) for women. Brief periods
of VLCD are "associated with successful weight control in a substantial
portion of patients several years after treatment."82:abstract
The Relapse Prevention Model52 combines applied behavioral
analysis, social learning theory, models of stress and coping, and strategies
for responding to temptation and brief lapses in adherence to behavior
change efforts. The Relapse Prevention Model focuses on avoiding situations
that lead to lapses or relapse (antecedents) and on identifying and practicing
alternative coping strategies (eg, avoidance, adaptation, adopting new
constructive behaviors). The Relapse Prevention Model involves learning
and practicing cognitive (influencing thoughts) as well as behavioral
(learning and applying skills) approaches.37,83 Development
of personalized strategies for maintaining weight loss is associated with
long-term maintenance of weight loss.84
Social support interventions maintain behavior change through social relationships
and interpersonal interactions38 and emphasize exchange of
information, advice, suggestions, empathy, and caring among close friends,
family, and others facing the same challenges (eg, trying to change diet,
to increase exercise, or to quit smoking). Social support intervention
includes small-group sessions with varying degrees of structure and professional
guidance as well as other forms of support, such as one-to-one meetings,
"buddy systems" (pairing up), and telephone contacts. Social
support intervention and support from family and friends improve the effectiveness
of weight loss maintenance.39,40,84,85 Relapse prevention and
social support approaches are not mutually exclusive but represent two
distinct emphases in strategies to enhance maintenance of behavior change.
Because they include activities based on each person's unique situation,
these strategies are ideally suited for application in multiethnic, multicultural
Management of Obesity as a Chronic Disease
Obesity is a chronic disease requiring long-term care.35,41,42,86
Seven of nine diabetes studies showed that chronic care management reduces
health care use and costs of care.4 The failure of the medical
care system to effectively address obesity arises, in part, from reluctance
of medical systems to undertake expensive, long-term financial commitment
for care that may be too costly to sustain. However, abundant data now
show the effectiveness of health systems in changing risk-related behavior.
Treatment programs must involve medical systems and must include a variety
of health professionals--including physicians, dieticians, exercise physiologists,
and geneticists.25,41,86 The health care system is a "bully
pulpit" for intervening in health-related behavior. Relatively small
amounts of weight loss confer disproportionate health benefits,22,36
and guidelines for management of chronic disease help integrate current
knowledge into everyday medical practice. Ignoring obesity in medical
encounters and in assigning covered benefits may be as damaging as ignoring
Although weight loss sustained as long as a year may provide health benefits,
these benefits are limited if the weight loss is not sustained over the
long term. Unfortunately, weight regain is common, and many persons who
lose substantial amounts of weight regain that weight during the next
two to four years.7 The most promising methods for sustaining
weight loss over long periods of time include increasing number of contacts
with the program and extending length of the maintenance.42,43
Some low-cost, minimal intervention strategies (such as phone contact,
mail contact, or both47) may improve sustained weight loss.
Weight management programs without a maintenance component are probably
not worth their cost.
Participation in group sessions (as opposed to individual sessions) also
is associated with better weight maintenance,87 probably because
of the peer support provided.
Can Weight Management Programs
Succeed in Medical Care Systems?
care systems are neither efficient nor effective for delivering behavioral
prevention services.88 More than 60 randomized trials have
shown that brief physician assessment and advice substantially raises
long-term smoking cessation rates among patients,89-91 but
only a few encouraging studies have addressed dietary92 and
exercise63,64,93 change in response to intervention provided
in the medical office. The Trials of Hypertension Prevention67
tested efficacy of weight loss and sodium restriction programs--alone
and in combination--using blood pressure change
as the primary outcome measure. Physical activity was an essential intervention
component, and individual weight differences between intervention and
control groups remained statistically and biologically significant after
three years of follow-up.66 Physical activity enhances weight-loss
success30 and can help sustain achieved weight loss.27
Health systems have a uniquely important role to play in promoting increased
physical activity.25 Case management is effective for improving
glycemic control among diabetics94 but is rarely integrated
into management of obesity.
Patterns of Diet, Weight
Assessment, and Counseling in KP
The KP Hawaii
Region recently completed a study in which 774 randomly selected adult
medical charts were comprehensively reviewed for receipt of 25 adult preventive
services during a five-year period.33 On the basis of observation
and staff interviews, we estimated that the actual cost of weighing a
patient was about $2.40 and that the cost of brief (two-minute) dietary
advice was $11.13 during 1996, our final year of observation (Table 2).
Because medical chart notes on dietary or weight loss advice were cursory
and vague, we defined any mention of diet or weight management (eg, "lose
weight" or "change diet") as advice or counseling. During
the five-year observation period (January 1, 1992 through December 31,
1996), the 774 persons were weighed 14,111 times, or 18 times each (a
mean of once every 3.3 months). Thirty-five percent of the group was weighed
more than twenty times. Only 3% (n = 25) of the sample was never weighed
during the five years, whereas 65% of persons were weighed more than
ten times. Conversely, 47% of the group never had any mention of diet
or weight in their chart notes over the entire five-year period.
The KP Regions
have a wide variety of programs for obesity management. Few of these programs
have resulted in lengthy maintenance of weight loss, and those that do
generally have low attendance. With the exception of a few seminars and
one-session interventions, all the programs involve copayments, which
are often substantial. The San Diego area of the KP Southern California
Region offers a 16-week Optifast medical weight loss program for extremely
obese patients, and Group Health Cooperative (GHC) of Puget Sound offers
a special behavioral and counseling program for patients who must lose
more than 30 lbs (13.6 kg). Except for GHC, which offers several programs
of unlimited duration for long-term maintenance of weight loss, most intervention
programs are limited in duration and do not focus on management of chronic
is rapidly becoming our nation's leading health problem. Diabetes rates
are exploding. Diabetic patients require several times the health care
resources that nondiabetic patients need. Consequently, obesity has also
become a major economic problem. Health care systems responded rapidly
and aggressively to the HIV/AIDS epidemic but not to obesity. Most KP
regions have weight management programs, but few of these programs are
integrated into chronic disease management programs, and most are not
subject to performance evaluation and accountability. In addition, most
weight management programs are viewed largely as public relations programs
instead of as integral components of medical care. The best programs still
lack a population-based approach and frequently are not covered benefits
but are instead fee-for-service programs.
show that long-term, skilled approaches to weight management are successful;
however, as for any other medical care process, inadequate training and
support produce inadequate results. Existing data about these programs
are not perfect and have resulted in conflicting reports, but weight management
can definitely prevent or delay progression of glucose intolerance into
diabetes. How then can we possibly justify not applying this knowledge
to persons so likely to be future candidates for amputation, renal failure,
blindness, and early death?
make changes in their weight, exercise, and diet--only to relapse soon
thereafter. Initial behavior changes can be achieved with minimal intervention,89,95
but long-term maintenance of those changes remains a problem. Nonetheless,
years of research have shown improved diet and lipid levels in response
to low-intensity messages, counseling, or both--in the context of medical
care.92,95,96 The impact of a message is greater when it is
tailored to an individual patient,96 and long-term maintenance
of weight loss definitely enhances long-term compliance.
to dietary and obesity counseling in the medical office include insufficient
physician training as well as lack of time, support staff, and compensation.97-99
In addition, medical training does not prepare physicians to deliver nutritional
counseling.100 However, physician counseling skills and practices
can be improved;101 and although physician support of patients'
behavioral change is critical, physicians need not deliver the intervention.
With appropriate training and video-based support, nurses can improve
substantially on physician advice to quit smoking,102 and trained
behavior change counselors can be even more effective. A system for using
physician credibility to support effective counseling delivered by other
medical staff can save money and physician time and can allow counseling
delivered by personnel who are properly trained for this task.
health care providers often grow discouraged at what they view as inadequate
impact of lifestyle messages, data shows that consistent change results
when clinicians make an issue of lifestyle. However, not everyone is changed
by therapy: 80% to 90% of persons treated for hypertension for many years
would be fine without therapy, and cardiovascular events are prevented
in only a fraction of persons who receive preventive therapy. Nonetheless,
a substantial minority (as many as a quarter to a third) of persons who
complete a well-designed weight management program sustain a clinically
beneficial level of weight loss over long periods of time.7,8,103
review103 of 870 weight management studies identified only
37 that met rigid criteria for inclusion. These 37 studies suggested that
weight reduction methods are ineffective for periods longer than two years.
However, even in that skeptical review, selected pharmacologic, dietary,
and surgical interventions and long-term maintenance were associated with
sustained weight management. In the past three to four years, a growing
amount of literature7,82,84,87 has contradicted prevailing
pessimism in this area. We have not included pharmacologic intervention
in the group of programs we believe are likely to have long-term benefit
because we think the jury is still out on this issue. Weight loss drugs
in current use have been used for only a few years, and the long-term
benefits and risks of these drugs are still being examined.
in Table 1 have been linked to sustained weight loss reliably but not
universally or inevitably. The relative effects vary--probably depending
on the nature, quality, and duration of intervention. This knowledge has
been largely ignored by health care systems, many of which have expensive
and elaborate bariatric surgery programs for an extremely small fraction
of the population--and only after they have already become morbidly obese.
Most health systems have enormous budgets for managing diabetes and cardiovascular
disease but reject serious weight management efforts on the grounds that
"nothing works" and that they "can't afford it." Those
assertions are no longer valid: The few studies4 done to date
suggest that such programs may actually be cost-saving. Whether these
programs are or are not cost-saving, however, does not explain the extraordinary
lack of action by health care systems despite the nation's epidemic of
obesity and diabetes. Particularly difficult to comprehend is the neglect
of intervention at the time glucose intolerance is diagnosed.
lifestyle intervention, weight management is largely outside the paradigm
of what the health care industry perceives as its proper business.88
Weight management programs exist but rarely include evidence-based activities,
content, and design. What the doctor says matters. If a physician regards
weight control as a cosmetic issue or as simply a matter of a patient's
willpower, a clear message is given: Diet and weight are not important
to health. At the same time, the reports of consensus prevention task
forces104,105 emphasize the critical role of behavioral intervention
within the medical care system. The United States must begin to address
these lifestyle issues effectively through its medical care system if
we have any hope of raising our morbidity and mortality rates above those
in the bottom tier of developed nations while we lead the world in health
care costs and in the proportion of population who are without health
paper was supported in part by Centers for Disease Control and Prevention
Grant No. UR5/CCU917124.
author would like to acknowledge inspiration and conceptual input from
Sasha Stiles, MD, of the Hawaii Permanente Medical Group when the work
was done (now with the Permanente Medical Group in Northern California);
and from Faruque Ahmed, MD, PhD, of the Centers for Disease Control
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