Preventive Medicine Column
Dr. David L. Katz
Medicare recently announced new regulations that authorize reimbursement for obesity management counseling by physicians. That’s good, assuming the counseling is good. We are a long way from being able to count on that, however.
The track record for the large majority of our clan is not pretty. Historically, physicians have mucked up weight management counseling by providing it, and by not providing it.
The problem with not providing it is pretty self-evident. If a patient presents who is clearly severely overweight – not to address it is both ludicrous and an abdication of clinical responsibility. It would be as if a patient walked into the office with a spear sticking out of their chest, and left in the same condition with no mention of it in between.
But bad counseling can be worse than none at all. When the best a doctor can do is blame the victim- “don’t you know that being so fat is bad for you?”- the net effect can range from an erosion of the patient’s self-esteem, to outright estrangement of the patient from the medical system. The former is bad enough- making a patient feel about an inch tall (note that if height goes down while weight remains constant, BMI actually goes up; talk about counter-productive!).
The latter, however, can actually be life threatening, when patients eschew vital preventive services, or neglect essential care to avoid the associated denigration. It may sound a bit melodramatic to suggest that bad obesity counseling can be lethal- but I know of at least one case where it was just so.
Docs don’t tend to get much training in nutrition, and while this has been oft lamented, it is difficult to fix due in part to the intense competition for real estate in the crowded landscape of medical education.
Even if time for robust nutrition education were claimed, it would only be a start. Training in behavior modification also tends to be limited, and would need to be upgraded considerably. Perhaps less daunting than these, additional training would be required for effective promotion of physical activity as well, along with the proper ways to measure and monitor not just weight but body composition.
And because in unity there is strength, approaches to weight control that engage the whole family are best. One person on a diet is weak; a family seeking health together is strong. So good counseling should address all household members, another area in which physician training (with the possible exception of family practitioners) is limited.
Were all such upgrades to occur in medical education, formidable challenges would still remain. The first is obvious: those notorious “15 minute encounters,” which are in fact often less, don’t allow time for conventional behavior modification counseling even by those who know how to provide it.
There are ways to address these issues, through education and adjustments to primary care models.
But even if with creative approaches, physicians would still be struggling to allocate time to weight management counseling and away from other matters. The solution to this is for physicians to initiate the counseling, and then defer to others better suited to address the details. Dietitians are the obvious choice. In some cases, health coaches could play this role as well. But for this strategy to work, there would need to be reimbursement for that counseling as well.
Another, and perhaps even better option, is for clinicians to be able to direct patients into well-established weight management programs. There is a lot to a comprehensive weight management program, and it’s unlikely that even a highly skilled and motivated physician could address all of this on his or her own. Two very compelling recent studies suggest that Weight Watchers does a far better job at this than primary care- so linking the two is attractive. But again, the reimbursement model does not yet correspond.
Even truly excellent clinical counseling for weight management will only be a small part of a comprehensive solution. The origins of prevailing weight gain and obesity are not clinical- they are not about physiology run amok- they are societal. are about food processing and suburban sprawl, vending machines and video games. Medical school does not provide a fix for any of these!
Reimbursement for obesity counseling is good, as far as it goes, if the counseling is good. But it doesn’t go all that far. We will see the toxic tide of epidemic obesity turn when, and only when, we fix the problem at its many sources in our society- and make eating well and being active the norm, rather than the exception. The promise of that day is great. We have miles to go to get there from here!
Dr. David L. Katz; www.davidkatzmd.com