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November 6, 2002

Undertreatment of Obesity

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JAMA. 2002;288(17):2177. doi:10.1001/jama.288.17.2177-JMS1106-3-1

Despite the epidemiological data linking obesity to a number of medical diseases, there is evidence that physicians continue to underrecognize and undertreat it in the medical setting. For instance, although the first-line intervention for obesity is nutritional counseling, exercise, and recommendation of lifestyle changes, only 42% of obese US adults who had visited a primary care physician for a well-care visit in 1996 had been counseled about weight loss. Those patients who had been counseled by a physician and told specifically that they should lose weight were significantly more likely to report attempts at weight loss than those who were not.1 Although this study relied exclusively on self-reported data from patients, which could have confounded its results, other studies have come to similar conclusions using different methods. Analysis of the National Ambulatory Medical Care Surveys found that of 55 858 US adult physician office visits, behavioral counseling on specific weight reduction strategies such as dietary improvements and exercise regimens were individually provided to no more than a quarter of obese patients. Obesity itself was also underreported. Only 38% of patients classified as obese by height and weight were reported as obese by their physician.2

A recent study of pediatrician referral patterns found that pediatricians frequently referred mildly underweight children but not moderately obese and overweight children, for nutritional workups.3 The lack of medical attention for obese children is compounded by the lack of reimbursement for the treatment of pediatric obesity. One study found that only 11% of pediatrician-ordered treatments for obesity were reimbursed.4

The undertreatment of obesity may, in part, be a response to the poor efficacy of current treatments for obesity. To date, the only medical intervention effective for the long-term treatment of obesity is bariatric surgery, which carries significant lifestyle and health comorbidities, and is thus indicated only for a relatively small subset of the obese population. The other interventions—lifestyle modification with respect to diet and exercise and pharmaco-therapy with concomitant lifestyle modification—result in a mere 5% to 10% weight loss overall with a maintenance period of one to two years at maximum, with 95% of all patients undergoing weight reduction regaining lost weight within seven years.1 These losses may be frustrating for patients and physicians, although studies have indicated that even short-term, minor weight losses of 5% to 10% can improve glycemic control, blood pressure, and lipid profiles.5

Given such poor outcomes from current weight-reduction strategies, physicians may feel unable to treat obesity effectively and at a loss to initiate a successful counseling session with concrete weight-reduction strategies. In fact, pessimism about treatment outcomes and a lack of counseling knowledge have been identified as significant barriers to treating obesity.6,7 Yet similar problems with behavioral counseling for smoking cessation have been overcome in large part not because of improved medical interventions but because of physician motivation and interest in improving these parameters. Several studies documented the effective components of smoking cessation interventions, and this information has been incorporated into resident education programs.8 Rates of behavioral counseling for smoking cessation have improved as a result of this and other work.9 A 1998 survey of Medicare managed care patients who reported any smoking during the preceding 12 months, 70.7% reported they had been advised to quit smoking by their health care provider.10 In contrast, only 38.8% of a similar group of adults who smoked were advised to quit in 1991.11

It is important to increase physician awareness of the importance of obesity as a medical problem. Currently, physicians often underemphasize the importance of weight loss with their patients and infrequently offer obese patients the information they need to understand the severity of their disease and the methods available to treat it. Although the available interventions for weight reduction lack long-term efficacy, the high financial and disease burden imposed by obesity in the United States demands increased research activity to improve use of the available interventions and also to develop new modalities to treat one of the nation's most pressing health concerns.

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