Obesity Management Team

Optimal treatment of obesity involves a multidisciplinary team, here in the US that often follows the Chronic Care Model (CCM) of health care delivery. The aim of the CCM is to “transform the daily care for patients with chronic illnesses from acute and reactive to proactive, planned, and population-based” (Coleman et al, 2009)

Patients are at the center of the team and are often assisted by a physician, nurse and/or nurse practitioner, dietitian, exercise physiologist, and behaviorist (Golay et al, 2003). Additional team members may include adjunct providers, including endocrinologists, bariatric surgeons, psychiatry, and gastroenterology service, cardiology, podiatry, orthopedics. As a chronic disease, it affects all specialties, and each can plan a part of the care plan. If, for example, a patient has uncontrolled diabetes, there will be great overlap with the endocrine team.

As obesity specialists, we utilize structured lifestyle changes. Focusing on the four pillars of obesity treatment – Nutrition, Physical Activity, Behavioral Modification, and Pharmacotherapy are central to patient success.

Multiple diet options have been proven effective for weight loss. As part of the MDT, Nutrition professionals include registered dieticians (RD), certified clinical nutritionists (CCN), and certified nutrition specialists (CNS). As with many aspects of healthcare, the nomenclature can be confusing.

Those outside the specialty mistakenly use the terms “dietitian” and “nutritionist” interchangeably. (I did it myself when I first met our registered dietician; It didn’t go down so great! Don’t worry I recovered well, and we are now a functioning team).

Bleich et al, (2015) note that “Nutrition professionals most commonly self-identified as the most qualified group to help patients lose weight (92%), sentiments supported by other health professionals (57%). Among nutrition professionals, 77% reported receiving high-quality training in weight loss counseling and were significantly more likely to report confidence (95% vs. 48%) and success (74% vs. 50%) in helping patients lose weight (p<0.05) than those reporting lower quality training”.

However, minimal weight loss is noted through exercise (aerobic or a combination of aerobic and resistance) alone (Haskell et al, 2007). Exercise appears to augment the effects of diet on weight loss. As part of the multidisciplinary team, an exercise physiologist (AEP) is responsible for diagnostic and functional testing, exercise prescription, exercise supervision, patient counseling, education, and outcomes analysis (Soan et al, 2014) and can design personalized exercise regimens based on patient’s specific needs. (Foster et al, 2017). The Exercise is Medicine initiative founded by the American College of Sports Medicine aims to raise the profile of exercise physiology and incorporate physical activity.

Psychological methods include behavioral therapy and cognitive therapy. They can teach patients the skills of problem-solving and awareness of negative thought processes (Foster et al, 2017). Utilizing the treatment algorithm based on the 5As framework (Assess, Advise, Agree, Assist, and Arrange), psychotherapy can play an important role in influencing weight gain, such as anxiety, depression, and binge eating. Ferrari et al, (2017) study looked at cognitive-behavioral therapy in groups (CBTG) combined with nutrition and physical education. They suggest that the causes of obesity cannot be generalized and that not every patient with obesity has psychological problems or personality traits related to their weight gain or difficulty with weight loss and should be tailored to the individual. Group treatment does, however offer benefits from the support they receive from each other and the positive peer influence to maintain the group norm of losing weight (Wadden, 2002)

Pharmacotherapy is ultimately the responsibility of the Physician/ Advanced practitioner however, medication selections are often decided using the input of other team members. By reviewing the dietician and behavioral evaluation, the patient may be diagnosed with Binge eating disorder, and the appropriate medication choice may be Bupropion, but this may be deferred if purge elements are noted. Exercise Physiologists consider how to coordinate patients’ insulin timing and doses with episodes of aerobic exercise to avoid hypoglycemia (Foster et al, 2017)

Additional members may include a Case Manager and Social Worker. These team members may be instrumental when addressing the social determinants of Obesity management.

Learn the key players in your community. Get out and identify your local experts, advocacy partners, and warriors. Reach out; more can be achieved as a collective. Know your own expertise and limitations and be willing to learn from each other. Do you know your team?