Transforming Obesity Care Using OMA’s Four Pillars | Insights from Project ECHO Program

The Obesity Medicine Association (OMA) is the oldest and largest organization of clinicians in the obesity treatment space. In 2024, it partnered with Project ECHO to create the program entitled, Treating the Disease of Obesity. Ethos of this program includes (1) obesity is a chronic and relapsing disease and (2) the use of person-first language (eg. “the patient with obesity” instead of “the obese patient”). The first session was in February 2024 by Dr. Angela Fitch, the Past President of OMA. She presented the four core pillars of clinical obesity treatment. Content from this presentation is described in this blog article.

Obesity is a multifactorial chronic disease that is complicated by many factors such as genetics, mental health, food environment, sleep, biology, healthcare access, stigma and bias, and life events. This is why it is important to treat the roots of obesity. Healthcare providers must focus on the chronic disease of obesity rather than the short-term episodic treatment. Over their lifetimes, people struggle with obesity and weight loss is abnormal. The human body is not engineered to lose weight because it’s not done by default. When people lose weight, the body resists like in a tug of war. As weight loss occurs with decreased caloric intake and increased activity, the body fights back by slowing metabolism, increasing hunger hormones, and decreasing fullness hormones. This is why weight regain is so common causing people to lose weight in the short term successfully but not in the long term. In other words, the tug of war favors weight gain.

The Obesity Medicine Association has a new journal entitled Obesity Pillars that is open access. In this journal, OMA wrote a statement to explain the definition of comprehensive care for patients with obesity. They stated it was healthful nutrition, physical activity, behavior modification, and medical management. In other words, obesity is a comprehensive, longitudinal, chronic disease. OMA updated its four core pillars of clinical obesity treatment from “Nutrition”, “Behavior”, “Physical Activity”, and “Medication/Pharmacotherapy” to (1) Nutrition Therapy, (2) Behavioral Modification, (3) Physical Activity, and (4) Medical Interventions. The four pillars were updated in 2024 to make them more holistic and inclusive with a focus on therapy.

Obesity treatment can be represented as a pyramid. However, the idea is not for patients to climb up the pyramid. They need to increase their treatment intensity as they increase their health risk with increasing adiposity and worsening disease state. In other words, this intensity increases not because patients have failed in the past but because they need it at that high level to accomplish their weight goal. Many patients feel surgery is a last resort, yet, even with new advances in pharmacotherapy, surgery is the most significant treatment modality to provide the longest and most sustained weight loss. It is important for healthcare providers not to look at obesity treatment as a pyramid but as pillars. In other words, patients can go back and forth. They might have surgery but may still need pharmacotherapy, prescriptive nutritional intervention, and lifestyle intervention.

For the evaluation of nutritional issues or current nutritional status, obesity specialists use a Three-Factor Eating Questionnaire (TFEQ), a Binge Eating Scale (BES), a 24-hour dietary recall, a Social Determinant of Health (SDOH), and an eating disorder questionnaire screening (SCOFF). They also evaluate the phenotype of patients’ nutritional behaviors. These include “always hungry, snacker”; “never full, volume eater”; “picky eater, limited palate”; “enjoyment eater, everything had to taste amazing or not worth it to eat”; and “emotional eater”. Patients may have more than one of these behaviors. Treatment options include making a referral to a registered dietitian for medical nutrition therapy; determining if the patient has support options via insurance or employer; planning portions of plants and protein; prioritizing protein for satiety and lean mass preservation (1-1.5 g/kg protein as a goal); using 500 kcal deficit with calorie tracking app; and incorporating a meal replacement plan like in the Look AHEAD (Action for Health in Diabetes) study. This lifestyle weight loss study in DM was the biggest trial done using meal replacements. The results showed that the diabetes remission rates were greater with intensive lifestyle intervention (which included meal replacements). At year 1, 40% of patients lost more than 10% of their weight on the meal replacement program. At year 8, approximately 27% of patients had greater than 10% weight loss with intensive lifestyle intervention. Also, patients who used more meal replacements lost more weight.

For behavioral modification, obesity specialists evaluate behavior contributors to obesity such as sleep, stress, and mood. Treatment options include writing a referral to a psychologist, health coaching, remote patient monitoring (RPM), and referring to programs provided by the insurance or employer.

For physical activity, obesity specialists assess the current activity level. They do this without making assumptions based on obesity (patient living in a larger body) because that’s a form of stigma and bias. In other words, they ask the patient directly using people-first language. Treatment options include advising on a plan with an initial goal of 150 minutes per week and reminding patients of the following tips: track steps and get 500 more steps/day each week; set the alarm and get up from the desk and walk 10 minutes each hour; use an under-desk cycle or walking pad; and do strength/resistance activity 2 times a week as an initial goal.

For medical interventions, obesity specialists evaluate medication management, bariatric procedures, and complication management. Treatment options for obesity include prescribing anti-obesity medications (AOMs); discussing the benefits of bariatric surgery and referring patients to surgeons as needed; considering endoscopic procedures (especially patients with RNY in the past); and treating the complications of obesity. Key treatment considerations include coverage, cost, complications, and contraindications. In general, 20% of weight loss is what many patients want to achieve as a goal. However, it is still important to identify with patients their goals for weight loss ( 5%, 10%, 15%, 20%, 30%, etc). For example, in Intensive Behavioral Therapy (IBT) programs like Weight Watchers, the data indicate that approximately 25% of participants achieve a weight loss of 10%. If a patient is not part of the 25%, then he/she will likely need to have additional treatment. With Tirzepatide, 90% of patients will get >10% weight loss; with Semaglutide, 75% will get that 10%; and with Phentermine/Topiramate, 47% will get 10%. So, matching a treatment intensity with the patient’s goal is important.

In a nutshell, obesity is a serious medical condition that needs to be recognized, assessed, and treated using a holistic lens and person-first language. As healthcare providers, it is imperative to treat the roots of obesity using the OMA’s four core pillars of clinical obesity treatment namely (1) Nutrition Therapy, (2) Behavioral Modification, (3) Physical Activity, and (4) Medical Interventions. A comprehensive approach is a must because obesity is a heterogeneous chronic disease.