NHLBI Working Group on Competencies for Overweight and
Obesity Identification, Prevention, and Treatment
6701 Rockledge Drive, Bethesda, MD 20892

May 3-4, 2005


Agenda
Participants
Summary

Working Group Report on Competencies for Overweight and
Obesity Identification, Prevention, and Treatment


Background and Purpose
Review of the Challenges in Obesity Education and Patient Care
Recommendations
  Undergraduate Medical Education (UME)
  Graduate Medical Education (GME)
  Continuing Medical Education (CME)
  Crosscutting Issues
References

A.   Background and Purpose

Overweight and obesity have reached epidemic proportion among U.S. adults and children and are major national public health priorities (1). More than 65% of U.S. adults are overweight or obese and about 16% of children ages 6 through 19 are overweight (1). Although the prevalence of overweight or obesity among adults at least 20 years of age is lower in non-Hispanic Whites than in non-Hispanic Blacks or Mexican Americans (i.e., 63% Whites, 71% Blacks, 73% Mexican Americans), these prevalence rates remain unacceptably high and are serious public health concerns (1). Obesity-related comorbidities such as metabolic syndrome are prevalent in both the adult and pediatric populations (2), while obesity-attributable medical expenditures increased from $39 billion in 1986 to $75 billion in 2003 (3).

These demographic and economic trends suggest a need to tackle the obesity epidemic from multiple fronts, including training medical students, resident physicians and clinicians in methods to identify, prevent, and treat obesity. Continuing research on the determinants of and factors related to obesity, as well as on intervention approaches to reduce and prevent obesity, will provide new results that will require translation into practice. This translation could be accomplished more effectively by enhancing competencies of medical students, residents, and physicians in the medical care of overweight and obese patients. Ultimately, engagement of multidisciplinary teams that include physicians and other health professionals to provide interventions at multiple levels (e.g., individuals and families) will be needed to help curtail the obesity epidemic.

The importance of including competencies in obesity care in medical school curricula, residency programs, and training of practicing physicians and other health care professionals was underscored by the U.S. Preventive Services Task Force (USPSTF) recommendations that “clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss of obese adults” (4). Numerous scholarly organizations similarly emphasized the importance of broad-based approaches to stem the obesity epidemic. The Institute of Medicine recommended that pediatricians, family physicians, nurses and other clinicians engage in preventing childhood obesity by routinely tracking BMI, providing relevant evidence-based counseling and guidance, and serving as role models in the community (5). In addition, the Institute of Medicine (IOM) recommended improvement in medical education by integrating behavioral instruction and skills for obesity care in the four-year medical school curriculum (6). The American Heart Association recommended that obesity prevention and treatment include behavioral measures (e.g., behavioral approaches to improving diet and physical activity) (2). The American Medical Association (7), the American Academy of Family Physicians (8), the American College of Preventive Medicine (9), the Agency for Health Research and Quality, the American Dietetic Association (10), the American Academy of Pediatrics (11), and the National Heart, Lung, and Blood Institute’s guidelines on obesity (12) underscored the importance of improving medical education by enhancing medical school curricula and residency programs to include obesity assessment, prevention, and treatment. The NHLBI Think Tank on Obesity Research recommended the launching of an obesity academic award as an important strategy to help counteract the obesity epidemic (13).

To advise the NHLBI concerning the structure of a potential Obesity Academic Award, the NHLBI convened a Working Group on May 4-5, 2005 to discuss competencies training for overweight and obesity identification, prevention and treatment. Dr. Robert Kushner, Professor of Medicine, Northwestern University Feinberg School of Medicine, chaired the meeting. Participants included representatives from public and private medical and academic institutions, the Association of American Medical Colleges, and NIH Institutes, including the National Institute of Diabetes, Digestive and Kidney Diseases, National Cancer Institute, and the NHLBI, which sponsored the meeting.

The goal of the meeting was to provide advice to the NHLBI and NIH as to whether an Obesity Academic Award program is needed and the components of a successful program. To meet this goal, the charge to the panel included the evaluation of two major issues:

  • Assessment of the challenges that medical schools, residency programs, and clinicians face in obesity training and practice; and,
  • Methods for incorporating obesity training and care into medical education and practice in undergraduate, graduate, and continuing medical education programs.

Speakers with extensive experience in all aspects of medical curriculum development and delivery presented their views on undergraduate and graduate education as well as continuing medical education. Perspectives of resident physicians, clinicians, academic deans, and the Association of American Medical Colleges (AAMC) were included. NHLBI resources and research on obesity and its relationships with sleep disorders were also presented.

The Working Group reviewed information on training for obesity care in medical programs and discussed the challenges and strategies for building successful obesity educational programs for undergraduate and graduate training, and for continuing medical education. They discussed a variety of issues: barriers to including competencies for overweight and obesity care in medical training, and methods for addressing those barriers; multidisciplinary team approaches to obesity education and practice; educational programs to meet competencies for graduate and postgraduate medical education; and, the recent Association of American Medical College’s Medical School Learning Objectives Report for obesity. Participants provided recommendations for improving medical students’, residents’ and clinicians’ competencies for overweight and obesity identification, prevention, and treatment.

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B.  Review of the Challenges in Obesity Education and Patient Care

The Working Group reviewed the evidence on obesity education in medical schools, graduate programs, and obesity care by clinicians, and concluded that gaps exist in the training of obesity assessment and care, behavioral medicine, and motivational interviewing skills (14, 7), and in availability of role models with experience in these areas. It was noted that the medical profession has often focused on the acute care model for obesity treatment, and has had a limited focus on prevention of health risk behaviors. A paradigm shift is needed from that model to a patient-centered model, one that involves early identification, prevention, and treatment of overweight and obese adults, with the patient playing an integral role. The review noted that moderately and severely obese patients with co-morbid conditions can be identified easily, but providers fail to identify overweight and mildly obese patients, thereby missing important opportunities for early prevention and treatment (14). For example, only 19% of overweight patients receive counseling compared to 94% of severely obese patients (15). The failure of healthcare providers to initiate or intensify treatment (referred to as “clinical inertia”) for overweight or mildly obese adults results in poor health outcomes for these patients. Shortcomings to delivery of adequate obesity care include lack of trained physicians, inadequate physician-patient contact time, inadequate or absence of reimbursement, biased beliefs of physicians regarding weight control of their patients, unsupportive practice environments (e.g., lack of effective team work, and competing demands), and unmotivated patients.

Lack of physician training in diet and physical activity counseling and behavioral therapy as well as ineffective use of adjunct modalities (e.g., pharmacotherapy) are further barriers to obesity care (16). A survey by the Association of American Medical Colleges (AAMC) found that 56% of graduating medical students stated that nutrition-related experiences during their training were inadequate, and fewer than 50% thought that they were well prepared to assess patients’ status for obesity (16). Although instruction in nutrition is one of the accreditation requirements by the Liaison Committee on Medical Education (LCME), instruction in obesity is not. The content of instruction in nutrition in many medical school curricula must be enhanced to include obesity identification, prevention, and treatment. Most residency programs do not include obesity care as part of their competency-based curricula, although the Accreditation Council for Graduate Medical Education (ACGME) requires competencies to include patient care, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice.

Another barrier to effective obesity care is the short physician-patient contact time (typically about 10 minutes), which limits meaningful counseling of the overweight or obese patient (17). Thus, long-term approaches to obesity care must include strategies that involve allied health professions and community partnerships for weight control in addition to counseling strategies in the clinic setting. Multidisciplinary obesity management teams consisting of clinicians, nutritionists, and physical activity specialists were thought to be essential for effective management of overweight and obese patients. Although the public perceives physicians as highly competent and credible in many areas of health, they are not seen as the primary source of weight management information. Thus, multidisciplinary teams, and partnerships with community health systems (e.g., health departments) and community programs (e.g., fitness centers) are critical to facilitate weight loss efforts.

The Working Group concluded that lack of reimbursement for clinical services to prevent and treat obesity is a major barrier that requires policy changes. Currently reimbursement for obesity care is only available for treatment of diabetes. The recent identification of obesity as a disease by the Center for Medicare and Medicaid Services could lead to more consistent reimbursement for proven clinical strategies for obesity treatment. Additionally, the Internal Revenue Service considers obesity treatment as an after-tax health care expense. Some employers provide incentives (e.g., reduce health insurance premiums) to workers, which could encourage employee health promotion programs. Reduced health-care costs and a positive return on investment have been reported in hospitals and worksite obesity intervention studies (18). Changes in these and related policies at the national level (e.g., full reimbursement for overweight and obesity prevention and treatment) are needed to manage overweight and obese patients effectively.

The inadequate attention to clinical management of overweight and obesity may stem from a perception that long-term weight loss interventions are ineffective. Evidence shows that short-term (i.e., 6 months or less) and long-term (up to 4 years) weight loss interventions are effective. However, few studies have shown positive effects for interventions delivered in clinical settings. Treatment of overweight and obese patients seems to be most effective in settings where medical education programs have incorporated competencies for obesity care into their curricula, where skills for effective overweight and obesity management are taught, and where both the health care provider and patient are given counseling and reinforcement (19).

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C.  Recommendations

The Working Group concluded that an Obesity Academic Award program, in tandem with continued research, could lead to improved clinical care for overweight and obese patients. The Working Group made the following specific recommendations:

    Undergraduate Medical Education (UME)
  • Medical school administrators (i.e., associate deans, course directors, and faculty) must recognize and support a competency-based obesity theme that is taught across the four-year UME curriculum and required for all students. Thematic integration is one in which obesity identification, prevention, and treatment are incorporated into courses using a variety of teaching methods including (but not limited to) lectures, case studies, small-group discussions, role plays, standardized patients, and problem-based learning across basic-science courses such as biochemistry and clinical training experiences such as ambulatory care rotations. Evaluation of knowledge and skills via examinations, standardized patients, and direct observations for example, in a wide variety of medical training topics is also critical. A multidisciplinary Task Force at each institution should be created to accomplish this integration.
  • Encourage opportunities for undergraduates to gain knowledge and skills in obesity care by interacting with resident physicians and other team members in the care of overweight and obese patients.
  • Integrate basic science courses with topics in the biological, physiological, intrauterine, inter- and intrapersonal, environmental and societal factors that affect obesity, including the long-term consequences of obesity on cardiovascular and other diseases.
  • Integrate screening into routine history taking skills and physical examination. During clerkship and clinical practice, provide opportunities for all students to assess patient weight status. Use evidence-based guidelines, and focus on disease prevention and counseling for behavior change.
  • Provide practice-based electives on overweight and obesity identification, prevention and treatment throughout the four years of medical education.
  • The medical school administrative leadership should have a centralized structure to modify curricula and should support a full-time coordinator, trained and committed faculty instructors, and clinicians experienced in obesity care. Ongoing faculty development sessions and role models are also needed.
  • Obesity Academic Awardees should collaborate with the American Association of Medical Colleges and the Liaison Committee for Medical Education to incorporate obesity education into competency requirements for accreditation.
  • An Obesity Academic Award initiative should encourage collaboration among medical institutions by, for example, having medical institutions work with other local medical schools within their state to disseminate widely their programs and curricula.
    Graduate Medical Education (GME)
  • Medical institutions should have strong institutional support from GME deans and residency directors, implement faculty development by training faculty who can teach in multiple programs, and involve residents in the teaching process.
  • Medical institutions planning for obesity GME programs should consider involving a network or group of at least three additional residency programs across institutions to develop, implement, and evaluate their program.
  • Institutions who receive the academic awards should plan to share GME materials, to mentor faculty, and to design faculty development sessions, retreats, conferences, electives, Web-based resources, and standardized patient cases.
  • Medical Institutions should collaborate with organizations such as the Accreditation Council for Graduate Medical Education, who can modify competency requirements for GME disciplines.
  • Improve the skills and competencies (education and training) of residents so that they are maximally effective in helping patients achieve and maintain a healthy weight, optimize medical management of the obese patient and promote best practice. Include a variety of opportunities and modalities for residents to manage their patients’ weight.
  • Train residents and faculty to be mentors and role models to medical students and other faculty and clinicians.
  • Encourage academic detailing to promote innovations in the systems of care for overweight and obese patients. (e.g., to learn about evidence-based clinical guidelines and resources, coding and reimbursement issues, and clinical care of the obese patient from other experienced faculty).
  • Form partnerships with other institutions (e.g., HRSA obesity referral centers, bureau of primary health care), community health service agencies, and clinical practice groups or networks to maximize the effectiveness of obesity care. A multidisciplinary team for obesity care must include dietitians, diabetes educators, exercise physiologists, nurses, health educators, and physical therapists. Structural and organizational modifications in the systems of care could help address issues impacting health care delivery, and could improve the quality of care.
    Continuing Medical Education (CME)
  • Strategies for CME should include training of faculty from a variety of disciplines in sufficient numbers to reinforce and institutionalize obesity training and care and expand the pool of health professionals who are competent to teach obesity management.
  • Pre-implementation evaluation of providers’ needs should guide CME program development.
  • CME and training programs should incorporate recommendations and conclusions of the Robert Wood Johnson Foundation’s expert panel on continuing provider education on obesity that are available at http://www.rwjf.org/files/research/CMEPanelReportSum.pdf.
  • Curricula for providers should include training in advocacy (community, healthcare systems, and regulatory bodies).
  • CME programs should provide opportunities for other faculty to share educational materials, mentor faculty, design faculty development sessions, retreats, conferences, electives, web-based resources, and standardized patient cases.
    Crosscutting Issues
  • All programs should integrate basic science and pathophysiology with clinical applications, which will also prepare the trainee to integrate new findings.
  • All programs should promote the use of practice guidelines (e.g., NHLBI Obesity Practice Guide and other resources), and risk factor and co-morbidity assessment and management.
  • All programs should provide training and education in team-based obesity management and incorporate innovations in the systems of care (e.g., electronic medical records, interactive technology communications) to facilitate the adoption of evidence-based obesity management.
  • For optimal impact, an Obesity Academic Award program should include a coordinating center to facilitate collaboration, specifically: communications among awardees and with organizations such as the AAMC, LCME and ACGME; sharing and dissemination of activities, curricula, and test materials; and approaches to mentoring faculty.
  • An Obesity Academic Award should include a strong evaluation plan to assess whether the program improved the competency levels (knowledge and skills) to identify, prevent, and treat overweight and obese persons effectively.
  • NHLBI should collaborate with organizations such as the LCME, AAMC and ACGME that are in positions to alter training requirements for entire disciplines.

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References

  1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR and Flegal KM. Prevalence of overweight and obesity among U.S. children, adolescents and adults, 1999-2002. JAMA, 2004, 291:2847-2850.
  2. Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation 2005, 111 (15): 1999-2012.
  3. Finkelstein EA, Fiebelkorn IC, and Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obes Res 2004 (1): 18-24.
  4. U.S. Preventive Services Task Force (USPSTF). Screening for obesity in adults: recommendations and rationale. Ann Intern Med 2003, 139 (11): 930-932.
  5. Institute of Medicine (IOM). Preventing childhood obesity: Health in the balance. The National Academy Press, Washington, D.C., 2005.
  6. Institute of Medicine (IOM). Improving medical education: enhancing the behavioral and social science content of medical school curricula. The National Academy Press, Washington, D.C., 2004.
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  8. Guzman SE. Practical Advice for family physicians to help overweight patients: An American Family Physician Monograph. Association of American Family Physician, 2005.
  9. Nawaz H and Katz DL. American College of Preventive Medicine Practice Policy statement. Weight management counseling of overweight adults. Am J Prev Med, 2001, 21 (1):73-78.
  10. Cummings S, Parham ES, and Strain GW. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2002, 102 (8):1145-55.
  11. American Academy of Pediatrics Policy Statement on Prevention of Pediatric Overweight and Obesity. Pediatrics 2003, 112, (2), 424-430.
  12. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. National Institutes of Health. Obes Res, 1998, 6 (Suppl 2): 51S-209S.
  13. Think Tank on Enhancing Obesity Research at the National Heart, Lung, and Blood Institute. National Institutes of Health Publication No. 04-5249, 2004.
  14. Kushner RF and Blatner DJ. Risk assessment of the overweight and obese patient. J Am Diet Assoc. 2005, 105 (5 Suppl 1): S53-62.
  15. Kristeller JL and Hoerr RA Physician attitudes toward managing obesity: differences among six specialty groups. Prev Med. 1997, 26(4):542-9.
  16. Association of American Medical Colleges (AAMC). Medical School Graduation Questionnaire: Final Report. http://www.aamc.org/data/gq/allschoolsreports/start.htm.
  17. Mechanic D, McAlpine DD and Rosenthal M. Are patients' office visits with physicians getting shorter? New Engl J Med, 2001, 344(3):198-204.
  18. Ozminkowski RJ and Goetzel RZ, Chang S, and Long SR. The application of two health and productivity instruments at a large employer. J Occupational Environ Med, 2004, 46, 635-648.
  19. Bodenheimer T, Wagner EH, and Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002, 288 (15):1775-1779.

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