Obese in the Exam Room: Patient Perception and Physician Challenges

By: Jennifer Webster
Tuesday, November 26, 2013
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A physician walks into an exam room where a longtime patient is waiting for his annual checkup. The physician glances at the computer screen and notes the digits: BMI=36.7. Does she do anything different from what she did last year?

The American Medical Association’s (AMA’s) 276‑181 vote to classify obesity as a disease does not present any particular instruction set to physicians, insurers or patients. Apart from scanning commentary in the blogosphere, will the average, busy primary care physician change how she spends 15 or fewer minutes with a patient who has obesity?

And, will the physician’s obligation to the patient change as institutions react to the AMA’s classification? For instance, will accountable care organizations become responsible for not just screening patient body mass index (BMI), but also keeping it under a certain level?

Presently, many large insurers, as well as Medicare and some state Medicaid plans, cover obesity screening and counseling. Many insurers’ coverage for obesity treatment includes discounted or free membership for health clubs or programs such as Weight Watchers. Additionally, some forms of bariatric surgery may be covered for patients who are extremely obese or who have comorbid conditions.

Following the AMA’s decision, will insurance companies be more likely to cover counseling for weight loss, special meals, sessions with exercise therapists, or medications? Will bariatric surgery be covered for obesity without comorbidities? Many experts who work with obese patients hope this will be the case. As a positive sign, the Affordable Care Act preventive services benefit requires physicians of patients with obesity to offer guidance on weight loss and make referrals. The physician may encourage her patient to look into these changing options. If the patient has Medicare, intensive behavioral therapy for obesity has been covered care since 2011. The primary care provider could schedule weekly visits initially, with follow-up visits tapered down to meet patient needs. However, services of a nutritionist or coach are not reimbursed, nor are ongoing services if the patient does not demonstrate weight loss.

Weight loss may also become a more important factor in workers’ issues, and the physician may encounter conversations about whether obesity as a result of weight gain following an injury is a compensable outcome of that injury.

A Patient Sits in an Examining Room

Her doctor walks in, glances at the EHR page flickering on the monitor and tells her, “You have a disease.”

Unlike the physician, the patient may never have heard that her BMI can be classified as a disease. However, as a woman of girth, she may have visited many physicians and heard multiple messages about her weight. In fact, obese patients are about a third more likely to see three or more primary care providers over the course of two years than average-weight patients.

The patient may have encountered disdainful comments from physicians and staff members, examining tables and other equipment of the wrong size, and unsolicited advice to lose weight. Unsolicited weight loss advice is one reason overweight and obese women give for switching primary care providers, according to Johns Hopkins University School of Medicine researchers.

“Your fat is hormonally active tissue,” her physician may tell her today. “It secretes proteins that cause inflammation, and may contribute to arthritis. Additionally, your body fat may affect how you metabolize some medications.”

According to Caroline Apovian, MD, FACP, FACN, a staunch supporter of obesity’s classification as a disease, fat is an endocrine organ.

“Leptin secreted from fat tissue signals the brain when you have fat stores, and this turns off hunger,” she says. “This is the hormone that decreases when you lose weight and you become hungry again.”

Problems can arise when the body becomes leptin-resistant. And fat is hormonally active in other ways, not to mention its role in other disease processes related to overweight and obesity.

Possibly, a discourse that characterizes fat as a disease rather than a personal trait or behavioral issue may paradoxically make the patient more willing to discuss her obesity because it is bracketed away from “her.”

On the other hand, some patients may be motivated by a neutral discussion about the role of food and weight in their lives, whether good or bad, says Alexis Conason, PsyD, a psychologist in private practice who specializes in overeating and body image. She contrasts obesity as diagnosed by a weight/height ratio to the more nuanced diagnosis of an eating disorder.

“One symptom in the DSM [Diagnostic and Statistical Manual] diagnosis [of binge eating disorder] is a level of distress; is this issue causing problems for the person or is the person distressed about their eating?” she says. “Not to say people don’t have emotional issues related to being people of fat. It’s not easy to live in society as an obese man or woman.”