Obesity Treatment Pearls for Primary Care from Lee Kaplan, MD, PhD

Lee M. Kaplan, MD, PhD

Obesity specialist Lee Kaplan, MD, PhD, in a recent interview with Patient Care Online, offered 3 take-home thoughts for primary care clinicians about approaching care for patients with overweight or obesity in their practices.

Dr Kaplan is associate professor of medicine at Harvard Medical School and director of both the Obesity, Metabolism & Nutrition Institute and the Obesity Medicine Fellowship Program at Massachusetts General Hospital.

Learn all you can

The first thing I would say that learning more about obesity is valuable, in and of itself. Learning why it is considered a disease, what the pathophysiology is. Even though we don’t know all of it yet, what we know is convincing, at least to many of us in the field. And if you communicate that information to patients, you will see that they are much more receptive to any other discussion you'll have with them about treating their obesity. So that's number one—there is immediate value in learning enough about obesity to communicate to patients that you understand that it is a pathophysiological problem, that is a bodily dysfunction at its root. You’re automatically, without saying it in so many words, interfering with the blame cycle that all patients have been exposed to in the healthcare system as well as elsewhere.

Distinguish wellness from treatment for obesity

Number 2 is that we need to distinguish promoting wellness from treating obesity. Wellness is a good goal on its own. We talked about apps and other electronic devices that can be used to support the treatment of obesity. Well, they can be used to support the treatment of all diseases because they can be reminders, they can be educators, they can be recorders of information. We should think about wellness as a good goal. But we should think about treating obesity as an independent goal. And we should require of any treatment of obesity that it be effective long term, and that it demonstrate enough improvement in obesity that it's worth the investment of time and money.

Understand heterogeneity is the rule

Number 3 is that we have to recognize the enormous heterogeneity of obesity. That means the heterogeneity in severity, heterogeneity of cause, heterogeneity of mechanisms, which taken together means that no single therapy is going to be effective for all patients. You have to be willing to try different therapies. We do that for diabetes, we do that for hypertension, we do that really, for all of the chronic diseases; we'll try something and if it doesn't work for a patient, we’ll add something or will substitute something.

Start with those at greatest risk

The heterogeneity of severity I mentioned would actually be a fourth thing I would emphasize for primary care providers. You don't have to go from not treating obesity, to treating everybody with obesity, because we don't have good enough clinical practice guidelines yet to do that. But let's start by taking the people whose obesity puts them at the greatest risk—either because they are more likely to die early, or their health care incurs the greatest personal or system-wide expense, or they have the greatest disruption to their lives, either physically or psychologically as a result of obesity. Start by saying to yourself, who are the patients who would most need and most benefit from effective therapy for obesity, because right now, the standard of care is so low, that if you just pick the sickest patients, and you focus on them and treat them first, you'll do a tremendous service overall. And as you get more comfortable treating the sickest patients and working with specialists, if need be, to learn how to treat the sickest patients, then it'll become second nature.

Most primary care medicine is practiced by reflex because you get a very good sense of whether somebody is sick or they're not sick when they approach you with a problem. And it is practiced by algorithm, because a lot of the preventive medicine is done by algorithms. So, between reflex and algorithm, what we want to do is to help primary care develop reflexes and get use to algorithms around obesity.

Listen to other Patient Care interviews with Dr Kaplan

"Obesity is a Medically Approachable Problem" and Other Lessons with Lee Kaplan, MD, PhD

The Future of Obesity Medicine in Primary Care: A Conversation with Lee Kaplan, MD, PhD