A Conversation with Scott Kahan, MD, MPH

Diplomate discusses latest research finding lack of obesity knowledge among health care providers

Health care providers have a limited understanding of evidence-based recommendations to address obesity, according to the findings of a recent study that ABOM Diplomate and Board Member Scott Kahan MD, MPH helped conduct. The authors of the study conducted a web-based survey of a 1500+ internists, family practitioners, obstetricians/gynecologists, and nurse practitioners to determine their understanding of obesity treatment guidelines. Study results, published in the April issue of the journal Obesity, indicate that most providers lack knowledge and understanding of recommended obesity treatments.

American Board of Obesity Medicine Medical Director Rekha Kumar, MD followed up with Kahan to ask about the research.

RK: There is a group of organizations devoting a lot of effort and resources into creating obesity medicine treatment guidelines. It is disappointing to see that health care providers’ knowledge of obesity treatment is not consistent with these well formulated guidelines. Are HCPs in the community able to easily access these guidelines or are they being published in journals that may not be easily accessible? Perhaps collaborating with large, established medical societies would allow more access to obesity treatment guidelines.

SK: Actually, this has already happened. The most recent guidelines and tutorials are published by professional societies – The Obesity Society, American College of Cardiology, American Heart Association, Obesity Medicine Association, Endocrine Society, and the American Association of Clinical Endocrinologists. This has been a positive development, in that there is better distribution to these societies’ members. However, I believe a key issue is that so many of the clinicians who are most in need of improving their obesity knowledge and practice are not a part of these organizations. A typical primary care clinician is not a member of an obesity-focused organization, and thus may never be directly targeted for dissemination of these guidelines. At the most basic level, obesity education needs to start in medical schools and residency training to systematically reach every student and trainee.

RK: Due to the barriers stated in the paper by primary care doctors such as lack of time, lack of education, and limited reimbursement for obesity treatment, do you ultimately see NPs or PAs taking on much of the front-line responsibility of addressing the issue of obesity with patients rather than MDs? In the paper, NPs seemed to score higher in their knowledge of various guidelines.

SK: There was little difference in knowledge between MDs and NPs in our research; frankly, everyone performed poorly. While provision of obesity services (or, at least, perception of reasons for minimal provision of obesity services) may be limited by time or reimbursement, lack of knowledge of the appropriate guideline-recommended care is most likely due to lack of training and limited options for continuing education in obesity. Imagine if only a fraction of primary care clinicians had been trained in treating diabetes or hypertension, and only a small fraction were even aware of the diabetes or hypertension treatment guideline recommendations? That is the current situation for obesity. We need to improve this training across the board, both for medical physicians and nurse practitioners, as well as physician assistants and other clinicians.

This should not be limited to primary care clinicians. Obesity touches essentially every patient and medical provider. Obesity is associated with 237 comorbid conditions – across every organ system and every patient demographic – nearly every type of specialist will treat patients who have obesity or weight challenges.  Thus, all providers need to have a minimal level of competence regarding obesity, just as we all need to know at least a bit about hypertension and diabetes.

RK: Do you think there is an element of “obesity acceptance” by HCPs based on the very poor knowledge of threshold to initiate various treatments? HCPs selected higher thresholds to initiate treatment than recommended by guidelines. Or is this due to a perception that pharmacotherapy and surgery are potentially more dangerous than evidence shows?

SK: The extreme prevalence of obesity and overweight has likely led to some degree of “obesity acceptance.” Combined with a sense of treatment futility and misconceptions among clinicians about treatment safety and efficacy, these may lead to lower willingness to consider treatments beyond behavioral counseling. Though I’m not sure whether these factors affect actual knowledge of the guideline recommendations for treatment escalation, which was what we assessed in our research. These would be good topics to explore in future research.