Contemporary Obesity Treatment: Caught in Clinical Inertia

Caroline M. Apovian, MD, FACP, FACN

Professor of Medicine
Boston University School of Medicine
Director, Center for Nutrition and Weight Management
Boston Medical Center
Boston, Massachusetts

Caroline M. Apovian, MD, FACN, FACP, has disclosed that she has received consulting fees from EnteroMedics, Ferring, Gelesis, Merck, Novo Nordisk, Nutrisystem, Orexigen, Rhythm, Sanofi, Scientific Intake, SetPoint Health, Takeda, Xeno Biosciences, and Zafgen and funds for research support from Aspire Bariatrics, Gelesis, GI Dynamics, MetaProteomics, MYOS Corporation, Novo Nordisk, Orexigen, Pfizer, Takeda, and The Dr. Robert C. and Veronica Atkins Foundation.

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Released: March 27, 2020

Despite more than 40% of adults in the United States living with obesity, a rate that has been increasing for more than a decade, healthcare providers find themselves in a climate of inertia around treating this common, chronic disease. The problem stems from several barriers to improving obesity treatment, including a lack of prescriptive guidelines, a cultural mindset around weight and weight loss, and cost.

Lack of Prescriptive Guidelines
For chronic diseases like hypertension and diabetes, practice guidelines and standards of care are prescriptive. They clearly state that you should not let a patient leave your office without addressing their high blood pressure or high blood sugar.

By contrast, based on current guidelines, primary care physicians and other specialists do not have to treat obesity. If we see a patient with obesity in our clinic, we can treat their comorbid conditions such as high blood pressure or diabetes without ever addressing their BMI. No one is penalized for neglecting to treat the obesity.

Cultural Mindset
Part of the reason we lack clear standards of practice for managing obesity is the lack of universal recognition of obesity as a disease; that’s a big problem for clinicians and patients, especially those patients who typically do not consider their obesity to be a disease requiring medical intervention.

Among patients who are eligible to receive bariatric surgery, only 1% to 2% undergo these procedures every year, despite most third-party payers offering coverage. When I encounter patients with extreme obesity and recommend bariatric surgery procedures as a viable option for them to lose the weight and keep it off, they frequently decline surgery, convinced that they should be able to lose weight on their own.

To pose a stark example of how we treat obesity vs other chronic conditions: If you had a patient with triple-vessel coronary artery disease to whom you recommended surgery, you would never expect them to say, “That’s okay, doc; I can do this on my own.”

Just as we would not expect the patient with severe coronary artery disease to manage their condition with diet and exercise alone, we should not expect an individual with BMI > 40 to manage his or her obesity without medical assistance. The disease of obesity cannot be overcome by willpower; we know that there are complex hormonal changes involved that almost force patients to regain the weight.

Cost Barriers
Currently, few available antiobesity agents are covered by third-party payers and these medications can be very expensive—some can cost as much as $1,700 per month. Many patients can’t afford them (although some newer agents have cash discount cards that can assist with access). For patients without insurance, the cost of bariatric surgery can be equally unaffordable.

Looking Forward
The new subspecialty of obesity medicine is gaining followers and attention. The American Board of Obesity Medicine has certified more than 3000 clinicians in recent years. With more physicians training in obesity medicine, we are seeing more fellowships sprout up around the country.

Once we have enough clinicians who are trained and vested in treating this disease, we will be able to generate guidelines that are prescriptive. I hope that these prescriptive guidelines will in turn prompt government agencies and third-party payers to offer broader coverage for antiobesity agents and to continue covering bariatric surgery. In addition, I hope that this will prompt patients to learn more about their disease and accept the treatments that are offered that will safely help them lose weight and, of most importance, keep that weight off.

Your Thoughts
What barriers do you see to effective treatment of obesity in your patients? Answer the polling question and join the discussion by commenting below.

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