Obesity: Are shared medical appointments part of the answer?
ABSTRACT
Shared medical appointments, in which a multidisciplinary team of healthcare providers meets with multiple patients in a group setting, may be an option for treating patients with obesity. To be effective, shared medical appointments need to address patients’ nutrition, physical activity, appetite suppression, stress management, and sleep.
KEY POINTS
- Shared medical appointments have been shown to improve clinical outcomes and patient satisfaction compared with traditional care. However, they have not been well studied in patients with obesity.
- A shared medical appointment allows multiple patients to be medically managed by a multidisciplinary team, promoting more efficient delivery of care.
- Both patients and practitioners are satisfied with shared medical appointments and find them clinically useful.
Maintaining patient confidentiality
Maintaining confidentiality of personal and health information in a shared medical appointment is an important concern for patients but can be appropriately managed. In a survey of patients attending pulmonary hypertension shared medical appointments, 24% had concerns about confidentiality before participating, but after a few sessions, this rate was cut in half.28
Patients have reported initially withholding some information, but over time, they usually become more comfortable with the group and disclose more helpful information.29 Strategies to ensure confidentiality include having patients sign a confidentiality agreement at each appointment, providing specific instruction on what characterizes confidentiality breaches, and allowing patients the opportunity to schedule individual appointments as needed.
Ensuring insurance coverage
A shared medical appointment should be billed as an individual medical appointment for level of care, rather than time spent with the provider. This ensures that insurance coverage and copayments are the same as for individual medical appointments.
,Lack of insurance coverage is a major barrier to obesity treatment in general. The US Centers for Medicare and Medicaid Services reimburses intensive behavioral obesity treatment delivered by a primary care practitioner, but limits it to 1 year of treatment and requires patients to meet weight loss goals. Some individual and employer-based healthcare plans do not cover dietitian visits, weight management programs, or antiobesity prescriptions.
EVIDENCE OF EFFECTIVENESS IN OBESITY
Few studies have investigated the use of shared medical appointments in obesity treatment. In the pediatric population, these programs significantly decreased BMI and some other anthropometric measurements,30–32 but they did not consistently involve a prescribing provider. This means they did not manage medications or comorbidities as would be expected in a shared medical appointment.
In adults, reported effects have been encouraging, although the studies are not particularly robust. In a 2-year observational study of a single physician conducting biweekly weight management shared medical appointments, participants lost 1% of their baseline weight, while those continuing with usual care gained 0.8%, a statistically significant difference.33 However, participation rates were low, with patients attending an average of only 3 shared medical appointments during the study.
In a meta-analysis of 13 randomized controlled trials of shared medical appointments for patients with type 2 diabetes, only 3 studies reported weight outcomes.23 These results indicated a trend toward weight loss among patients attending shared appointments, but they were not statistically significant.
Positive results also were reported by the Veterans Administration’s MOVE! (Managing Overweight/obesity for Veterans Everywhere) program.34 Participants in shared medical appointments reported that they felt empowered to make positive lifestyle changes, gained knowledge about obesity, were held accountable by their peers, and appreciated the individualized care they received from the multidisciplinary healthcare teams.
A systematic review involving 336 participants in group-based obesity interventions found group treatment produced more robust weight loss than individual treatment.35 However, shared medical appointments are different from weight loss groups in that they combine an educational session and a medical appointment in a peer-group setting, which requires a provider with prescribing privileges to be present. Thus, shared medical appointments can manage medications as well as weight-related comorbidities such as diabetes, hypertension, polycystic ovarian syndrome, and hyperlipidemia.
One more point is that continued attendance at shared medical appointments, even after successful weight loss, may help to maintain the weight loss, which has otherwise been found to be extremely challenging using traditional medical approaches.
WHO SHOULD BE ON THE TEAM?
Because obesity is multifactorial, it requires a comprehensive treatment approach that can be difficult to deliver given the limited time of an individual appointment. In a shared appointment, providers across multiple specialties can meet with patients at the same time to coordinate approaches to obesity treatment.
A multidisciplinary team for shared medical appointments for obesity needs a physician or a nurse practitioner—or ideally, both— who specializes in obesity to facilitate the session. Other key providers include a registered dietitian, an exercise physiologist, a behavioral health specialist, a sleep specialist, and a social worker to participate as needed in the educational component of the appointment or act as outside consultants.
WHAT ARE REALISTIC TARGETS?
- Nutrition
- Physical activity
- Appetite control
- Sleep
- Stress and mood disorders.
Nutrition
A calorie deficit of 500 to 750 calories per day is recommended for weight loss.7,8 Although there is no consensus on the best nutritional content of a diet, adherence to a diet is a significant predictor of weight loss.36 One reason diets fail to bring about weight loss is that patients tend to underestimate their caloric intake by almost 50%.37 Thus, they may benefit from a structured and supervised diet plan.
A dietitian can help patients develop an individualized diet plan that will promote adherence, which includes specific information on food choices, portion sizes, and timing of meals.
Physical activity
At least 150 minutes of physical activity per week is recommended for weight loss, and 200 to 300 minutes per week is recommended for long-term weight maintenance.7,8
An exercise physiologist can help patients design a personalized exercise plan to help achieve these goals. This plan should take into account the patient’s cardiac status, activity level, degree of mobility, and lifestyle.
Most patients are not able to achieve the recommended physical activity goals initially, and activity levels need to be gradually increased over a period of weeks to months. Patients who were previously inactive or have evidence of cardiovascular, renal, or metabolic disease may require a cardiopulmonary assessment, including an electrocardiogram and cardiac stress test, before starting an exercise program.
