An Overview of the Care Management Institute’s Weight Management and Obesity InitiativeWilliam Caplan, MD; Trina Histon, PhD; Helen S Pettay, BA https://doi.org/10.7812/TPP/03-058Weight Management and Obesity Initiative Strategic Model, Focus, and GoalsAs prevalence of overweight and obesity reached epidemic proportions,1 clinical intervention alone became obviously insufficient to address the problem. In January 2002, the Care Management Institute (CMI) of Kaiser Permanente (KP) launched the Weight Management and Obesity (WMO) Initiative to develop and implement a plan to address this critical public health issue. The strategic model for weight management includes the following five interlocking components:
This multidimensional, public health approach evolved through the expertise and commitment of a clinical network of stakeholders and experts within and outside KP. Clinical leads included Warren Taylor, MD, KP Northern California; Jonathan Brown, PhD, Center for Health Research, KP Northwest; Scott Gee, MD, KP Northern California; Gary H Wong, MD, KP Southern California; Sasha Stiles, MD, Codirector, Multidisciplinary Weight Management Program, formerly KP Hawaii, currently KP Northern California; and Keith H Bachman, MD, KP Northwest. This clinical advisory group documented the current "KP landscape" in weight management, delivered initial tools and strategies for primary care settings, and began a rigorous evidence review to identify optimal intervention. Under the leadership of William Caplan, MD, and Trina Histon, PhD, of CMI, the initiative also set longer-term goals: to establish prevention and management of overweight and obesity as an organizational priority; to develop metrics to quantify effectiveness; to optimize and standardize program components; to develop evidence-based risk stratification approaches; and to enhance clinician and member skills through tools and education. External CollaborationGiven the public health approach to combating such a complex and multilayered problem, CMI also sought external collaboration with other health plans, federal agencies, and academia to identify and disseminate effective models for prevention and treatment of overweight and obesity. Organizations represented in the collaboration have included the following: Centers for Disease Control and Prevention, HealthPartners, National Institutes of Health, Geisinger Clinic, Robert Wood Johnson Foundation, American Dietetic Association, American Academy of Family Practice, American Association of Health Plans, North American Association for the Study of Obesity, and International Life Sciences Institute Center for Health Promotion. KP/CDC National MeetingsOne of the strongest collaborations has been forged between CMI and the Centers for Disease Control and Prevention (CDC). As part of that partnership, a working group was formed with the goals to identify practical, effective nonsurgical approaches for the prevention and treatment of overweight and obesity; to increase the likelihood of adoption and implementation of these interventions and partnerships, thus leading to improved health outcomes for KP members and communities; to identify clinical research opportunities that support these goals; and to create a forum linking colleagues in the academic and research communities, federal agencies, and practicing clinicians who are actively engaged in assessing and implementing programs for overweight and obese patients. Although the initial goals focused on the medical setting, the KP/CDC working group participants quickly recognized that an approach limited to medical settings would probably not be effective without reinforcing strategies in the community, workplace, and home. This recognition reemphasized the need for expanded partnerships between health care providers, communities, schools, nongovernmental organizations, and state and national government--especially between health care providers and payers at that level. Four KP subgroups convened to address specific areas of concern:
Weight Management Strategies IdentifiedMeetings, held in June and November of 2002, were structured to identify practical, effective strategies that could be rapidly implemented to help prevent and treat obesity among KP's 8.3 million members. Speakers were invited from numerous entities, including research, government, health care, and private industry as well as from KP. Brief presentations, followed by long discussion, produced much insight and suggestions for population-based weight management strategies. The following section summarizes strategies by general category; presenters are attributed (in parentheses) and are listed in Table 1. (Many of these presentations were included as part of The Permanente Journal's Weight Management and Obesity Symposium Vol 7, No. 2.) Lessons learned from smoking cessation (Gee). Dr Gee described how successful smoking cessation program strategies do not directly transfer to programs for preventing and treating obesity. How to talk to patients about obesity: stigma and discrimination (Brownell). Dr Brownell stated that attention to tone and technique is required to work effectively with obese members. Varying acceptability of terms used to describe excess weight exists among overweight and obese people, a factor making it necessary to test prevention and treatment messages for acceptability. Prevention and treatment in adults (Pi-Sunyer, Myers). Drs Pi-Sunyer and Myers discussed the Diabetes Prevention Program, the NIH guidelines for treating obesity, and the role of medical nutrition therapy. Obesity is a chronic disease, for which modest weight loss (5%-10% of body weight) offers considerable medical benefits. Lifestyle change (diet and physical activity) is the basis of therapy, and registered dieticians are preferable providers for addressing dietary issues. Building a population-based approach (Taylor). Dr Taylor discussed components of addressing obesity at the population level. Primary and early secondary prevention are important, and a broad spectrum of programs is appropriate for overweight and at-risk members. KP must move ahead with programs in the absence of conclusive evidence about efficacy; incorporating measures of effectiveness into program design is important too. Increasing physical activity (Pronk, Hill). Drs Pronk and Hill described pedometer-based programs to increase physical activity. Because the environment is important for promoting or discouraging physical activity, community partnerships are needed to implement effective programs. Multiple points of entry to pedometer-based programs already exist at KP--mandating flexible program models--and broad worksite implementation at KP is fundamental. Behavioral intervention (Brownell, Gee). Dr Brownell reviewed the current status of behavioral treatment in research trials, and Dr Gee discussed brief negotiation, a motivational interviewing strategy. Behavioral treatment is associated with increased weight loss, but the degree to which behavioral treatment can be offered in primary care settings at KP is not resolved. Brief negotiation increases primary care providers' confidence levels in addressing behavior change and can be learned quickly. Bariatric surgery (Stiles). Dr Stiles addressed the need for a national database to capture information about all bariatric surgery patients because such a database is essential to developing models of care, best practices, and long-term effectiveness studies. Role of interactive technology in supporting weight loss and weight maintenance (Sallis, Strecher, Tate). This panel presented their experience with computer- and Internet-based weight management technology. Computer-based programs apparently work for adolescents as well as for adults and allow individual participants to change more than one behavior at a time. Tailored messaging enhances effectiveness, and the Internet can be an effective way to deliver behavioral therapy components of weight management programs. Nutritional approaches for preventing and treating overweight and obesity (Dietz, Myers, Rolls). These panelists discussed many existing and potential--and potentially conflicting--key nutritional messages for preventing and treating obesity. For example, a simple and visually appealing construct is the energy density of foods; the related message focuses on lowering the energy density of food to control weight. Definitions of the metabolic syndrome (Valdez). Dr Valdez discussed multiple existing definitions of the metabolic syndrome. Consensus is still emerging about what criteria define this syndrome. Impaired glucose tolerance, waist circumference, and triglyceride: HDL-C ratio are proposed indicators of metabolic risk. Role of pharmacotherapy in weight management (Wadden). Dr Wadden discussed several studies evaluating effectiveness of sibutramine and orlistat for inducing and maintaining weight loss. Pharmacotherapy is useful as adjunctive therapy in weight loss programs, to which lifestyle change in diet and in physical activity is fundamental. Culturally competent care for overweight and obese members (Karanja, Foreyt). Drs Karanja and Foreyt discussed weight loss intervention in African American and Mexican American populations, which are at much greater risk for obesity and related conditions than is the non-Hispanic white population. Community- and family-based intervention takes on increasing importance, socioeconomic and environmental issues change effectiveness of weight management intervention, and cultural differences regarding dietary preference and weight-related issues must be considered and respected. Cultural strength can form the foundation of effective programs, and community coalitions can address environmental issues. Community-based intervention (Robinson, Woodward-Lopez). Drs Robinson and Woodward-Lopez addressed community- and school-based intervention. School-based programs to reduce TV viewing and to increase physical activity have proved effective, and community coalitions can result in rapid program development. Purchasers' perspective (Isham, McDonald). Drs Isham and McDonald discussed weight management as viewed by employer-purchasers of health care services. A discussion of health promotion and prevention activities must be framed in terms that employers understand; return on investment is a successfully used concept, as is incorporating primary prevention in any discussion of more costly secondary and tertiary health care. National, state, and community initiatives (Dietz, Nussbaum). Drs Dietz and Nussbaum described political and governmental initiatives to address obesity. All levels of community coalitions and stakeholders--such as physicians, parents, and educators--are fundamental to creating program and environmental change. Clinical Management Tools and ResourcesCMI Weight Management Source Book2A source book of weight management and bariatric surgery programs in KP also has been developed as part of the Weight Management Initiative. The purpose of the CMI Weight Management Source Book is to provide an informational resource for clinicians, administrators, and managers interested in improving care for patients who are overweight or obese or who are at risk of becoming overweight or obese. The Source Book provides information on the process of planning as well as building a business case for weight management activities and outlines key elements of both weight management and bariatric surgery programs throughout KP. The Source Book is intended to meet the needs of anyone within KP who wants tools, knowledge, and support for improving or creating a weight management program. The Source Book provides an early snapshot of what KP currently provides to members regarding weight management activities. The book may also serve as a vehicle to further explore these themes and to help prioritize, standardize, refine, and evaluate approaches to weight management programwide. The resources are meant to help begin an active process of integrating appropriate models of weight management at the regional and local levels within KP to ensure that excellent care happens routinely and is not a matter of chance. The Source Book can be found at the Permanente Knowledge Connection: http://pkc.kp.org. GuidelinesCMI is working with one of its health system collaborators (HealthPartners in Minneapolis) to conduct a literature review from which evidence-based guidelines, models of care, and successful practices for evaluation and treatment of overweight and obesity can be developed. In addition, the initiative's subgroup focusing on identification and management of adults at high risk for overweight and obesity has been working with KP Regions to develop evidence-based guidelines on treatment for high-risk populations, eg, populations with impaired glucose tolerance and sleep apnea. Posters and Tipsheet
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