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- The obesity rate for rural residents is 5% higher than it is for urban dwellers.
- Treating obesity requires continuous management that’s tailored to the unique needs of the patient.
- In a weight loss program, it’s more effective to show patients what to do instead of telling them what not to do.
- Intensive lifestyle interventions act as an immunization and are our best strategy to positively impact the lives of the obese in rural communities and beyond.
There’s something special about being a doctor in a rural area. Although I grew up, and was educated in, a city, I chose to practice in an underserved community in Maryland to repay my medical school scholarship. I liked it so much that I stayed 30 years!
Practicing in a rural area is special because of the closeness you feel to your community, your neighbors and especially your patients. These areas are typically underserved, so as a physician, you really feel needed. But being “special” isn’t always a good thing. Sadly, data from the National Center for Health Statistics shows rural residents suffer from more chronic conditions than their urban counterparts. This is especially true of obesity as the rate for rural residents is 5% higher than it is for urban dwellers.
Obesity causes or contributes to over 200 chronic diseases, including diabetes, heart disease, stroke, kidney disease and certain cancers. With a supermajority (71%) of Americans now overweight or obese, an enormous burden of chronic illness is taxing the limits of many rural health care communities. Fifteen years ago, I was challenged to look past the chronic illness burden and place focus on the root cause. So, I asked a simple question:
“What works to help people lose weight?”
First, we need to understand obesity is a chronic disease. It’s not a human failing or personal decision. It’s a disease of many origins that plays out in our modern environment of food and activity. Telling a person to cut down on calories and increase activity, something I told my patients to do for years, should work, but it clearly doesn’t. It’s true that we gain or lose weight due to calorie balance, but that’s not a complete understanding of the genesis of obesity. It’s also not particularly helpful to us in planning treatment.
Like all chronic diseases, treating obesity requires continuous management that’s tailored to the unique needs of the patient. Many clinicians, trained to focus on the consequent illness, don’t directly address the issue. The real problem is that the structure of a traditional office-based practice doesn’t allow for treatments that effectively tackle obesity, such as coaching a person on how to change their behaviors. In typical office practices, we teach for understanding and expect behavior change. But that approach just isn’t working, as evidenced by the continued rise in obesity rates.
I saw the obesity pandemic in a new light after reading the Diabetes Prevention Program in 2002. This was a groundbreaking national study that compared an intensive lifestyle intervention to medication or traditional office-based care. The patients were all overweight with prediabetes and the goal of the study was to prevent overt diabetes. When it was apparent the lifestyle arm was clearly superior in preventing diabetes, the study was concluded early. From this, I realized that if I didn’t provide my obese patients with lifestyle intervention services, they would fail at weight loss.
With this in mind, I co-founded Maryland Healthy Weighs (MHW) in 2008. Many of my patients enrolled. We didn’t prescribe any weight loss medications ─ a personal decision I made when structuring the program. Instead, we held weekly group coaching sessions built around a 12-week curriculum, a mid-week call to the health educator, meal replacement strategies, recordkeeping and increased activity. I included these elements in the curriculum because they have the best clinical evidence to support their effectiveness. If you’re interested in an unbiased review of the literature on various weight loss strategies, including medication and surgery, I recommend this one from the American Heart Association.
When the weight loss target was reached, the patient transitioned to a less intensive or “phase 2” program. While the participants learned a lot, they were successful because the expectation was that they acted on what they knew. In other words, participants were coached to change their behaviors.
The joy for me was seeing many of my struggling long-term patients succeed. Patients loved being able to stop medications when their clinical targets were so successfully achieved, something that proved to be a strong motivator for many. Most importantly, though, many of my assumptions about what should work to treat obesity were replaced with actual truths.
The single most important lesson I learned was that it’s more effective to show patients what to do instead of telling them what not to do. A simple paradigm shift combined with the other program elements was the key to patient success.
For those tasked with running health care organizations, know this: cost savings from successfully tackling obesity can be dramatic. From April 2016 to March 2017, 150 MWH patients lost an average of 15% of their BMI during an average of 20 weeks in the program. This led to medication reductions or elimination and better chronic illness control that resulted in an estimated annual medical care cost savings of $822,300 for the group (MWH data).
My journey with MHW lasted 10 years and was possibly the most personally enjoyable years for me as a doctor. But it was hard work for the patients and the program staff. Thankfully, there’s no need to start from scratch to launch a program of your own; frameworks are readily available. The Centers for Disease Control and Prevention (CDC) will supply the curriculum used in the Diabetes Prevention Program study. Additional resources exist, including one from the CDC outlining 24 strategies a community can use to prevent obesity.
The rewards of building an obesity program are numerous – including cost savings and improving the health of the community you care so much about. But until we have better options from traditional medicine, intensive lifestyle interventions act as an immunization and are our best strategy to positively impact the lives of the obese in rural communities and beyond.
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