Reimagining Obesity Care for PCPs

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In 2018, Andrew Kraftson, MD, was approached by a colleague with a recurring dilemma: Primary care clinicians were both struggling with the complexities of obesity care, unsure how to best treat these patients and frustrated with an ineffective referral process.

Reflecting on his medical training in the early 2000s, Kraftson, a clinical associate professor of metabolism and endocrinology at the University of Michigan in Ann Arbor, recalled the sparse education on obesity — reduced to simplistic advice to "eat less and exercise more," and brief references to bariatric surgery.

As medications like semaglutide have gained popularity in recent years, many primary care clinicians are uncertain about how to effectively manage these potent treatments and navigate their potential side effects.

"There was a dearth of training, and that problem continues," Kraftson said. "There has to be a bridge between the days of 'just try harder, we're not going to give them any tools', and 'I'm going to give you an injection, but I don't have much time to talk about it'."

Determined to close this gap, Kraftson helped spearhead the development of the Weight Navigation Program (WNP) at Michigan Medicine, Ann Arbor. In collaboration with Dina Griauzde, MD, an assistant professor of general medicine and research and quality director of the WNP, he set out to embed board-certified obesity specialists and expertise directly into primary care.

The program launched as a pilot in 2020 to provide high-risk patients with individualized and evidence-based weight management treatments in primary care clinics.

A study published last month in JAMA Network Open found patients enrolled in the WNP an average of 12 pounds, or 4.4% of their body weight within a year compared with minimal weight loss among similar patients who were not part of the program.

Over 40% of WNP participants achieved a weight loss of at least 5%, a critical threshold for reducing health risks related to obesity compared with less than 20% of similar patients not in the program.

The study took place before the approval of semaglutide and tirzepatide for weight management, which has spurred researchers to pursue a follow-up assessment of weight loss approaches among patients with access to the drugs.

To qualify for the program, patients must have a body mass index of at least 30 and have at least one weight-related health condition, such as sleep apnea or high cholesterol.

Since its inception, the WNP has treated 1200 patients out of the 2300 who have been referred. The program has a growing team of more than eight clinicians, about half of whom were existing PCPs trained in obesity medicine and half are new hires who already had received such training.

"It's very hard to deliver high-quality obesity treatment in a routine primary care visit when you're dealing with five or six issues," Griauzde said. "The program carves out 60-minute, weight-focused visits, which allows time to understand prior experience, unique barriers and challenges, and preferences."

Kraftson and Griauzde said they hope to provide a replicable model for more specialized obesity management strategies nationwide. They offer these tips to help primary care practices adopt a more structured and effective approach to obesity care:

Recognize the training gap in obesity medicine: According to Kraftson and Driauzde, acknowledging that obesity medicine training is significantly underrepresented in the majority of medical school and residency curriculums is important. A lack of specialized education leaves many healthcare providers without necessary tools and knowledge to effectively manage obesity in their patients.
Dedicate time for obesity management: Implement dedicated, 60-minute visits focused on weight loss. This approach allows for thorough medical and weight assessments, understanding of the patient's prior experiences and preferences, as well as consideration of cost and insurance constraints. Michigan Medicine's WNP doctors only provide weight-focused visits for half a day per week. If they have unfilled WNP slots, these are made available for same-day primary care appointments. This has been an efficient use of time and resources, Griauzde said. Practices could consider using unfilled weight-focused slots for urgent visits and starting one with 30-minute slots instead of 60 minutes.
Develop in-practice expertise: For larger practices, identify key clinicians who may want to take the lead on obesity management by becoming the "expert" for the practice.
Smaller practices might invest in training and certification through the American Board of Obesity Medicine. For advanced practice providers, obesity certification is available through the Obesity Medicine Association, Kraftson said.
Become familiar with local weight management resources: Allocate time for the obesity specialist to conduct clinical observations of local weight management programs and resources, such as home weight loss programs or bariatric surgery clinics. Doing so helps the specialist understand program requirements, patient commitment, and financial elements, enhancing the overall care strategy.
Establish safe medication practices: When setting up medication treatment protocols, establish how to address lifestyle changes and ensure the practice is equipped for safe prescribing and monitoring, Kraftson said. Steps could include designating staff to manage medication prior authorizations, oversee remote patient monitoring, conduct safety evaluations, and track patient progress.
Integrate mental and behavioral health support: Identify local resources to support mental and behavioral health, which are critical components of comprehensive obesity management. Screen for eating disorders and medical issues like cardiovascular disease or thyroid disorders that may contraindicate certain treatments.
Develop and use population health management tools: Create dashboards and other tools to support the management of a population of patients with obesity. These tools can help track patient progress and ensure regular follow-up visits, which are vital for the effectiveness of lifestyle counseling and weight management.