By Judith Graham
Kaiser Health News
Doctors assess patients' breathing, heart rate and blood pressure routinely at office visits. Soon, they may be adding body mass index to that list too.
Tracking this measure – an indicator of whether someone is obese or overweight – as if it were a vital sign at medical checkups is among a new set of strategies recommended for battling obesity, a concern that some experts predict will affect 42 percent of adults by 2030.
Although professional medical societies have said for years that physicians should monitor patients' body mass index, most doctors fail to do so. For example, a 2006 survey of family physicians found that fewer than half checked BMIs for children over the age of 2, even though 71 percent knew this has been recommended.
Just over 40 percent of adult patients in commercial HMOs had documented BMI measurements in 2009 and 2010, according to a survey by the National Committee for Quality Assurance, an organization that evaluates health plans. That figure falls to 12 percent for patients in commercial PPOs, a more common type of plan.
The Institute of Medicine last week called for the medical profession and health insurers to become more rigorous in their approach in a report proposing an anti-obesity campaign that would involve every part of society, from individuals and families to schools, communities, workplaces, the food industry and the media.
Pointing to the more than 90 million children, teens and adults counted as obese, well-established links to medical conditions such as diabetes, hypertension, heart disease, and arthritis, and annual healthcare expenses exceeding $190 billion, the report urged comprehensive and sustained action.
For physicians, monitoring body mass index – a ratio of height to weight – is at the top of the list of priorities because it's the best way to identify people who have a weight problem. (Adults are counted as obese if they have a BMI of 30 or higher; children if their BMI is at the 95 percentile or higher for kids of the same age and sex.)
"We need to normalize the process of obesity screening and lifestyle counseling so they're usual and people expect this," said Dr. Sandra Hassink, a member of the panel that prepared the IOM report and director of the Obesity Initiative at Nemours, a pediatric health system in four states.
Medical groups call for change
Groups such as the American Medical Association and the American Academy of Pediatrics have recommended regular BMI checks for years. Several health care systems also have embraced the practice. Kaiser includes BMI as a "vital sign" in electronic medical records for nearly 9 million members, and it is planning to do the same for physical activity, another contributor to the obesity epidemic, said Ray Baxter, the plan's senior vice president for community benefit and health policy.
(Kaiser Health News is not affiliated with Kaiser Permanente.)
So why the problem? Many harried physicians are unprepared to advise people about how to change their behaviors, unconvinced they have time to do so, and therefore look skeptically at screening, said Dr. Robert Kushner, clinical director of the Comprehensive Center on Obesity at Northwestern University.
If doctors are overweight themselves, they're less likely to recognize the issue in their patients, research shows. What's more, doctors aren't trained in medical school to handle weight issues. They also often aren't convinced obesity treatments work, and many believe there aren't good community programs to which they can refer patients.
"The question is, how many programs are out there for primary care doctors to refer to in the community, and answer is – not many," said Dr. Ned Calonge, a Colorado physician who is the immediate past chairman of the U.S. Preventive Services Task Force.
Northwestern is tackling a part of that by weaving instruction in "lifestyle medicine" throughout all four years of a new medical school curriculum being introduced this August.
Another significant problem has been a historic lack of reimbursement from insurers for obesity screening and counseling. That changed last year for seniors, when Medicare said it would cover up to six months of weight loss counseling for obese beneficiaries as part of a package of new preventive services. Nearly 13 million Medicare members are thought to be obese.
Meanwhile, new preventive services guidelines from the government call for all insurance plans to cover obesity screening and counseling without charge to patients.
And insurers are expanding childhood obesity programs following a 2010 recommendation from the U.S. Preventive Services Task Force that endorsed comprehensive weight management programs for youngsters at least 6 years old. Previously, the task force supported BMI screening but not weight loss programs.
Seeking evidence-based programs
For the insurance industry, the challenge now is providing evidence-based programs that can be introduced on a broad scale.
UnitedHealth Group is promoting "Join for Me," a year-long behavioral modification program piloted with the YMCA of Greater Providence, R.I., in which youngsters 6 to 17 years old, accompanied by a parent, learn about healthy eating and exercise in a group led by a coordinator.
"Doctors are in short supply" and it makes sense to conduct intensive behavioral change programs in the community, not in their offices, said Dr. Deneen Vojta, senior vice president of UnitedHealth's Center for Health Reform & Modernization. For overweight and obese adults, the company is looking at offering a version of the Diabetes Prevention Program, a well-studied intensive intervention that has been shown to help people lose weight.
WellPoint has taken a different approach, choosing to work through doctors and with the Alliance for a Healthier Generation, an organization that's trying to convince health plans to offer more comprehensive coverage for obesity counseling and treatment. The alliance asks participating plans to offer four visits with a child's primary care doctor and four visits with a dietitian if the youngster is found to be overweight or obese. So far several plans, including WellPoint, Aetna, Humana and Highmark, Inc., have signed up, and 2.4 million children are covered.
WellPoint recently launched a limited pilot study of this type of benefit in California and is learning what physicians need and members want before deciding whether to roll it out more broadly, said Harvinder Sareen, clinical program director for the insurance company.
Insurance companies and some self-insured employers are also exploring the use of financial incentives -- cash payments or reduced premiums or deductibles – to motivate members to keep their weight in check and to adopt other lifestyle changes. One program at UnitedHealthcare offers members up to $250 for reaching a BMI of 25 or less, and similar incentives for not smoking and lowering cholesterol and blood pressure.
"Is there coverage [for obesity] is yesterday's conversation. Today's conversation is how to design coverage to encourage people to use it and continue using it," said Karen Ignagni, president of America’s Health Insurance Plans, an industry trade group.
Others disagree that coverage for obesity counseling is adequate.
"The problem is there's no real incentive for the insurance industry to pay for better prevention and treatment, because the costs are immediate while the benefits are long-term," said Dr. David Ludwig, director of the new Balance Foundation Obesity Prevention Center at Children's Hospital, Boston. "Although reducing the prevalence of obesity is one of the most profitable investments the healthcare system could make, it doesn't make a lot of sense for individual plans when families change policies every three to five years."