Obesity Training and Reimbursement Should be a Higher Priority

Don Bradley MD, MHS-CL
Anand Parekh MD, MPH
Nichole Jannah
Hannah Martin
Anne Valik MPH
William Dietz MD, PhD
Jenny Bogard MPH
Christine Gallagher MPA










The United States has been facing a mounting obesity epidemic for over a generation, but our health care system has struggled to keep up. Given the complexity of obesity and the pace of curricular change, obesity education for our health-provider workforce is still lacking. There are wide disparities in quantity and quality among programs and disciplines. Similarly, public and private payers have taken vastly different approaches towards coverage for obesity treatment and prevention, which even leaves the most educated providers unsure of what services each patient can access. Because coverage decisions are based partly on what providers are prepared to provide and curricula are based partly on what services are typically covered, these problems reinforce one another. Despite these challenges, several important steps have been taken recently to tackle both sides of the problem. The steps include the development of new Provider Competencies for the Prevention and Management of Obesity and the launch of the My Healthy Weight pledge to standardize coverage for obesity counseling services.

Why We Must Act

In the US, more than one-third of the adult population and nearly one-fifth of the children have obesity. Adult obesity prevalence is projected to reach nearly 50 percent by 2030. Adult diabetes prevalence currently hovers around ten percent and is further projected to affect one-third of the adult population by 2050. Estimates for the total annual medical cost of obesity in the U.S. range from $147 billion to $210 billion, with billions more lost in productivity due to absenteeism and presenteeism. Obesity is also a national security issue. As of 2010, 27 percent of young adults were disqualified for military service due to obesity.

Improving Obesity Education for Health Care Providers

Despite these shocking rates of obesity, fewer than one in four physicians feel that they received adequate training in counseling patients on diet or physical activity. Obesity concepts are underrepresented on medical licensing examinations and substantial gaps in provider knowledge related to obesity care have been recently documented. This is not surprising considering that less than 30 percent of medical schools meet the minimum recommended number of nutrition-related content hours.

The decision to develop interprofessional obesity competencies grew out of two related activities. A 2013 convening and 2014 white paper that we organized and authored on training doctors for prevention-oriented care, established that a major barrier to improving the knowledge base was a lack of clarity on what exactly should be taught. At the same time, a publication by several members from an Innovation Collaborative associated with the National Academy of Sciences, Engineering, and Medicine’s Roundtable on Obesity Solutions pointed to the need for integrated approaches to obesity prevention and management.

These led to the formation of a working group consisting of 24 diverse organizations representing a dozen health professions involved in the care of people with obesity. Over the course of 18 months, the working group developed 10 core competencies for obesity education that include demonstrating knowledge of obesity as a disease and its epidemiology, recognition of bias and stigmatization, interprofessional collaboration, and the need for patient-centered communication and physical accommodations.

To promote the integration of the obesity competencies into training programs, we launched an Innovation Award for Health Care Provider Training and Education to recognize health professional training programs that provide innovative nutrition, physical activity, and obesity counseling education and have incorporated one or more obesity competencies into their curricula. Now in its second year, the Innovation Award recognizes the leadership of inventive educational models from all health disciplines and serves to inspire others with examples of what can be achieved.

Improving Reimbursement for Obesity Services

Payments to providers for counseling in nutrition, physical activity, and behavioral health for obesity are another major barrier to the prevention and management of obesity. Although some health insurers have increased coverage for preventive care services, adequate reimbursement for obesity care is rarely a top priority. A survey of Medicaid coverage of obesity services shows that coverage is highly variable and often deficient across states.

To address the lack of coverage and standardization with the insurance marketplace, we convened over 20 private insurers, large self-insured employers, and state Medicaid agencies to devise a standardized benefit obesity counseling services. These forward-leaning payers collaborated for over a year to develop the My Healthy Weight pledge, which launched in November 2017 and now boasts 11 signatories who collectively cover over 10.5 million lives. Key components of the pledge include covering intensive behavioral interventions and evidenced-based community programs for both adults and children with specified risk factors. While these benefits are currently structured for a fee-for-service payment model, we hope to move towards quality-based payment models for obesity in the future.

Looking to the Future

Moving the needle on the obesity epidemic will require all schools and programs that train health professionals to integrate obesity education into their curricula. To facilitate this effort, we have created a database of curricular resources for educators and will continue to recognize exemplary training programs annually through the Innovation Award. We will also identify and address profession-specific gaps in provider education and training on obesity prevention and management.

To capitalize on the momentum of the founding members of My Healthy Weight and support their continued leadership in this process, we will provide ongoing technical assistance and resources as our first cohort of signatories works to implement the benefit for the plan year 2019. We are also working with additional payers to sign the pledge for the plan year 2020.

The costs of obesity emphasize the need for revising care delivery and the importance of clinical-community partnerships to effectively mitigate the obesity epidemic. These improvements cannot come overnight and will require that educators, students, health care providers, health systems, payers, employers, and governments make obesity prevention and care a high priority.

Hannah Martin, MPH, RD, Senior Policy Analyst, Bipartisan Policy Center

Jenny Bogard, MPH, Founder and Managing Partner, Commonality

William Dietz, MD, Ph.D., Director of Sumner M. Redstone Global Center for Prevention and Wellness, George Washington University

Anne Valik, MPH, Founder and Managing Partner, Commonality

Nichole Jannah, Research Assistant, STOP Obesity Alliance, Redstone Center, George Washington University

Christine Gallagher, MPA, Research Project Director, STOP Obesity Alliance, Redstone Center, George Washington University

Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy Center

Don Bradley, MD, MHS-CL, Associate Consulting Professor, Duke University School of Medicine

10 replies »

  1. Obesity is rising at an alarming rate. We need to have an integrated approach to obesity prevention and management. The obesity stats are shocking. We need to provide education and training on obesity prevention and management. Solution like care management can be of help to monitor progress.

  2. I’m with you on this one, Peter, at least to the extent that the tax can be fairly designed and effectively administered.

    U.S. obesity rates are roughly twice that of Western European countries (except UK) and ten times what it is in most Asian countries. It’s close to double our own level in the 1970’s and early 1980’s. Why? It’s certainly not genetic at the population level. I attribute it to a combination of much higher portion sizes now vs. 40-50 years ago, the proliferation of fast food restaurants, and a higher percentage of meals eaten outside the home. Healthy food also costs roughly 12 times as much as junk food on a per calorie basis which makes affordability an issue for lower income people and access to healthy food is also a problem in low income so-called food deserts.

    I think portion sizes in restaurants may have increased over time at least partly in response to higher wage expense in order to sustain the perception of value for money among customers. The proliferation of fast food restaurants makes it far easier to access fast / junk food than it was 50 years ago when there were far fewer such places. More two income households make it harder to eat as many meals at home now that so many more women are in the workforce.

    I don’t think counseling services and preventive medicine are adequate answers..

  3. Occam’s Razor when it comes to obesity, but the nutrition/medical establishment is only slowly adapting to the new, better research.
    “There it is again – no hunger. You’d think that colleagues in medicine and dietetics would eagerly embrace an eating plan that addresses the key driver of obesity – perpetual hunger. Instead they fail to discuss/promote the single most important effect of LCHF diet”
    Prof. Tim Noakes

  4. “my grandchildren are demanding action. ”

    Apparently not loud enough. Are your grand kids demanding action on global warming? If they are, are we bothering to listen?

  5. I am reminded that our nation’s heritage originated with a commitment to minimize the actions of centralized, coercive, autocratic and bureaucratic government. Along with the cost and gaps in quality that plague our nation’s healthcare, we will need to energize the obligations of each community to improve the health of their own citizens. To acknowledge our pervasive levels of cognitive dissonance, I offer an updated definition for community and Social Capital.

    COMMUNITY may be defined as
    .a Cluster of persons identifiable by certain uniform attributes,
    .typically as Families residing within a geographically defined region,
    .who share a valued awareness about their interconnected identity
    .that is borne out of mutually experienced events and
    .each person’s memory of the ecological and cultural traditions
    .associated with these mutually experienced events.

    SOCIAL CAPITAL may be defined as
    .a community’s norms of Trust, Cooperation and Reciprocity that
    .its citizens spontaneously express for resolving the social dilemmas
    .they encounter daily within their community’s civil life
    .WHEN caring relationships are persistently nurtured
    .within the social networks of the community’s citizens, especially
    .the generational caring relationships originating from
    .within the micro-neighborhood network of each citizen’s family.

    Since the ecological and cultural heritage of each community is unique, a locally driven strategy to rebuild the resiliency of its own Social Capital will be required to reduce our nation’s burgeoning obesity, homelessness, entrenched poverty, mass shootings, maternal mortality, substance addiction and mid-life depression. I am reminded that a community based strategy has already been achieved by our agriculture industry. It is the most efficient and effective among the world’s advanced/developed nations, by a wide margin. Hint: the Smith Lever Act was passed by Congress to establish the Cooperative Extension Service, county by count, 104 years ago. We lack only the will to make it happen for our healthcare industry. The stakeholders in each community already exist and lack only a nationally sanctioned focus to apply the collective action projects, by trial and error, that will achieve steady progress.

    COLLECTIVE ACTION may be defined as
    .a Cluster of persons within a community who share
    .a commitment to achieve a goal for improving their dignity
    .with a set of tasks to be completed by the persons of the Cluster
    .including the delegation of certain tasks variably
    .to their selected representatives or a separate institution.

    Really, it is not very complicated. To focus the effort, it should be implemented with a budget of $1.00 per citizen per year and a 10-year sunset provision. Just take a deep breath and read this again, my grandchildren are demanding action. How about yours?

  6. “Estimates for the total annual medical cost of obesity in the U.S. range from $147 billion to $210 billion,”

    “Payments to providers for counseling in nutrition, physical activity, and behavioral health for obesity are another major barrier to the prevention and management of obesity. Although some health insurers have increased coverage for preventive care services, adequate reimbursement for obesity care is rarely a top priority.”

    Obesity is entrenched in U.S. culture. The best way to fight it and change culture is with a tax. Tax calories, fat, sugar. This can be done with bar codes at check out and itemized on the bill. Once the consumer sees the financial outcome of food shopping decisions then they will change those habits. If they don’t then at least they’d contribute to the cost of treating obesity – maybe even their own.

    All other “solutions” is just nipping around the edges.

  7. Obesity represents another conundrum within the Disruptive Processes that collude to induce Unstable HEALTH. Why do we have this genetically driven susceptibility that was spared by evolution? What is the potential benefit of excess weight? During times of food scarcity, the ability to absorb a larger portion of calories available until food availability eventually recurred might represented this advantage, aka hunter-gatherer folks. And, if you have an accident with the inability to eat for several days, remember that the degradation of fat is eliminated as water by the kidneys and carbon dioxide from the lungs. If you are overweight, starvation will automatically trigger a supply of IV fluids.

    Two recent studies on BMI changes (JAMA and NEJM) during infancy and the first 3-5 years of life after birth further define the issues. If you are over-weight during Kindergarten and your parents are over-weight, you are destined to live with life-long obesity. A very large Social Capital investment would be required to mitigate the family traditions that conspire with the genetics that prevail. Since this investment would not be very predictable or definable by actuarial standards, it really is not strictly speaking insurable without a capitation process (another long story). We would be better served by a recognition that world wide nutrition will be a really big deal not long from now. Each person’s Basic Survival Plan should include at a minimum:
    .Restful Sleep (as in a Home with Caring Relationships),
    .Good Mealtimes (as in nutritious and socially connected),
    .Balanced Exercise (as in physical, mental and spiritual) and
    .Family Traditions (as in identity formation and crisis intervention).

  8. In 2014 an iconoclastic book included an exhaustive study of nutrition research since the 1950’s and concluded nutrition advice has been dramatically wrong and likely is a primary cause of obesity (and associated ailments).
    “since 1961, the entire American population has…been subjected to a mass experiment, and the results have clearly been a failure. Every reliable indicator of good health is worsened by a low fat diet.” Page 330 in The Big Fat Surprise by Nina Teicholz.
    The book does a deep analysis of the research as well as the socio political factors that were in play. Compelling reading.
    Building on Dr. Palmer’s observation, if we launched a massive obesity initiative based on this faulty research it would a colossal waste, though certainly lucrative for some.

  9. Wonderful lofty goals. What a nice outcome to shoot for. Great group of leaders.

    Recall that we really do not know very much about why there are so many obese people and that a campaign for change has to be very nimble and flexible at this stage because new knowledge is popping up every day. I.e. your tactics might have to change a lot. Something orthogonal to nutrition might be a principle cause of obesity (like adrenocortical hyperactivity, etc.)

    You also need to have access to the brains of biochemists to keep you near the path of progress. All medicine is ultimately–at the root– biochemistry.

    But, great and timely effort. Congratulations.