Currently, success in sustained weight loss is evaluated based upon different definitions of success by patients, providers and researchers. However, a growing body of evidence suggests that losing somewhere between five to ten percent of current weight leads to major improvements in key health areas, including diabetes, lipid blood levels, and even mortality. The National Heart, Lung, and Blood Institute, part of the National Institutes of Health examined a wide-array of randomized controlled studies and recommended a ten percent reduction in weight to achieve lower blood pressure, lower LDL-cholesterol and triglycerides, increased HDL-cholesterol and lower blood glucose levels and decreased incidence of Type-2 diabetes.

For the purposes of mitigating the health and productivity impact of overweight and obesity, a consensus definition of the amount of sustained weight loss necessary to improve health would help us evaluate the efficacy of overweight and obesity interventions and inform reimbursement policies and health benefit design by public and private third party payers and employers accordingly.

Some research has shown that increased physical activity leading to fitness improves the health of people with overweight and obesity independent of weight loss. There is not yet, however, agreement in the medical research about consistent definitions and measures of fitness. Future recommendations about defining success may include fitness or other functional outcomes associated with the improved health and quality of life for people with overweight and obesity.

Most individuals who are overweight or obese and many of their health care providers have unrealistic weight-loss goals; few succeed in achieving those goals. These unrealistic goals may be to achieve a societal norm that is mostly cosmetic. Promoting the health improvements that result from a five to ten percent sustained weight loss could help focus the dialogue on obesity towards healthy outcomes.

The Stop Obesity Alliance Recommends:

• Promoting the use of a sustained loss of five to ten percent of current weight as a key measure to judge the effectiveness of weight reduction interventions.

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Few research studies and clinical programs have described effective interventions for patients with lower levels of overweight or obesity, before obesity becomes severe and co-morbidities develop. At a BMI of 40, (or a BMI of 35 with co-morbidities), bariatric surgery may become an effective option for treatment for some individuals.

The paucity of effective treatments is compounded by the dominant focus of obesity research on single interventions. Furthermore, these interventions are often carried out in a homogenous group of patients, often without including details on individual characteristics that could guide "real-world" application and help clinicians to tailor treatments for different individuals. Studies often report a range of results from minimal to large, without information indicating for whom treatments were most or least successful.

Consequently, there is an urgent need to develop, test, and evaluate interventions that include multiple components (surgery + behavioral treatment + diet, for instance, or personal trainer + diet + drugs, diet and exercise plan) among diverse populations at lower levels of overweight and obesity, before co-morbidities develop. Eventually, this effort may lead to the creation of screening tools that could help match an individual patient's characteristics and needs with appropriate interventions.

While individuals who are overweight or obese seek help and advice in many non-medical settings, primary care providers, and in some cases specialists who are acting in a primary care capacity, see many people with overweight or obesity, whether for weight management, treatment of co-morbidities, or both. As such it is important that these providers are positioned to provide effective screening and treatment to people across the weight spectrum, from lower to more severe levels of overweight and obesity. Various research studies on primary care physician practice patterns have shown, however, that these providers often do not provide such services, due to a number of factors including time, knowledge of treatment modalities, and potential discomfort with broaching the topic with patients.¹

To achieve these goals, the STOP Obesity Alliance recommends:

• Encouraging innovation around treatments, intervention and disease management with support from employers, insurers, and other payers.
• Supporting efforts by professional organizations to train health professionals, in order to develop and disseminate best practices for obesity treatment that incorporate tailoring treatments for individuals to achieve maximal results.
• Identifying and disseminating successful or promising practices for interventions.
• Encouraging governmental and non-governmental entities to focus on translating the research on obesity management into recommendations for best practices in the care of obese and overweight individuals.

¹ See, for example: Bardia, A.; Holtan, S.; Slezak, J.M.; Thompson, W.G. (2007). Diagnosis of obesity by primary care physicians and impact on obesity management. Mayo Clin Proc August 2007;82(8):927-932

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There is no evidence that stigmatizing overweight and obese individuals motivates them to lose weight. In fact, stigmatization may postpone and even prevent these individuals from getting treatments that could improve their health. Similarly, providers without effective treatments to offer may avoid discussions about obesity out of fear of offending their patients. Stigma and fear of offending people with overweight and obesity can silence patients and providers and keep them from addressing obesity directly and constructively. Personal responsibility for behavior change is critical to successful sustained weight loss. But, until recently, the discussion of personal responsibility has been the beginning and the end of the obesity debate. To effectively address this epidemic, we must also deal with broader societal barriers to reducing obesity.

Individual perceptions of the causes and prospects for reducing obesity among patients, providers and payers may influence decisions about obesity treatment, particularly in a time of health care cost containment. Cultivating a positive environment, will allow for open and honest discussions about stigma, and increased understanding about the environmental and individual causes of obesity are likely to reduce the stigma of being obese, thus reducing this barrier to successful treatments.

The STOP Obesity Alliance recommends:

• Incorporating educational messages about the environmental and individual causes of obesity.
• Including awareness messages into obesity public initiatives conducted by both government and private entities.
• Supporting efforts to include stigma awareness and training for health professionals.
• Facilitating inclusion of people who are obese or overweight in the development and dissemination of awareness messages and efforts.
• Encouraging the inclusion of measures of access to health care services by ensuring medical technology is accessible and comfortable for people who are overweight or obese (e.g., MRIs, beds, wheelchairs, mammography facilities).
• Engaging in ongoing research on the impact of stigma as it relates to: the pursuit of successful weight management tools; the willingness of the overweight and obese to seek help; the relationship between weight and socio-economic status; and the willingness of public and private decision makers to invest in individual treatment.
• Finding language for health care providers to approach the topic of weight loss in a way that leads to an effective and open discussion with patients.

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Throughout the current research landscape, most contributing factors of overweight and obesity are examined separately, with little research or agreement on how aspects of one domain influence another. There is a need for an enhanced collaborative effort among both governmental and non-governmental entities to study all of the important factors contributing to the obesity epidemic and how they interact with each other. The research agenda should examine both the factors and impact of obesity as it relates to health services, socio-economics, the health care system, benefit design, environmental factors/costs, and other broad issues that may affect the epidemic.

Policy makers need reliable information to assess the relative value of addressing the obesity epidemic directly. What are the impacts on productivity, military preparedness, employment patterns and international competitiveness? Addressing how overweight and obesity affects these areas, and encouraging research that addresses a broad spectrum of root causes and contributors to overweight and obesity will become increasingly important as this epidemic progresses.

The STOP Obesity Alliance recommends the formation of a broadened research agenda that includes the following four areas:

Clinical Research

• Clinical research that measures the impact of incremental weight loss—e.g., five to ten percent—on health improvements across the spectrum of, and tailored to, the severity of overweight and obesity.
• Clinical research that measures the impact of interventions on non-weight health outcomes (such as exercise to improve fitness and quality of life) for improved health of people who are overweight or obese.
• Explore re-defining what constitutes "evidence" for obesity interventions — overweight and obesity result from a combination of factors interacting with each other; successful interventions are also likely to be multi-component, with no single intervention ensuring widespread success. Yet, the standard for evidence-based medicine, the randomized controlled trial, is ideally suited to assess the effect of a single cause or intervention. It is time to reconsider how to rigorously evaluate interventions that do not fit the single cause-and-effect standard to incorporate both environmental and individual factors important for ameliorating obesity.²

Actionable Research

• Develop and disseminate best practices to translate successful or promising interventions to real-world practice including clinical, school, worksite and community-based settings. For example, practice-oriented translational research approaches can be used to identify and overcome barriers to the dissemination, adoption and sustainability on:
• Effective implementation of evidence-based practices;
• Establishment of effective and economical modes of care; and
• Effective and economical health promotion strategies.³
• Develop rigorous methods that answer questions such as, "Do treatments work in the real world of everyday practice?" or "For whom do interventions work best?" For example, use of a "practice-based evidence for clinical practice improvement" can fill gaps in information needed by clinical and health policy decision makers and facilitate better understanding of what occurs when interventions developed in controlled environments with small samples of people are applied in the field with thousands of people with diverse backgrounds and needs.⁴

Health Services and Policy Research

• Applied health services research to address the immediate needs of payers, providers, individuals, employers and other stakeholders who are on the front lines of the obesity epidemic. For example, research is needed to better understand how treatment for obesity and its comorbidities is affected by access to care issues related to third-party health insurance coverage design in both the public and private sectors.
• Additional cost-benefit analysis on interventions related to overweight and obesity for both public and private sectors

Quality Measurement and Improvement Research

• Support efforts by NCQA to develop measures on the evaluation and treatment of obesity in primary care settings.
• Support efforts by NQF to create a nationally-endorsed framework for quality measurement and public reporting for the prevention and treatment of obesity across the continuum of care.

²Jain A. Treating obesity in individuals and populations. British Medical Journal 331:7529 (December 2005), 1387-1390.
³"Translational Research Overview." University of Connecticut Health Center, The Ethel Donaghue Center for Translating Research Into Practice and Policy. Available at: http://trippcenter.uchc.edu/Translation_Research/research.htm. Accessed November 8, 2007.
⁴Horn, S.D., and Gassaway, J. (2007). Practice-based evidence study design for comparative effectiveness research. Medical Care: 45(10) Suppl 2. S50-S57.

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The report focuses on three interconnected dimensions of this issue that, with greater understanding and awareness, could lead to action with profound effects on the obesity epidemic in America: 1) how success is defined; 2) the perception that treatment is futile; and 3) the stigma against people who are overweight or obese.

While science proves the seriousness of overweight and obesity and its link to deadly conditions such as diabetes and heart disease, there is no consensus today among patients, providers and researchers on what constitutes successful weight loss. As described in this paper, overweight and obese people and their health care providers often have unrealistic weight-loss goals and very few succeed in achieving them. Promoting a more realistic approach that is based on improving health outcomes could be critical to changing obesity's hold on our society.

Another major barrier in the prevention and treatment of overweight and obesity is the perception or assumption that nothing works. When the effort required to treat overweight and obesity by the patient and physician is assessed alongside the results of what both professionals and consumers view as only modest amounts of weight loss, treatments seem hardly worth the effort. This sense of futility can be overcome by focusing on sustainable and realistic step-wise results.

Stigma against people with overweight and obesity is another pervasive trend and a reality for the lives of people with overweight and obesity. Research shows that as obesity increases in prevalence, so does stigma against the overweight and obese. Unquestionably, the role and responsibility of the individual is critical to successful weight loss and without it, lessening obesity will be unachievable. An emphasis on personal responsibility alone has not been enough to curb the epidemic. This paper is designed to highlight other factors within our health care system and health policies that shape the environment for individual action and could encourage addressing obesity.

The gap between society's ability and success in responding to obesity and obesity's known serious economic and health consequences is wide. Whether rooted in the belief that overweight and obesity is a matter of personal responsibility or that treatments are ineffective, this paper looks at factors contributing to the disconnect and proposes possibilities for bridging it as a way of improving health and productivity in America.

The above copy is the executive summary.

For the complete report, please see the PDF below.

Re-Visioning Success: How Stigma Perceptions of Treatment and
Definitions of Success Impact Obesity and Weight Management in America