Patient Engagement

Patient Engagement Survey: The Failure of Obesity Efforts and the Collective Nature of Solutions

Insights Report · September 13, 2018

Analysis of the NEJM Catalyst Insights Council Survey on Engaging Patients in Stemming Obesity. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Kevin G. Volpp and Namita Seth Mohta

Health care providers view obesity as an epidemic, and many call it a high or extremely high priority at their organizations. Yet clinicians find patients’ engagement in addressing their obesity to be suboptimal. These and other findings from the latest NEJM Catalyst Insights Council survey reveal much about why U.S. society is not succeeding in addressing obesity. Patients hold responsibility for their actions, but providers’ approaches to address obesity often fall short as well.

Patients and PCPs Hold Primary Responsibility for Addressing Obesity

From the Patient Engagement Insights Report: The Failure of Obesity Efforts and the Collective Nature of Solutions. Click To Enlarge.

One of the biggest challenges is patient engagement. The survey respondents — who are clinicians, clinical leaders, and health care executives at U.S-based organizations directly involved in health care delivery — report high rates of obesity among their patients. More than half (53%) say that between one-fourth and half of their organizations’ patients are obese, while another third (34%) say that more than half of patients are obese.

Yet 44% of survey respondents say their obese patients are not very engaged or not at all engaged in addressing their weight. Only 10% describe their obese patients as extremely or very engaged. The rest are considered moderately engaged.

Who Is Responsible for Weight Loss?

Low patient engagement is concerning, particularly in light of the fact that survey respondents overwhelmingly (90%) consider the individual patient as one of the top stakeholders holding responsibility for addressing obesity. This near-universal response reflects the national shift toward encouraging personal responsibility in health care (as we have seen in Medicaid programs and high-deductible health plans) as well as the movement toward patient-involved shared decision-making.

And what of the primary care physician’s role in treating obesity? One might expect PCPs to be considered equally important as patients. Indeed, primary care is strongly represented in the survey, with 89% of respondents saying individual PCPs or PCP teams are among the top stakeholders for addressing obesity.

When it comes to effective strategies for improving patient engagement around weight loss, exercise, and healthy diet, Insights Council members cite provider support (such as motivational interviewing) and peer support (such as patient groups) in equal measure. But we must acknowledge that lack of success in combatting obesity reveals that such approaches are inadequate — either because adoption rates are too low, or because obesity is caused by a complex array of environmental, physiological, and decision-making factors that individual clinicians may recognize but have few tools to offset.

Survey respondents says the biggest barriers to engaging patients in treatment for obesity are the difficulty of sustained weight loss, along with lack of patient perception of obesity as a problem or health issue (both cited by 39%). Close behind is lack of patient adherence to treatments (31%).

In these responses, health care providers and leaders seem to be pointing a finger at their patients. Is that fair? Medical treatments for obesity tend to be ineffective, other than bariatric surgery, which is a big step to take, carries risks, and is not appropriate for all patients.

A Collective Approach to a Big Challenge

How many health care providers do you know who have the time and the training to engage in meaningful motivational interviewing? If we expect clinicians to successfully treat obesity, they must have the right tools. Furthermore, we should recognize that the physician need not necessarily be the clinical team member to interact with the patient in all of these counseling and engagement strategies. While it may make sense to have these activities originate through the physician’s office, other team members are often better-suited for follow-up, such as nutritional counselors. We also should not overlook the potential of technology tools and apps to connect with patients.

Health care providers can play an important role in influencing local and national policy to put in place regulatory changes that support people living healthier lifestyles. This could involve ways to facilitate physical activity or more controversial approaches such as taxation or regulation of food that clearly is unhealthy and contributing to obesity. In written comments, survey respondents bemoan the lack of involvement of other stakeholders to address social determinants of health and a food industry that pushes inappropriate portions of unhealthy processed products.

Although weight loss can be exceedingly difficult, health care providers and patients working collectively and iteratively will have a better chance of reducing obesity in the future.


What is the best way to reverse the obesity epidemic in the United States (e.g., clinical, social, legislative, etc.)?

“Reverse income equality – people have to have the time (viz., not holding down two jobs) and the income tackle obesity. The #1 health problem is income inequality.”
— Director of a nonprofit payer in the South

“Affordable healthy foods; not cheap fast food. Change the perception of obesity; getting to normal BMI.”
— Director of a nonprofit payer in the Midwest

“I think it has to be recognized as a societal health problem. You could almost liken the epidemic to something like polio. You must require government intervention, community service intervention, public awareness, positive incentives for addressing prevention as early as in the school systems, etc. If it is not addressed at all levels, then reversal and prevention will fail. I think unfortunately it will require a large investment in government resources and industry resources to reverse the trend.”
— Clinician at a midsize for-profit physician organization in the Northeast

“I think the education needs to start at a young age to begin teaching healthy eating habits, exercise and stress reduction to AVOID adult obesity. I think insurance companies could offer more financial incentives for those participating in healthy lifestyle activities, such as reduction in co-pays or reduced monthly premiums.”
— Clinician at a large nonprofit community hospital in the Midwest

“Incentivize healthier lifestyles. Possibly through employer engagement. My patients have sedentary jobs, and are struggling to make ends meet. They are very wary of
taking time from work to make themselves healthier.”
— Department chair at a midsized nonprofit hospital in the Northeast

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council — who comprise health care executives, clinical leaders, and clinicians — about engaging patients in stemming obesity. The survey explores the role of various stakeholders both inside and outside of the clinical setting, levels of patient engagement and organizational priorities, and approaches to treatment options and barriers to success. Completed surveys from 725 respondents are included in the analysis.

There is near-universal agreement that both the patient and some primary care representation must be among the top stakeholders with primary responsibility for addressing obesity. Though most respondents identify patients, they are divided on the primary care aspect. Many respondents also call for governmental action and greater involvement by community and business leaders. One physician at a large teaching hospital in the West says, “We need a multipronged approach at individual, family, primary care, and community levels with a few legislative measures.”

Health Care Providers Use Many Approaches to Treat Patients with Obesity

From the Patient Engagement Insights Report: The Failure of Obesity Efforts and the Collective Nature of Solutions. Click To Enlarge.

Download the full report to see the complete set of charts and commentary, data segmentation, the respondent profile, and survey methodology.

Download Full Report

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