Obesity Bias Affects Coverage, and Consumer Perceptions

Bias against persons with obesity is so longstanding that consumers often believe their health plans won’t cover treatment even when that is not the case, a leading advocate for obesity care told attendees Sunday at the annual meeting of the American Association of Diabetes Educators.

Ted Kyle, RPh, MBA, founder of ConscienHealth and past chair of the Obesity Action Coalition, told a packed session that obesity bias continues to affect policy, despite the evidence of obesity’s connection to a host of costly health problems.

People assume their insurance will pay for a visit to the doctor or the hospital, but studies show they are far less certain whether it will pay for a dietitian or bariatric surgery, Kyle said. In some cases, “there is a gap between perception and reality because people don’t know coverage has changed.”

Kyle and Richard Linquist, MD, medical director of Swedish Weight Loss Services in Seattle, Washington, described how obesity is a complex disease in which adipose tissue is far more metabolically active than once believed. Obesity is no less a chronic condition than diabetes or heart disease, Lindquist said, but it’s not treated that way.

After Kyle described how routine health plan exclusions persist, and many physicians will not prescribe obesity therapy, Lindquist took attendees through a tour of what fat does to the body, starting with the inflammatory processes it triggers.

“Insulin resistance,” he said, “is at the heart of the inflammatory response associated with this disease.” And for a host of reasons, that response doesn’t simply go away just because someone loses weight. Kyle pointed out that 60% of obesity is genetic.

Strategies for treating obesity must be long-term, Lindquist said. No one would stop giving medication to a person with high blood pressure or diabetes once therapy brought it under control, he said. “Obesity fits the same paradigm.”

Bias continues, Kyle said, despite increased knowledge of obesity as a disease process and its undeniable health effects. There have been some signs of progress, the most significant being the American Medical Association’s 2013 declaration of obesity as a disease.

Weight bias is so pervasive, Kyle said, that the healthcare system is not immune—both in treatment and in research. Health professionals are some of the worst offenders, as studies show that physicians view their own patients as weak-willed, lazy, and lacking in self-control. This only make obesity worse, he said.

Attitudes in primary care are not shared by leading professional societies that have studied the evidence. Bariatric surgery has received much attention in the past year, in light of studies that show that for some patients, it not only promotes weight loss but also reverses diabetes. This spring, the American Association of Clinical Endocrinologists came out with an updated guideline for obesity that called for covering treatment, and the American Diabetes Association issued guidelines for when surgery should be used to treat diabetes.

The result of bias has been a lack of access to care, whether it’s surgery or therapy, Kyle said. Some adolescents who are candidates for surgery take so long to gain approval that they are no longer adolescents, he said.

The good news is that attitudes are changing. Ongoing tracking of “bias signals,” which use Google surveys, show that just since August 2015 there has been an uptick of Americans who view obesity as a disease. Many still view the problem as a moral failure, but more see it as result of environmental factors.

A national employer survey from 2014 shows more employers are covering treatment, but the best coverage occurs among the largest employers. The National Association of Insurance Commissioners has called on health plans to cover treatment, and a 2014 requirement guarantees coverage for federal employees.

Diabetes educators play a role in treating obesity by helping patients with self-care, Kyle said. “You all do a marvelous job with self-care,” he told the group, but self-care is just one tool, and patients need the full spectrum of available treatments.

Both diet and exercise are important for weight loss, said Lindquist, who said he has worked hard to stay out of the “diet wars.” While he will not endorse any one diet, in general, most obesity experts prefer some type of reduced carbohydrate diet.

He said that obesity and prediabetes need to be treated aggressively. Waiting until a person has full-blown diabetes to start treatment, “is sort of like waiting for cancer to become metastatic.”

Ultimately, Lindquist said, patients will benefit when obesity is treated like the chronic condition it is. “it treatable and manageable,” he said. “We don’t think of it as curable.”

“If you stop treating it, it will come back,” Lindquist said.