Shared Medical Appointments
Shared medical appointments at the heart of a novel Cleveland Clinic program for morbidly obese patients who want to avoid bariatric surgery.
By Bartolome Burguera, MD, PhD, Kelly Nocero, RN, Dawn Noe, RD, Cheryl Reitz ,RD, Kathryn Corte, RD, Emily Bostin, RD, Melissa Matthews, NP, and Beth Abood, RN
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The prevalence of morbid obesity (body mass index [BMI] ≥ 40 kg/m2), has become an epidemic. People with morbid obesity have a significant risk of developing medical complications, such as cardiovascular disease, Type 2 diabetes, dyslipidemia, hypertension, sleep apnea, depression and certain types of cancers. Obesity also increases all-cause mortality.
Bariatric surgery is currently the most effective therapy to treat morbid obesity. However, the current rate of utilization of bariatric surgery is only 1/100th of the entire existing morbidly obese population.
Despite the fact that so few patients opt for bariatric surgery, it is becoming evident that conventional approaches to obesity therapy have very limited effects, as the Swedish Obesity Study and other studies — including ours — have shown. Therefore, it’s imperative that we develop effective obesity interventional therapies as alternatives to bariatric surgery.
In response to that need, we set up an intensive lifestyle intervention program based on scientific evidence for patients with morbid obesity who are not candidates for, or are not interested in, undergoing bariatric surgery. Shared medical appointments (SMAs) are at the heart of this novel program.
There are already an important number of studies showing the beneficial effects that behavioral therapy, along with pharmacotherapy, have on weight loss—with a resulting improvement of diseases associated with obesity. Some of these reports have shown the beneficial effects that even a small weight loss can have on improving the general health of obese individuals.
We previously have shown that morbidly obese patients who received an intensive lifestyle intervention had a greater percentage of weight loss than patients receiving conventional obesity therapy (–11.3 percent vs. –1.6 percent).6 Of note, 31.4 percent of patients included in the intensive lifestyle intervention group, were no longer morbidly obese after just six months of intervention.
Our SMA intensive lifestyle intervention program focuses on giving patients the therapeutic tools they need to become more accountable and to slowly obtain control over their weight.
Patients first have an individual appointment and then follow-up monthly visits together with a physician and dietitian, in the context of SMAs.
The 90-minute SMAs are carried out by a physician, a dietitian, nurse and medical assistant. Every SMA group includes five to seven patients. All of them are following one of the three dietary programs. Once a group is formed, it usually stays the same and no new patients are added.
During each visit, we review the five areas detailed above. We also briefly review any endocrine issues that patients are having. We work closely with the patients’ primary care physician (an endocrinologist).
Since initiating this program one year ago, 200 patients (including approximately 40 Cleveland Clinic employees) have participated. At six months, approximately 65 percent of the patients who started the program stayed enrolled. The average weight loss is 10 percent of the initial body weight after six months. It is well known that obese patients with comorbidities who lose 5 percent to 10 percent of their initial body weight reduce their cardiovascular risk.
The level of program acceptance by our patients is significant. They appreciate the knowledge, motivation, encouragement, therapeutic tools and sense of accountability that the program provides. Patients especially enjoy the positive support from their peers during the SMAs. They learn from other people’s successes and failures as well as their own. At the same time, the program is individualized, with an emphasis on identifying the best approach for every patient.
|Dr. Burguera is Director of Obesity Programs at the Endocrinology & Metabolic Institute. He is also a Professor of Medicine at Cleveland Clinic Lerner College of Medicine. His specialty interests include medical management of obesity, diabetes and insulin resistance. He can be reached at 216.444.6568 or firstname.lastname@example.org. Nocero is Specialty Care Coordinator in the Diabetes Center. Noe, Reitz, Corte and Bostin are registered dietitians working at the Diabetes Center. Matthews is a nurse practitioner with special interest in Diabetes and Obesity. Abood is a nurse manager at the Endocrinology & Metabolism Institute.|