From June 11 through June 13, 1999, the North American Association for the Study of Obesity (NAASO) convened a 23-member task force whose charge was to come to a consensus on a broad range of outcome measures that clinicians and researchers could use to measure health and treatment effectiveness of the obese patient. The outcome measures were to be broad in scope, measuring quality of life, as well as economic and clinical parameters. Additionally, recognizing the economic and time constraints of clinical practice, but understanding the importance of integrating outcomes research into practice, the task force members were explicitly requested to make their recommendations evidenced-based and the outcome measures valid, feasible, and relevant. The result of these efforts is presented in the following supplement. TOOLS was driven by NAASO's wide-ranging vision that recognizes obesity as a distinct medical condition warranting a systematic approach to identify persons at risk, intervene with recognized effective treatment options, and measure outcomes to assess treatment effectiveness and improve quality of care—an approach that parallels other chronic diseases. The National, Heart, Lung, and Blood Institute guidelines on the assessment and treatment of overweight and obesity fulfills the first mandate of this vision (identify persons at risk) and provides some evidence of current treatment efficacy. However, we are at a very early stage of developing treatment options, and, the payers of health care are asking for evidence of treatment effectiveness before they will pay for treatment. Additionally, we have learned historically from other chronic diseases that as our ability to measure aspects of disease improves, our understanding of the disease improves, and our ability to treat the disease improves in parallel. What is still needed to improve obesity treatment and provide evidence for reimbursement purposes is the routine assessment of treatment effectiveness. To do this, we must measure the health outcomes of our patients and use parameters that capture the complexity of the disease. Although weight or body mass index change are the most commonly accepted “health outcomes” used for the overweight and obese patient, they fail to measure the complexity of the disease and the multidimensional impact of treatment. For instance, the impact of a lifestyle intervention that increases physical activity but results in little weight loss is not adequately captured with existing measures. If this intervention's outcomes were presented to a managed-care organization, they would likely deem it “unsuccessful” and not offer reimbursement. On the other hand, if lipid levels or health-related quality of life were measured as well, then the fuller spectrum of the intervention's impact on health could be seen. Although this is a simplistic example, a thread of our current reality can be seen. For obesity researchers and clinicians, it is common knowledge that a 5% to 10% weight loss has a profound impact on clinical and quality of life outcomes. However, to managed-care groups, patients and many clinicians, 5% to 10% weight loss is often considered inconsequential. Placing so much emphasis on weight loss alone when society has historically had unrealistically high expectations creates a situation in which treatment is often deemed “unsuccessful” even if it improves health. It is up to us, obesity clinicians and researchers, to define and then measure the health outcomes that truly capture the complexity of the disease and the multidimensional impact of treatment. Establishing a recognized set of outcome measures among the community of health care professionals, scientists, and providers will substantially advance outcomes research in obesity. It will also provide a powerful guide for focusing on key components of health as a basis for quality improvement and allow for valid comparison of care delivered within and across health-care settings. This would, in turn, provide insight into the effectiveness and cost-effectiveness of the medical management of obesity. Hence, within this issue of Obesity Research are the tools: a set of outcome measures that one can use to measure treatment effectiveness. A clinician or researcher can use many of them like the contents of a tool box to comprehensively evaluate treatment effectiveness. Specific tools can also be used, such as the short form-36 for assessing general health-related quality of life. On the other hand, an individual may be concerned with only the obese diabetic patient or the obese patient with cardiovascular disease, and would select the tools appropriate to these conditions, as discussed herein. We did not alter the contents of the papers to fit into a standardized set of recommendations. Rather, we provided the best evidence to support a variety of measures (some with overlap) that can be used by clinicians as they see fit. This issue of Obesity Research contains three main sections: 1) “Outcome Research: Present and Future,” 2) “Outcomes Measures in Obesity: The Evidence” and 3) “Perspectives.” The first section, written by three experienced researchers and clinicians in health-service research, discusses the present and future of outcomes research, providing guidance or “lessons learned” that can be applied to the field of obesity. Drs. Connors, Einbinder, and Mr. Bolmey were our advisors and helped us reach a consensus on the final set of outcome measures. The second section contains the topic-specific, evidence-based papers. At the end of this section, there is the “Summary of Outcome Measures,” a chart that summarizes the recommendations and provides information on how to obtain and use the recommended questionnaires. The last section, “Perspectives,” provides insight into what directions NAASO must take to ensure that obesity and weight management become more fully integrated into the medical system. The perspectives are from representatives of the major payers of health care—managed care, government, and employers—and from clinical groups: the American Academy of Family Physicians, the American College of Obstetrics and Gynecology, and the American College of Physicians. These representatives listened to our presentations and discussions during the two-day conference and were asked to address three questions: 1) “From your perspective, how should obesity treatment be approached, as a disease entity or a healthy lifestyle issue?”; 2) “What strategies would be most successful within your organization to disseminate and implement the TOOLS outcome measures?”; 3) “What is your recommendation to NAASO to elicit support for the disease management of obesity on a national level?”. This section provides tremendous insight into how these groups perceive obesity and its treatment in 2002 and offers direction for the future. I would like to commend NAASO for its progressive stance in supporting the TOOLS task force. I would especially like to thank all of the task force members who worked diligently for more than a 2-year period to fulfill the mission of this task force. I would also like to acknowledge the Department of Health Evaluation Sciences at the University of Virginia School of Medicine and Laura Eindbinder, M.B.A, R.D., who helped me conceptualize and implement this task force. Lastly, I would like to acknowledge and thank Corinne Borel from NAASO and Helene Rosenhouse-Romeo, R.D., from Obesity Research who helped tremendously in the publication of these proceedings. We hope that this supplement of Obesity Research and set of outcome measures will improve the treatment of obesity.
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Anne Wolf (2002) studied this question.