By Deborah Borfitz 

September 8, 2020 | Many chronic diseases—including high blood pressure, raised cholesterol, type 2 diabetes, lower back pain, and some cancers—are closely related to being overweight. A common goal in managing such conditions, and preventing their occurrence, is therefore to help people shed the extra pounds.

Success requires more than repetitive verbal admonishments by their physician to eat less and exercise more, says bariatric surgeon Ioannis Raftopoulos, M.D., who directs the weight management program at Holyoke Medical Center (Massachusetts). Patients need ongoing, sometimes daily, guidance and interaction with their doctor for sustained weight loss.

Telemedicine is an affordable way to do that and the results can be better than what can be accomplished with in-person visits, Raftopoulos says. That has been his personal experience over the past five years both with his surgical patients and those in the weight loss program involving a swallowable gastric balloon and Bluetooth-enabled smart scale.

In a recent presentation to the Health Information Technology Committee of the American College of Surgeons, Raftopoulos shared how he has been using telemedicine to improve clinical outcomes. Having “unlimited communication” with patients is what’s most critical, as well as most lacking, in chronic disease management, he says. “Telemedicine is absolutely necessary for physicians to do their job properly, but also for patients to be able to participate in a more intensive follow-up.”

In whatever capacity doctors are using telemedicine to follow chronic disease patients, don’t compromise on the technology—be it a body composition scale, blood pressure monitor or glucometer (all available for under $100 and sometimes covered by insurance)—to do the job right, he advises. “Try to establish a way to communicate with patients in the same way you would at the office and don’t assume they… lack the financial freedom to make such choices.” Among his patients, almost 90% are willing to make the sacrifice once they understand the rationale.

The workflow around telemedicine visits is completely different than for office visits, Raftopoulos additionally points out. Virtual visits can be completed in half the time and leave no holes in the schedule due to fewer no-shows and flexibility in appointment times. “If one patient forgets a scheduled phone call, I can call the next one [in line],” he says. Patients who forgot their scheduled call are contacted and oftentimes available later the same day. “I can be more efficient, and effective, because I’m not stuck waiting.”

Combining office and telemedicine visits, as appropriate for individual patients, doctors can manage more cases in the same space of time. And video visits are typically unnecessary, he adds. Communication by phone makes for shorter visits that are just as effective as a Zoom call and requires less technical know-how on the part of patients. Those in greatest need of physician engagement, notably those with socioeconomic disparities, are often the same people who do not own a smartphone or any other type of video-enabled device.

Optimizing Outcomes

Raftopoulos’ experience with telemedicine extends to the Elipse procedureless gastric balloon of Allurion Technologies, for whom he participated in a clinical trial of the device in Europe in 2014 and another in the U.S. in 2018 and 2019 conducted at 11 sites nationally, including Holyoke Medical Center. The Elipse balloon is not commercially available in the U.S., he says, but it is in his homeland of Greece where he has remotely worked with about 150 patients since 2015 who have opted to swallow the digestible balloon in lieu of bariatric surgery.

No special procedures are required, and the balloon automatically deflates and exits the body via the stools after 16 to 20 weeks, says Raftopoulos. While inflated, it restricts the amount of food a person can consume.

The results Raftopoulos has had with the Elipse balloon are better than those achieved by others using the device, both because he incorporates an additional exercise and nutritional protocol and pioneered the idea of following patients remotely. Average weight loss Raftopoulos has observed is 20% of initial weight (about 41 pounds), all achieved via telemedicine. In fact, after the pandemic hit the U.S., Allurion Technologies seemed to follow his lead with announced enhancements to its proprietary program to include at-home fitness, mental health and nutritional content so providers could “stay in closer contact with existing patients.”

Underpinning the decision was a statement issued by the Centers for Disease Control and Prevention noting that people with serious underlying medical conditions, including obesity, are at potentially higher risk for severe illness from COVID-19. A recent study conducted at New York University and published in Clinical Infectious Diseases (DOI: 10.1093/cid/ciaa415) also demonstrated that of 3,615 patients admitted to the hospital with COVID-19, those less than 60 years old with a body mass index (BMI) greater than 35 were 3.6 times more likely to be admitted to critical care compared to individuals with a BMI under 30.

During his virtual discussions with patients, Raftopoulos focuses on changing the way individuals eat and exercise every day, he says. “I have patients who have lost over 50 kilograms (approximately 110 pounds) within six months with the balloon and during the COVID-19 pandemic, which is almost better than surgical procedures for weight loss.”

The smart scale that is part of the Allurion program provides measurements of weight as well as percentage of fat, water, and muscle mass, plus bone mass and base metabolic rate, explains Raftopoulos. Weight loss by itself can be misleading. His exercise and nutritional protocol specifically targets the portion that is fat, which is the true yardstick of success, by demonstrating which physical activities and nutritional algorithms are moving that needle—and better prepare patients for what they have to do after the balloon comes out.

The scale connects with Bluetooth and is tied to a smartphone app on to facilitate remote tracking. Similar scales and apps are commercially available, allowing data to be shared remotely any number of ways, including email and text message, Raftopoulos says. 

High-Intensity Care

The telemedicine component of Raftopoulos’ practice, while rewarding and delivering good results, is labor-intensive, he is quick to disclose. Patients are sending him data on a weekly basis that he reviews before calling them to offer his guidance.

Recently, for example, a patient trying to lose weight prior to bariatric surgery had gotten off track after feeling fatigued and light-headed, he says. Since her mother has diabetes, she wrongly surmised her blood sugar was dropping. Raftopoulos had to stop her from self-medicating with high-calorie juices and advised her to reduce the dose of her prescribed hypertension drug. The feedback ensured she would keep exercising and lose weight, and the entire conversation happened via text on a common online portal within a few minutes.

More typically, when faced with an issue like this, patients on a weight loss program would wait potentially weeks for an appointment with their physician and the damage would have already been done. “That’s why people ultimately don’t lose weight,” he says. 

But patients can’t be seen more often in the office, even when the COVID-19 outbreak has ended, because the healthcare system can’t bear the cost of such high-intensity care and the human resources required. The pandemic has made it painfully obvious that telemedicine is the future, Raftopoulos adds, and needs to be “protected, supported and cultivated. It’s the only way we can improve the quality of care we provide patients.”