Nuanced Approach More Likely to Achieve Effective Weight Management

Despite our failed efforts historically, the myriad tools from pharmacotherapy to devices and gastric procedures now available should prompt renewed focus on individualizing care to improve morbidity and mortality, aided by the 2019 Obesity Algorithm.

with Harold E Bays, MD, and J. Michael Gonzalez-Campoy, MD, PhD

The Adult Obesity Algorithm has been updated and released by the Obesity Medicine Association (OMA).[Bays 2019] Harold E Bays, MD, medical director of the L-MARC Research Center in Louisville, Kentucky, and a co-chair of the OMA Obesity Algorithm,1 told EndocrineWeb, “nothing in this document tells a clinician how to manage patients” but rather the Algorithm should be seen as the “go to” resource for when clinicians are unclear of a clinical application or want better insight into the underlying science.

“This comprehensive document reflects the current clinical translation of our understanding of the evolving science of obesity,” said Dr. Bays, a member of the OMA Board of Trustees; the overall management goals are aimed to improve patient health, quality of life, and address body weight and composition to reduce morbity and mortality.1

Doctor works with patient to devise an effective individualized weight loss plan.

Commitment to Treat for Obesity Must be Affirmed by Every Clinician

The authors of the updated Obesity Algorithm reiterated that more needs to be done to reverse the trend towards an increased prevalence of obesity among adults and youth since 1999 with ~40% of US adults (>20 years) and ~18.5% of youths (ages 2-19 years) with obesity.

When asked by EndocrineWeb how the OMA Adult Obesity Algorithm (AOA) might be used in clinical practice, J. Michael Gonzalez-Campoy, MD, PhD, FACE; Medical Director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology, PA, said “this is a comprehensive document that clearly defines overweight and obesity as a continuum of a chronic disease, which mandates effective treatment. The document will lend support to clinical practices by including billing codes and concisely defining the therapeutic interventions for the disease of obesity, and for the complications of the disease.”1

“Obesity can be caused by genetic or developmental abnormalities, adverse reactions to medications, nutritional imbalance, and unfavorable environmental factors that promote an increase in adipose tissue. The resulting excess body fat can lead to adverse metabolic, biomechanical, and psychosocial health consequences. All these components play a role in the understanding— and thus, the evaluation and management—of patients with the disease of obesity.” — AOA 2019

The OMA Adult Obesity Algorithm is a living document that is updated annually, said Dr. Bays. The 2019 update addresses the intensifying role of obesity in a myriad of comorbidities: metabolic disease, cardiovascular disease, hypertension, diabetes, dyslipidemia, fatty liver disease, and some cancers; and provides an essential overview of treatments for lipodystrophy as well as investigational anti-obesity pharmacotherapies.1

 “Since obesity is currently the second most preventable cause of cancer,” lessening the prevalence of obesity may well reduce the risks and incidences of many chronic diseases,” he said.

Target Obesity Therapy Toward Achieving Normal Adipose Tissue

 “The most important addition to the latest Obesity Algorithm is that it establishes adiposopathy (sick fat disease) and adiposity (fat mass disease) as individual subsets of obesity that are each not treatment targets,” said Dr. Gonzalez-Campoy.  “It is not enough to focus on pounds of fat mass lost (weight on the scale) or body mass index; rather, we now have to focus on returning adipose tissue dysfunction to normal (treatment of adiposopathy).”

The obesity algorithm accepts that clinicians will take a patient-centered approach to the management of patients with obesity.1 Recognizing the stages of obesity will best inform the diagnosis and treatment plan for each patient, including the ability to individualize medication selection.2

While much of the comprehensive evaluation of the patient with overweight or obesity applies to all patients, laboratory and diagnostic testing will also aid in personalizing treatment plans, which should encompass:

  • Diet/Nutrition3
  • Physical Activity/Movement
  • Behavioral Counseling
  • Pharmacotherapy
  • Gastric procedures (ie, endoscopic devices, procedures, and bariatric surgery)
  • Possible referral to an obesity medicine specialist

The most appropriate nutritional therapy for weight loss should be safe, effective, and most importantly, one to which the patient can adhere for the long-term. The adult obesity algorithm does not recommend any one specific nutritional approach, presenting instead, the benefits and risks of the most common programs. With demonstrated effect, the algorithm also accounts for the importance of exercise and movement, cautioning that for patients who have been sedentary, a medical evaluation would be advisable before they initiate any physical activity effort.1

Despite Clinical Urgency, Patient Must be a Willing Participant 

As most are well aware, before approaching a patient regarding their weight status, it is essential to establish the patent’s readiness to changem in order for a comprehensive program to be most effective.  Motivational interviewing is described as an approach to ‘move the patient from indifference toward positive or healthy changes. As such, an expansive section is devoted to the role and application of motivational interviewing in fostering effective weight management.3,4

This section describes the stages of motivational interviewing, and reviews principles and techniques for clinicians to incorporate into their care approach with common patient scenarios. In addition, there is also a section on Behavioral Changes and Eating Disorders to better help clinicians engage patients to identify and address potential barriers to effective and successful long-term weight management. There is also a section on technological advances (ie, devices, procedures) in weight management.

Another useful section focuses on the role of emerging diagnostic tests. To best address the overall medical wellness of the patient, giving due consideration to impact of comorbid disorders—such as cardiovascular disease, neuropathy, retinopathy, osteoporosis—and the adverse impact that many medications may have on body weight.

As all chronic diseases require co-management, patients need to appreciate the full picture of their individual condition in order to accept their clinical team’s recommendations. In addition, when approaching the issues of obesity medicine in your clinical practice, you are also educators—to your staff and in the community, so this document will provide important resources to aid you in this role, Dr. Bays said.

Facing Clinical Inertia— First Step to Supporting Effective Weight Control 

When asked about clinical barriers to care when considering patients with obesity, Dr. Gonzalez-Campoy pointed to clinical inertia as the overriding challenge for practitioners.

“Acting to implement obesity treatment is still not the norm,” he said, adding that clinicians are “adept at treating all of the complications of obesity such as diabetes, hypertension, sleep apnea, cardiovascular disease, but not obesity itself,” he said. And, patients are failed hurdle given that there are still clinicians who entertain the “outdated but still prevalent attitude that pharmacotherapy should not be used to treat obesity.”

However, Dr. Gonzalez-Campoy added: “these guidelines, along with the recent American Academy of Clinical Endocrinologists and Endocrine Society Guidelines,5 make it the standard of care to use pharmacotherapy to treat this chronic disease of overweight, obesity, and adiposopathy,”

Dr. Bays compared the current state of knowledge of obesity with the initial states of knowledge about other metabolic disorders, such as diabetes, hypertension, and hyperlipidemia – “we started out with only a few pharmacotherapies for each of those diseases, but as understanding and knowledge grew with continued research,” we now have substantial armamentaria and can personalize treatment.

The AOA provides information about all of the currently approved anti-obesity drugs, including their indications, contraindications, warnings, adverse effects, and other important considerations for clinicians to know before prescribing them. While the OMA does not endorse functional foods, nutritional supplements or over-the-counter therapies, the authors emphasized the importance of having a familiarity with products that patients may be using, with false expectations.

Dr. Gonzalez-Campoy emphasized that “not treating overweight, obesity and adiposopathy is tantamount to malpractice in 2019 – there is no excuse to ignore them, and to treat only their complications (diabetes, hypertension dyslipidemia, etc).”

“Clinicians need one place to go to start addressing the diagnosis and management of obesity,” said Dr. Bays, “the AOA is that resource—it aims to empower clinicians to provide optimized care for their patients.”

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