Janet Nzisa | Editorial Assistant
MULTIDISCIPLINARY TEAM APPROACH TO MANAGING OBESITY
Volkan Demirhan Yumuk, Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Turkey, opened the session by stating that obesity is a relapsing chronic systemic disease that requires multiple referrals from different disciplines. Yumuk presented a population study that showed that 92% of participants did not receive treatment despite having characteristics associated with obesity, demonstrating that obesity is underdiagnosed. Another study from a children’s hospital, with data collected from electronic records in the USA, demonstrated that 20.4% of inpatient children with several symptoms associated with obesity were discharged, and only 1.7% were diagnosed with the disease. Furthermore, the above study shows that healthcare professionals (HCP) rarely inform patients in the high-risk waist circumference category overweight that they are at risk of developing obesity if the situation is not addressed. Obesity is associated with other health complications, and if unaddressed it could progress to fatality. Yumuk presented a study that demonstrated the health complications caused by different stages of obesity such as sleep apnoea, pulmonary disease, gynaecological abnormalities, infertility, depression, stroke, coronary diseases, and Type 2 diabetes.
There are several unresolved issues in obesity management, such as lack of collaboration among HCPs, lack of knowledge and training, lack of formalised standards of services, lack of sustainable follow-up, lack of education for people with obesity, and so much more. A multidisciplinary approach to tackling obesity would bring about benefits to both people with obesity and HCPs by covering several unmet needs in obesity management. According to EASO, an integrated multidisciplinary team for obesity management should consist of the following: a physician with special training in obesity management; a dietician; a behavioural therapist; an exercise specialist; a bariatric surgeon (if surgery is required); an obesity nurse; and a social worker. Yumuk explained that his institution in Turkey consists of several people from different disciplines, and went on to propose a strategy that would improve obesity management, which involves a discussion with a person with obesity, diagnosis, and direction on weight management. He referred to these as the ‘three D’s strategy, and believed that these are the elements for successful weight loss outcomes in patients. There are unmet needs in obesity management in Europe due to lack of a multidisciplinary approach (obesity teams and centres), obesity specialists, guideline availability and implementation, people with obesity-centred approach, long-term care, and monitoring.
Yumuk confirmed that EASO is currently working on future objectives to create a network of specialists in obesity management across the EASO member countries, and build accredited obesity centres. Here, the quality and efficacy of care are given at the highest standards for the patient, with a holistic team in the accredited centre, quality control, data collection, and analysis, as well as education and research to advance obesity care and science.
UPDATE ON GUIDELINES: WHAT ELSE DO WE NEED?
Luca Busetto, Department of Medicine, University of Padua, Italy, started the session by explaining that the complexity of obesity requires diagnostic and staging processes that should be integrated with anthropometric and clinical data. Furthermore, he stressed that the decision for treatment to be used should be based on the clinical staging of the disease rather than anthropometry. As obesity is linked to other chronic conditions, he explained the importance of addressing these medical issues as well, which include cardiovascular disease and Type 2 diabetes. Surprisingly, the data presented showed that different risk factors require more weight loss than others; an example provided by the speaker was that hypertension required 0–5% weight loss, while risk associated with cardiovascular mortality requires >15%. It was clear that obesity management is not just about weight loss, but also about reduction of risk factors and overall health improvement; therefore, BMI alone is not an accurate way to measure obesity. Busetto suggested that guidelines should also include the management of other medical complications associated with obesity. He emphasised that the choice of the appropriate initial intervention, such as lifestyle, anti-obesity medications, or bariatric surgery, should be based more on the individual therapeutic targets rather than anthropometric parameters alone. Busetto highlighted his belief that the choice for the appropriate initial level of interventions should be discussed with and agreed upon by the patient, whilst taking previous therapeutic attempts into account, which should be a multidisciplinary approach for obesity management.
CLINICAL IMPACT OF THE CONCEPT OF OBESITY IN ADIPOSITY-BASED CHRONIC DISEASE
Emerging data on adiposity-based chronic disease were presented by Jeffrey I. Mechanick, Clinical Professor of Medicine, Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai, New York, USA, and Director of Metabolic Support, The Mount Sinai Hospital, New York, USA. Mechanick began the session by describing adiposity as excessive amounts, distribution, or function of adipocytes, fat, and fat mass. As stated by Mechanick, the BMI model of obesity diagnosis is outdated, and less accurate than the novel adiposity-based chronic disease (ABCD) model. He further went on to provide the different stages of ABCD model. Stage I is described as the risk of developing obesity; Stage II is the pre-disease stage; Stage III is the obesity development stage; and Stage IV is where other health complications associated with obesity occur.
The American Association of Clinical Endocrinology (AACE) and American College of Endocrinology (ACE) put together clinical practice guidelines for medical care of patients with obesity, presented by Mechanick, that stated obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life. Additionally, Mechanick presented a paper from the Czech Republic that compared the BMI model to the ABCD model in the detection of chronic diseases. This original paper concluded that the ABCD model provided early detection and stratification of chronic diseases, such as cardiometabolic-based chronic disease (CMBCD), compared to the BMI model. Additionally, the researchers for this study stated that the ABCD model could further improve the early prevention of chronic disease before it progresses to Stage IV. Previously, clinicians would wait for several symptoms in Type 2 diabetes before introducing hypoglycaemia management; however, with the advanced ABCD model presented by Mechanick, clinicians are able to act earlier by analysing the primary causes, and metabolic causes such as insulin resistance in diabetes.
Mechanick went on to present a 3D CMBCD model, in which Stage I presents with primary causes, that are either due to genetics or lifestyle choices. This then progresses to Stage II, the pre-disease stage, whereby an individual can be described as overweight due to abnormal adiposity. Further progression will result in obesity, Stage III, and obesity-related complications (Stage IV). Stage IV of ABCD leads to severe complications such as CMBCD and dysglycaemia-based chronic disease.
Mechanick concluded that there were only 27 papers on this ABCD model topic; however, there are currently two clinical practice guidelines for ABCD. He encouraged healthcare professionals to replicate similar studies in different cultures and different populations to further validate the ABCD model, as this model could further improve the early prevention of obesity and chronic diseases before they progress to Stage IV.
In conclusion, all of the speakers agreed that the best way to tackle obesity management is through a multidisciplinary approach, following the current guidelines, and furthering the current research to validate the novel data.