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TOS, AHA, ACC release new guidelines for obesity treatment
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The American Heart Association, American College of Cardiology and The Obesity Society have released new clinical practice guidelines to assist health care providers with the management of patients with obesity. The joint guidelines have been published online concurrently with Obesity Week 2013.
The obesity guidelines are one of four cardiovascular disease prevention guidelines being released today by the AHA and ACC, according to a press release. Other guidelines include lifestyle management, cholesterol and CV risk assessment.
Harvey Grill, PhD, The Obesity Society (TOS) president, said the obesity treatment guidelines will go a long way toward helping health care providers offer empirically based and effective weight-loss treatments for overweight and obese patients, according to a statement released by TOS.
“It’s been 13 years since clinicians have had access to such a resource, far longer than any specialty is expected to wait for updated recommendations,” Grill said. “This public release is yet another encouraging sign that obesity is finally being recognized and treated as a serious disease that affects far too many people in the US and around the globe.”
Understanding the guidelines
The goal of the obesity guidelines was to help primary care providers address weight management as a pathway to promoting the health of their patients, according to Donna H. Ryan, MD, associate editor-and-chief of Obesity, co-chair of the writing committee that developed the guidelines, and professor emeritus at Louisiana State University’s Pennington Biomedical Research Center.
Donna H. Ryan
“To understand these guidelines, you have to understand the context in which primary care providers are operating. First of all, most of them have not been trained in obesity etiology or pathogenesis, much less in its diagnosis and treatment, and they’re operating in a culture that has a lot of misinformation about weight management,” Ryan said during a teleconference ahead of Obesity Week 2013.
That culture, Ryan said, promotes dietary supplements and diets that promise quick and easy weight loss. Five specific areas of focus have been documented in the guidelines.
Identifying patients who need to lose weight
Recommendations under the first area of focus include measuring height and weight and calculating BMI at annual visits or more frequently; using the current cut points for overweight (BMI >25-29.9) and obesity (BMI ≥30) to identify adults who may have an increased risk for CVD and current cut points for obesity to identify adults who may have an increased risk for all-cause mortality.
Health care providers are recommended to advise their overweight and obese adult patients that the greater their BMI, the greater their risk for CVD, type 2 diabetes and all-cause mortality. Waist circumference (WC) should also be measured at annual visits or more frequently in overweight or obese adult patients, according to the recommendations.
Matching treatment benefits with risk profiles
Under the second area of focus, the task force suggests that health care providers counsel overweight and obese adult patients with risk for CV factors, including hypertension, hyperlipidemia and hyperglycemia.
“In terms of identifying benefits of weight loss, we recommend providers counsel patients that lifestyle changes which produce even modest weight loss can result in clinically meaningful health improvements — reductions in triglycerides, glycemic control, reductions in HbA1c, and reductions in risk for type 2 diabetes,” Ryan said. “These benefits begin in weight loss in the range of 3% to 5%, although most studies that we recommended to goal for weight loss was 5% to 10%. Of course, greater amounts of weight loss will improve blood pressure, LDL, HDL, and reduce the need for medications to control BP and glucose and lipids.”
Diets for weight loss
It also is important for clinicians to prescribe a diet that promotes a reduced caloric intake for obese or overweight patients who would benefit from weight loss in conjunction with lifestyle interventions.
According to the guidelines, any of the following methods can be used to reduce food and caloric intake: prescribe 1,200 kcal/day to 1,500 kcal/day for women and 1,500 kcal/day to 1,800 kcal/day for men; prescribe a 500 kcal/day or 750 kcal/day energy deficit; or prescribe one of the evidence-based diets that restrict certain food types (ie, high-carbohydrate, low-fiber, or high-fat foods).
“We came down loud and clear that there is no ideal diet for weight loss and there is no superiority for any of the diets that we examined,” Ryan said of the 17 different weight-loss diets studied. “So, our recommendation is that providers prescribe a diet to achieve reduced caloric intake as part of a comprehensive lifestyle intervention. And what that diet looks like should be determined by the patients’ preferences and their health status.”
Lifestyle intervention and counseling
In addition, patients who are overweight or obese should be encouraged to participate in a comprehensive lifestyle program that supplements their goals to reach an adequately lower calorie diet and increase physical activity through behavioral techniques, according to the guidelines.
“The gold standard would be an onsite, high-intensity program that is 14 sessions in 6 months that would be comprehensive diet and physical activity. It could be provided in group or individual sessions, but face-to-face by trained interventionist to deliver the counseling, and continue for a year or more,” Ryan said.If patients do not have access to such high-intensity approaches, Ryan said the task force recommends commercial, Web- or telephone-based programs as a second option.
The guidelines also recommend using a very low calorie diet (defined as <800 kcal per day) in limited circumstances and only when provided by a trained practitioner. Clinicians are encouraged to advise their overweight or obese patients to participate in a weight-loss maintenance program for more than 1 year if they have successfully lost weight from these approaches.
Selecting patients for bariatric surgical treatment for obesity
The final recommendation advised clinicians that patients with a BMI of 40 or more and comorbidity may benefit from bariatric surgery. Also, it is recommended that clinicians offer referral to experienced bariatric surgeons for consultation and evaluation.
According to the guidelines, there is insufficient evidence to recommend for or against bariatric surgery among patients with a BMI <35.
The guidelines state that patients should be informed that specific types of bariatric surgery could depend upon individualized factors, including age, severity of obesity/BMI, obesity-related comorbidities, operative risk factors, risk of short- and long-term complications, behavioral and psychological factors, and more.
Critical next step
Ryan said pharmacotherapy was not addressed when these guidelines were developed.
“The only medications available were sibutramine and orlistat, and sibutramine was coming off the market and was removed shortly thereafter; we think that is a good opportunity for future guidelines,” she said.
In addition, the task force did not address critical areas on physical activity or weight gain due to medications, and Ryan said these areas would be good areas of focus in the future.
“The next step is the most critical, and that is translation of these guidelines, and we’re looking forward to working with the AHA, ACC, TOS and other organizations to getting these guidelines out into practice,” Ryan said.
For more information:
Jensen MD. Circulation. 2013;doi:10.1161/01.cir.0000437739.71477.ee.
Jensen MD. J Am Coll Cardiol.2013;doi: 10.1016/j.jacc.2013.11.004.
Jensen MD. Obesity. 2013;doi:10.1002/oby.20660.
Ryan DH. TOS Opening Session. Presented at: Obesity Week; Nov. 11-15, 2013; Atlanta.
Disclosure: Ryan reports consultancy with Alere Wellbeing, Amylin, Arena Pharmaceuticals, Eisai, Novo Nordisk, Nutrisystem, Orexigen, Takeda and Vivus; ownership/partnership/principal with Scientific Intake. See the full document for all other authors’ relevant financial disclosures.
Perspective
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Alan J. Garber, MD, PhD
The American Association of Clinical Endocrinologists will not endorse the recent CV risk reduction guidelines of the ACC and the AHA. The first and most broadly applicable reason is that the new guidelines from ACC and AHA are not consistent with the AACE guidelines for lipid management and CV risk reduction. There is a difference [in] the organizational view of evidence bases for these guidelines: The ACC uses an extremely narrow, very tightly-defined set of relatively few clinical trials, and excluded other forms of clinical evidence from their consideration. While that may appear to be superficially reasonable, there are large populations of patients at risk for CVD in America for whom large-scale randomized controlled trials have never been done, and in whom evidence is otherwise available only through lesser levels of evidence, such as epidemiologic or database analyses.
We believe that patients dying of CVD should benefit from the totality of medical knowledge and medical information, as well as the medical experience of skilled health care professionals. For that reason, we think there should be multiple levels of consideration in the recommendations for CV risk reductions, and that the current guidelines are insufficiently narrow for the broad population in the United States.
Perspective
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Jeffrey I. Mechanick, MD
These guidelines had been reviewed by AACE; we were unable to endorse these guidelines, even though they add quite a bit to the momentum in managing obesity and the obesity epidemic in this country.
Firstly, these guidelines fail to view obesity in the full form of a disease, which is what AACE, The Obesity Society and other societies had espoused over the last few years. In fact, at the recent meeting of the American Medical Association in June, using Resolution 420, which was authored by AACE, the AMA adopted a position that obesity is a disease.
These particular guidelines advance the field of obesity by urging all physicians to risk-stratify their patients for risk of obesity and risks as a result of obesity based on the BMI. However, they may fall short in introducing the use of pharmacotherapy, and also using the complications-centric model for risk stratification that AACE has developed.
We view all efforts to improve care for the obese patient as movements forward in providing and optimizing health care in this country. But, within the obesity space, we strongly support a position where obesity is genuinely regarded as a disease, and that management is based on a complications-centric approach.
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