Miriam E Tucker

May 26, 2016

ORLANDO, Florida — New evidence-based obesity-management guidelines from the American Association of Clinical Endocrinologists (AACE) recommend approaching obesity as a chronic medical condition, with the focus firmly on improving patient health rather than weight loss per se.

The clinical practice guideline executive summary was published online May 24, 2016 in Endocrine Practice, along with a color-coded graphic algorithm and a separate statement about incorporating obesity management into the medical chronic-care model.

The full evidence review will be published later this year, also in Endocrine Practice.

The document and algorithm expand on AACE's 2014 obesity "framework" to cover screening, diagnosis, evaluation, therapeutic decisions, treatment goals, and follow-up.

They provide a scheme for obesity staging (from 0 to 2) using anthropomorphic and clinical evaluations in addition to body mass index (BMI), with different cutoffs for certain ethnic groups, and recommendations to screen for 16 weight-related comorbidities. Based on that information, guidance is given for the use of lifestyle modification, when to consider weight-loss medications, individualization of their use, and when to consider bariatric surgery.

"We think what we've developed is a model for the chronic care of people with obesity, applicable to real-world care and comprehensive in nature," AACE Obesity Scientific Committee chair W Timothy Garvey, MD, told Medscape Medical News in an interview here at the AACE 2016 Annual Meeting, during which the guidelines are being officially launched.

"We hope to establish a care model that's relevant to primary care and subspecialty care that will optimize the benefit/risk ratio and that identifies a rational approach to when you use medicines, how you use medicines, and the treatment goals. Nobody has really specified that. I think we address some of those issues in an evidence-based manner," Dr Garvey indicated.

How Do the Guidelines Compare?

Dr Garvey pointed out that other obesity guidelines either are not evidence-based or are limited to answering selected questions when only strong scientific evidence is available and therefore "may not be meaningful or translatable to actual patient care.…We think these guidelines fill that void."

Asked to comment, Michael D Jensen, MD, who cochaired the panel that developed the 2013 joint obesity guidelines from the American College of Cardiology (ACC)/American Heart Association (AHA)/Obesity Society (OS) called the AACE effort "very commonsense and built of good judgment" but also said that it doesn't have the "scientific rigor" of the ACC/AHA/OS document.

Indeed, as Dr Garvey noted, the ACC/AHA/OS document was designed to answer just five questions with very specifically defined data, whereas the new AACE guidelines answer nine questions and include a wider range of evidence. Moreover, only one of the five currently marketed weight-loss drugs was available at the time the ACC/AHA/OS document was developed, so it doesn't include specific guidance on their use.

In the meantime, the US Endocrine Society also issued guidelines on the pharmacological management of obesity in January 2015, which endorsed use of approved weight-loss medications for people with a BMI of 30 kg/m2 and above or at least 27 kg/m2 with one or more comorbidities.

Dr Jensen commented: "Because of the nature and intensity of the way [ACC/AHA/OS] did it, we could only address five questions, but I think we answered those definitively….Theirs [AACE] is a much broader approach."

Nonetheless, Dr Jensen said that he has only one major disagreement with the AACE algorithm: it advises consideration of weight-loss drugs in people who are obese but have no other medical problems.

"There are no data anywhere in the literature [to support] that if you give medications, which all have risks and expenses, to people who are completely healthy to begin with, you're going to do anything other cost them money and [subject them to] the risk of complications from the medications."

And Dr Jensen noted that while he absolutely agrees with AACE's complication-based staging approach rather than the current BMI-based schema, "nothing in the literature says that interventions will be more effective if you categorize people that way."

Moving the Field Forward

But another obesity expert praised the AACE effort.

"This update and expansion of the AACE algorithm will be a valuable resource for endocrinologists, and I suspect in some cases general providers as well. Their complications-centric approach to risk stratification is a useful paradigm shift to align disease severity with treatment intensity," said Scott Kahan, MD, director of the National Center for Weight and Wellness and chair of the Obesity Society's clinical committee.

Dr Kahan added, "I also applaud that they have attempted to include ethnic considerations."

Dr Garvey told Medscape Medical News that although the guideline is very comprehensive, nothing in it should be difficult to incorporate into routine clinical care.

"This can be done in the context of a routine patient visit.…I don't think what we're advocating in terms of best practices takes you much beyond initial patient physical history and review of systems."

He also said that AACE hopes the document will prompt insurers to cover obesity treatment more consistently. "More and more employers are recognizing the value of obesity care and asking for coverage for obesity medicine for their employees. We have a lot of work to do, but hopefully these guidelines will provide a rational framework to move that process down the road."

Dr Garvey reports that he is a consultant for AstraZeneca, Vivus, LipoScience, Daiichi Sankyo, Janssen, Eisai, Takeda, Boehringer Ingelheim, and Novo Nordisk. He is a shareholder with Ionis, Novartis, Bristol-Myers Squibb, Pfizer, Merck, and Eli Lilly. He has received research grants from Merck, Weight Watchers, Sanofi, Eisai, AstraZeneca, Lexicon, Pfizer, Novo Nordisk, and Elcelyx. Disclosures for the coauthors are listed in the article. Dr Jensen is on an advisory board for Novo Nordisk. Dr Kahan has no relevant financial relationships.

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Endocr Pract. Published online May 24, 2016. Article

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