Evidence needed on obesity definition, treatment, AACE declares



WASHINGTON – Obesity requires a medical definition that goes beyond gauging a person’s body mass index if cost-effective care is to be delivered in an integrated fashion, according to a consensus statement issued by the American Association of Clinical Endocrinologists and the American College of Endocrinology.

"The definition of obesity as a disease is not perfect," Dr. W. Timothy Garvey, who chaired the AACE/ACE Obesity Consensus Conference, said in a media briefing. "We rely upon an [anthropometric] measure of body mass index, which is a measure of height versus weight, and there was consensus that this was ... divorced from the impact of weight gain on the health of the individual. This imprecision in our diagnosis of obesity was constraining us."

In 2013, the American Medical Association officially recognized obesity as a disease. Better codification of what actually constitutes "obesity, the disease," will allow a more integrated and effective approach to treating it, said Dr. Garvey, professor of medicine and chair of the department of nutrition sciences at the University of Alabama at Birmingham. To do so, the AACE/ACE held an intensive, 2-day session that largely featured spontaneous discussions between panelists and audience members representing four specific obesity "pillars": biomedical, government and regulation, health industry and economics, and research and education sectors.

A constant theme across the sectors was the need for a definition of obesity that accounts for cultural differences, ethnicity, and the presence or absence of cardiometabolic markers of disease in persons who are overweight or obese.

The conference’s multidisciplined approach informed the consensus statement that obesity is a chronic disease that should be treated with the established AACE/ACE obesity algorithm and met with lifestyle interventions. The consensus statement also addressed our current "obesogenic" environment, which many participants said was created in part by the abundance of nonnutritious foods.

In an interview, Dr. Susan Kansagra, deputy commissioner of the New York City Department of Health and Mental Hygiene, said that by working with local vendors and their suppliers, among other actions, her agency is focused on increasing access to more nutritious foods in neighborhoods across the city as a way to shape the food environment. "It’s not people who’ve changed over the past 30 years; it’s the environment," Dr. Kansagra said at the conference.

Also addressed by the consensus statement was the need for preventive care, particularly at the pediatric level, and more cohesive public awareness campaigns that could affect how private payers develop their reimbursement strategies. Audience member Dr. Robert Silverman, medical director of CIGNA Healthcare, said that payers would respond to the need for obesity care, but that what currently is missing is "a tie between the evidence and the complications [of obesity]."

"We learned that different stakeholders require different levels of evidence," AACE President Jeffrey I. Mechanick said in the media briefing. "So, we’re going to be able come up with a more efficient way to make recommendations about research so that private insurance carriers, the Centers for Medicare & Medicaid Services, or regulatory agencies have the type of data they require to facilitate the action [they need]."

Dr. Jeffrey I. Mechanick

These differences were brought to light during the conference as various audience members representing the Centers for Disease Control and Prevention, the Food and Drug Administration, the CMS, the National Institutes of Health, and others involved in research and policy making, addressed the panel to either explain or defend why their agency operates as it does.

In the case of the CMS, a statutory organization, it can apply coverage only according to what the agency is mandated to do, said Dr. Elizabeth Koller of the CMS. The level of evidence the agency looks for, she said, includes "hard endpoints of clinical relevance, like reductions in sleep apnea and degenerative joint disease." The CMS is also concerned about the lack of long-term data on interventions, the durability of interventions, and which characteristics are common in people who relapse in their disease, said Dr. Koller, who addressed the group as an audience member.

"Hearing from the CMS was incredibly helpful. We learned so much," said Dr. Mechanick, director of metabolic support at the Mt. Sinai School of Medicine in New York, in an interview.

Dr. Mechanick also said this was the first of three meetings, the next to be held in about a year, where the ultimate goal would be to use the evidence base they will have created to develop recommendations for all involved in delivering obesity care.

The talk was "polite," Dr. John Morton, chief of bariatric surgery at Stanford (Calif.) University and president of the American Society of Bariatric and Metabolic Surgery, said in an interview, but he said he thinks there is bias against people with obesity. "We wouldn’t be having this discussion if it were about cancer," he said in the interview. "Sometimes we think the consequences of obesity are the result of a personal decision, and that may skew people in a direction where they don’t necessarily want to provide help."


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