The obesity epidemic has reached critical proportions. A new practice guide from the American Gastroenterological Association aims to help gastroenterologists engage in a multidisciplinary effort to tackle the problem.
The guide, entitled “POWER: Practice Guide on Obesity and Weight Management, Education and Resources,” includes a comprehensive clinical process for assessing and safely and effectively managing patients with obesity, as well as a framework focused on helping practitioners navigate the business operational issues related to the management of obesity. Both are in press for the May issue of Clinical Gastroenterology and Hepatology (2016. doi: 10.1016/j.cgh.2016.10.023 ).
The POWER model recognizes obesity as an epidemic and as an economic and societal burden that should be embraced as a chronic, relapsing disease best managed across a flexible care cycle using a team approach.
Gastroenterologists are uniquely positioned to help provide that care, whether as a team leader and developer or by joining forces with an existing care team, according to the lead author of the practice guide, Andres Acosta, MD, PhD .
“Every single gastroenterologist is at the front line of this obesity epidemic. Before patients develop diabetes or joint problems or cardiovascular disease, they are already in our clinics, they already have [gastroesophageal reflux disease], they have nonalcoholic fatty liver disease, they have colon cancer – and those conditions present even earlier than the other complications of obesity,” said Dr. Acosta of the Mayo Clinic, Rochester, Minn.
The guide is a model for addressing obesity – the root cause of many of these conditions – rather than simply treating its symptoms, he added.
The approach to obesity management promoted by POWER involves four phases along a continuum of care: assessment, intensive weight loss intervention, weight stabilization and reintensification when needed, and prevention of weight regain.
It is designed for flexibility across different practice types and different patient needs, according to Sarah Streett, MD , who is also an author of the practice guide and the episode-of-care framework (Episode-of-Care Framework for the Management of Obesity: Moving Towards High Value, High Quality Care model). The episode-of-care framework was developed to “help gastroenterology practices assess their ability to participate in and implement an episode of care for obesity, and understand the essentials of coding and billing for these services,” according to an AGA press release.
Lifestyle changes are the cornerstones of obesity management and maintenance of weight loss, but the POWER model includes much more, as it incorporates guidance on the use of pharmacotherapy, bariatric endoscopy, and surgery.
“We tried to make it extremely simple, bringing it down to the busy clinician level,” Dr. Acosta said. “We want to be able to embrace and tackle obesity… in a very straightforward manner.”
Gastroenterologists shouldn’t be afraid of taking on obesity, he added.
“We feel comfortable managing extremely complicated medications, so we should be able to handle the obesity medications. We are already endoscopists… so we want all gastroenterologists to say, ‘I can do this, too; I can incorporate this into my practice,’ ” he said.
Further, gastroenterologists already have a relationship with bariatric surgeons, so referring those with obesity for surgery if appropriate is also simple, he added.
When it comes to moving through the four phases of care, each should be addressed separately using the best evidence available. Realistic goals should be set, and only when those goals are met should care move to the next phase, according to the guide. Learn how to implement the AGA Obesity Practice Guide at www.gastro.org/obesity .
The assessment phase should include a medical evaluation to identify underlying etiologies, screen for causes of secondary weight gain, and identify related comorbidities. A nutrition evaluation should focus not only on nutritional status and appetite, but also on the patient’s relationship with food, food allergies and intolerances, and food environment. A physical activity/exercise evaluation should explore the patient’s activity level and preferences, as well as limiting factors such as joint disease.
A psychosocial evaluation is particularly important, as behavioral modification is a critical component of successful obesity management, and some patients – such as those with a low score on the weight Efficacy Lifestyle Questionnaire Short-Form – may benefit from referral to a health care professional experienced in obesity counseling and behavioral therapy.
Gastroenterologists already work with other specialists, including nutritionists, psychiatrists, and psychologists within their institutions and communities, so the POWER model is an extension of that.
“That’s what this proposes – a multidisciplinary team effort,” he said.
The approach to treatment should be based on the findings of these assessments.
“Physicians should discuss all the appropriate options and their expected weight loss, potential side effects, and figure in the patient’s wishes and goals. Furthermore, physicians should recognize special comorbidities that may favor one intervention over another,” the authors wrote.
The intensive weight loss intervention phase should be based on modest initial weight loss goals, which increase the likelihood of success, increase patient confidence, and encourage ongoing efforts to lose weight. Further, modest weight loss vs. larger amounts of weight loss – is more easily achieved and maintained. In addition to lifestyle changes, an evaluation of whether other interventions are needed is important, particularly in patients with weight regain or plateaus in weight loss.
The weight stabilization and intensification therapy for relapse phase is essential to prevent weight regain and its associated consequences. This phase introduces patients to the attitudes and behaviors that are likely to lead to long-term maintenance of weight loss, the authors note.
The prevention of weight regain phase – a maintenance phase – is unique among obesity care guidelines, and is a critical component of obesity management, Dr. Acosta said.
“Helping patients lose weight and keep it off requires a comprehensive and sustained effort that involves devising an individualized approach to diet, behavior, and exercise,” he and his colleagues wrote.
In addition to detailed steps and tips for moving through this care cycle, the POWER guide also details the various tools to facilitate adherence to a healthier diet and lifestyle. Various medications, including phentermine, extended-release phentermine/topiramate, lorcaserin, and liraglutide are described, as are various types of bariatric endoscopy and bariatric surgery.
A section on addressing the unique needs of obese children and adolescents is also included in the guide for those gastroenterologists who treat children.
“Obesity really begins in childhood, so it is a pediatric disease in its origin, so it was important to us to incorporate issues unique to children for our pediatric GI colleagues,” Dr. Streett said.
Importantly, the practice guide was developed with input from the Society of American Gastrointestinal and Endoscopic Surgeons, The Obesity Society, the Academy of Nutrition and Dietetics, and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. and the program has been endorsed with additional input by the American Society for Gastrointestinal Endoscopy, American Society for Metabolic and Bariatric Surgery, American Association for the Study of Liver Diseases, and the Obesity Medicine Association.
This collaborative approach is also unique among existing guidelines, and is important, given the need for practitioners across the care spectrum to work together to address obesity, she said.
“What we’ve been doing [individually] hasn’t worked successfully, so that is something that people recognize in the field of medicine: Obesity is something that has physiological, nutritional, dietetic, socioeconomic, and behavioral aspects and we need to have a multipronged approach for success. We need patients to be hearing similar messages and having their care integrated,” she said, adding that “as we move toward a value-based schema, this is the perfect disorder to address in that way.”
Dr. Acosta is a stockholder of Gila Therapeutics and serves on the scientific advisory board or board of directors of Gila Therapeutics, Inversago, and General Mills. Dr. Streett reported having no disclosures.
