What Is Obesity Medicine? Introduction to the the Field of

What Is Obesity Medicine? Introduction to the the Field of Obesity Medicine

Objectives As a result of this presentation, participants will better understand: Definition of obesity medicine How to diagnose obesity History, trends, and evolution of obesity medicine Challenges and opportunities in the field

What Is Obesity Medicine? The field of medicine dedicated to the comprehensive care of patients with obesity Source: Obesity Medicine Association 2016

Evolving Definitions of Obesity Body mass index (BMI) has been the traditional method for “defining” obesity. BMI is a calculation of weight in kilograms to height in meters squared. The field of obesity medicine looks BEYOND BMI to better assess and treat patients and address their individual needs. Weight Categories BMI, kg/m2 Underweight 18.5 Healthy Weight 18.5 and 25 Overweight 25 and 30 Obesity Class I 30 and 35 Obesity Class II 35 and 40 Obesity Class III 40 “Abnormal function or excessive fat accumulation (or adiposity) in the body that may impair health.” World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000:894 1-253.

Taking It One Step Further: The Edmonton Obesity Staging System (EOSS) for Assessing RISK Stage 2 co-morbidity moderate abse nt abse nt abse n ag e Me dic al Me nta l Fu nc tio na l Stage 3 t end-s tage e nd- s Sharma AM et al. Int J Obes. 2009 Obesity tage e nd- s Stage 0 t m ild pr ris e-c k lin fa ic ct al or m ild s moderate n ga or e d- ag en am d re ve se re ve se Stage 1 Stage 4

Edmonton Obesity Staging System Stage 0: No obesity-related risk factors Stage 1: Pre-clinical risk factors – borderline HTN or DM, minor aches or psychopathology Stage 2: Established obesity-related disease – HTN, DM, PCOS, moderate limitations ADL Stage 3: Established organ damage – MI, CHF, DM comp, significant limitations of ADL Stage 4: Severe disabilities – end stage and limitations like wheelchair use Sharma AM and Kushner RF. Int J Obes. 2009;33:289-95

Edmonton Staging System Can Predict Mortality Better than BMI Padwal Padwal R et al. CMAJ. 2011 R, Sharma AM et al. CMAJ 2011

Is Obesity a Disease? PROS CONS “Obesity is a complex, multifactorial disease that develops from the interaction between genotype and the environment. Our understanding of how and why obesity occurs is incomplete; however, it involves the integration of social, behavioral, cultural, and physiological, metabolic, and genetic factors” “ If obesity is truly a disease, then over 78 million adults and 12 million children in America just got classified as sick.Everyone has friends and acquintances who now qualify as diseased. Yet many sensible people, from physicians to philosophers, know that declaring obesity a disease is a mistake. Simply put, obesity is not a disease. To be sure, it is a risk factor for some diseases. But it would be false to say that everyone who is obese is sick as to say that every normal weight person is well” 1998 - National Heart, Lung, and Blood Institute (NHLBI) “Overweight and obesity are chronic diseases with behavioral origins that can be traced back to childhood” 2013 - American Academy of Family Physicians 2013 - Richard B. Gunderman, MD, PhD

Obesity Increasingly Becoming Officially Recognized as a Disease “ a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences” “ obesity is a serious chronic disease with extensive and well-defined pathologies, including illness and death” “Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans” 2 “Obesity is a chronic disease, prevalent in both developed and developing countries, and affecting children as well as adults” 3 Mechanick JI et al. Endocr Pract. 2012;18:642–648. 2. AMA position statement. At: http://www.ama-assn.org. Accessed Oct 2014. 3. WHO. Obesity and overweight. At: http://www.who.int/dietphysicalactivity/media/en/gsfs obesity.pdf. Accessed Oct 2014. 4. US Food and Drug Administration. Federal Register. 2000;65(4):1000-1050.

Complexities of Appetite Regulation AGRP: agouti-related peptide; α-MSH: α-melanocyte-stimulating hormone; GHSR: growth hormone secretagogue receptor; INSR: insulin receptor; LepR: leptin receptor; MC4R: melanocortin-4 receptor; NPY: neuropeptide Y; POMC: proopiomelanocortin; PYY: peptide YY; Y1R; neuropeptide Y1 receptor; Y2R: neuropeptide Y2 receptor. Apovian CM, Aronne LJ, Bessesen D et al. J Clin Endocrinol Metab. 2015;100:342362.

Hypothetical “Feed-forward”: Positive Feedback Mechanism to Drive Weight Up High-fat/ High-carb food Increased endocannabinoids and resistance to leptin and insulin Hypothalamic injury -CNS insulin and leptin resistance 1. Increased food intake 2. Weight gain “Brain can’t tell how much fat is stored, how much food is eaten” 1.Reduced sense of satiety 2. Craving Slide courtesy of Louis J. Aronne, MD. Wang J, Diabetes, 2001 DiMarzo V pers comm; Ozcan L, et al, Cell Metabolism; 2009

Obesity Affects Millions of People in the United States: Obesity Today No state has a prevalence of obesity less than 20%. 6 states and the District of Columbia have a prevalence of obesity between 20% and 25%. 19 states and Puerto Rico have a prevalence of obesity between 25% and 30%. 21 states and Guam have a prevalence of obesity between 30% and 35%. 4 states (Alabama, Louisiana, Mississippi, and West Virginia) have a prevalence of obesity of 35% or greater. Prevalence reflects Behavioral Risk Factor Surveillance System (BRFSS) methodological changes started in 2011, and these estimates should not be compared to those before 2011. Centers for Disease Control and Prevention. Obesity Prevalence Maps. https://www.cdc.gov/obesity/data/prevalencemaps.html. 2015 Obesity Prevalence map. Accessed September 12, 2016.

Is This Our Future Obesity of Tomorrow? Prevalence of Obesity Among U.S. Adults Ages 20-74

Obesity diagnosis, % Yet, Obesity Remains Underdiagnosed in the U.S. Proportion of Actual Diagnoses of Obesity by BMI 100 80 57 60 46 35 40 20 23 10 0 30-34.9 35-39.9 40-44.9 45–49.9 50 BMI 23% of individuals with a BMI between 35-40 kg/m2 are diagnosed with obesity 43% of patients with BMI 50 kg/m2 are not diagnosed Crawford AG et al. Popul Health Manag. 2010;13:151–161. Data from the GE Centricity System/EMR data of 6 millions records in the US

The Economic Burden of Obesity in the U.S. Direct medical spending due to obesity and its comorbidities is estimated to be 210- 316 billion annually: 21-28% of total U.S. healthcare spending When also accounting for the indirect, non-medical costs of obesity, the overall annual cost is estimated to be 450- 556 billion Direct medical costs (U.S. healthcare spending) 21% Indirect, non-medical costs (food, clothing, employer costs, absenteeism, lost productivity) Brill. The Long-Term Returns of Obesity Prevention Policies (2013). Available at: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf405694 ; Cawley et al. PharmacoEconomics 2014: Nov 9. Overall cost of obesity: 450-556 billion/year

Cost of Living Changes with Weight Loss Reduces medication Reduces co-pays Reduces time off work and lost wages Reduces food costs Reduces accident proneness Reduces risk for cancer Reduces hospitalizations Reduces doctor visits Change in the Cost of Living after Weight Loss Can Be Dramatic: ITEMS Estimated Annual Costs Mean medical/drug costs (BMI 35)1 7,337 Out-of-pocket healthcare expenses2 2,684 Employment inactivity costs3 1,017 Commercial weight loss program fees4 678 Prescription co-pays (5 medications at 10) 738 Grocery and dining costs5 6,012 TOTAL 18,466 1. Health Management Research Center, University of Michigan, 2001; 2. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2006; 3. Source: Colditz, GA. “Economic costs of obesity and inactivity,” Med Science Sports Exercise, 1999; 4. Marketdata Enterprises, Inc., 10/02; 5. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2006

The Good News? Modest Weight Loss Can Reduce Disease Risk Potential impact of 5% average BMI reduction in the U.S. by 2020: - 3.5 million cases hypertension avoided - 0.3 million cases cancer avoided - 2.9 million cases heart disease and stroke avoided - 3.6 million cases diabetes avoided - 1.9 million cases arthritis avoided Levi et al. F as in fat: how obesity threatens America’s future, 2012. Available at: http://healthyamericans.org/assets/files/TFAH2012FasInFatFnlRv.pdf

Obesity Care Gap If treating obesity reduces the risk of so many health conditions and healthcare costs, why do so few healthcare providers diagnose and treat obesity?

Few People with Obesity are Treated in the U.S. 80 million adults with obesity in the U.S. 1% receive a prescription for an antiobesity medication in a given month 195,000 people per year receive bariatric surgery Sources: CDC 2014 (adults is defined as 20yrs. American Heart Association. Statistical Fact Sheet 2013 Update: Overweight and Obesity. http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm 319588.pdf. Accessed June 9, 2014. Understanding the Treatment Dynamics of the Obesity Market, IMS Database (NPA) Aug 31, 2014; ASMBS website, estimated number of bariatric surgeries, published July 2016; asmbs.org

What Drives the Large Care Gap in Obesity? Challenges and Barriers to Care Past failures Misaligned perceptions of success Clinician competence and confusion Prescription coverage Limited advocacy Time constraints Difficult, emotional conversations Patient engagement Few effective treatment options Provider reimbursement Cultural stigma and bias Rx market history of withdrawals Lack of clear guidelines Obesity as a disease vs. condition Competing clinician priorities STOP Obesity Alliance. Available at: www.stopobesityalliance.org/wp-content/assets/2010/03/STOP-Obesity-Alliance-PrimaryCare-Paper-FINAL.pdf. Forman-Hoffman V et al. BMC Family Practice. 2006;7:35.

Challenges in the Past: An Evolution of the Reimbursement Landscape Behavioral Therapy Reimbursement Prior to 2012: Behavioral therapy often outright excluded by most payers, as well as most other services. Bariatric surgery intermittently covered. 2010 2011 As of 2012: Medicare and most private payers cover USPSTF-recommended screening and behavioral counseling when delivered by a primary care provider (not a specialist) 2012 2013 Going Forward: Affordable Care Act (ACA) mandates coverage of screening and counseling. Coverage remains inconsistent in terms of number of visits and insurer guidelines. 2014 Centers for Disease Control and Prevention. http://www.cdc.gov; Department of Health and Human Services Centers for Medicare and Medicaid. IBT for obesity. ICN 907800. January 2014. 2015

What Is Weight Bias? Negative attitudes toward individuals with obesity Stereotypes leading to: stigma rejection prejudice discrimination Verbal, physical, relational, cyber Subtle and overt Slide courtesy of the Obesity Action Coalition, www.obesityaction.org

Why Understanding Weight Bias Is Important It prevents patients affected by obesity from seeking care and professionals from offering care. It’s the last socially acceptable form of discrimination. It hampers our nation’s efforts to effectively combat the obesity epidemic. It is a primary driver around the current limitations of access to treatment. Recognizing and combatting bias, both your own and in the community, is an important step in addressing obesity. Slide courtesy of the Obesity Action Coalition, www.obesityaction.org

Coping with Weight Stigma Study: Survey of 2,449 women How do they cope with weight-stigma experiences? - 79% reported eating, turning to food as a coping mechanism - Stigma is a stressor - Both acute and chronic forms of stress - Eating is a common response to stress Puhl and Brownell, 2006; slide courtesy of the Obesity Action Coalition

What Might Comprehensive Medical Obesity Treatment Include? Nutrition Physical Activity Behavior Medication

Growth of the Field of Obesity Medicine 2011-2015 saw a total of 36,303 newly certified physicians by the American Board of Internal Medicine New sub-specialties include adolescent medicine, transplant heart failure and transplant cardiology, critical care medicine, geriatric medicine, and addiction medicine The American Board of Obesity Medicine (ABOM) was created by the Obesity Medicine Association and The Obesity Society in 2011 and has more than 2,000 Diplomates as of 2017. The growth of this group is faster than any other field of medicine This is a pathway many have and will continue to travel Now OBESITY MEDICINE is at the frontier

Number of ABOM Diplomates 2068 1582 1155 798 587 2012 2013 Slide courtesy of the American Board of Obesity Medicine, www.abom.org 2014 2015 2016

Acknowledgements and Resources Slides courtesy of: Obesity Treatment Foundation Advancing obesity treatment through clinical research and education ObesityTreatmentFoundation.org With support from: Obesity Medicine Association: Clinical leaders in obesity medicine (obesitymedicine.org) The Obesity Society: The leading scientific society dedicated to the study of obesity (obesity.org) American Board of Obesity Medicine: Certification as an American Board of Obesity Medicine diplomate signifies specialized knowledge in the practice of obesity medicine and distinguishes a physician as having achieved competency in obesity care (abom.org) Obesity Action Coalition: Dedicated to giving a voice to the individual affected by the disease of obesity and helping individuals along their journey toward better health through education, advocacy and support (obesityaction.org) Other key organizations: American Society for Metabolic and Bariatric Surgery; American Association of Clinical Endocrinologists; Endocrine Society