Conversations from ObesityWeek® 2023

The American Association of Clinical Endocrinologists (AACE) and European Association for the Study of Obesity (EASO) have adopted the diagnostic term “adiposity-based chronic disease” to clinically stage obesity severity and clinical response to therapy.

W. Timothy Garvey, MD, associate director of the department of nutrition sciences at the University of Alabama at Birmingham, was a part of a panel focused on this topic at ObesityWeek® 2023. He spoke with MD /alert about the significance of this diagnostic term, what it means for staging a patient, and advice to clinicians. 

Can you explain the term, adiposity-based chronic disease? 

Well, back in 2014, this professional organization, AACE (American Association of Clinical Endocrinologists), we wondered why we were developing new clinical tools to treat obesity that were effective and safe but that they were underutilized and obesity as a disease was under diagnosed. Many patients remained [obese]; the evidence-based therapies were not accessible to them. So, we put together a consensus conference, if you will, of all different segments of society that had a vested interest in obesity that needed to work together to support a solution. And this includes not only a number of professional societies, pharma, but also large employers, CEOs of health organizations, healthcare organizations, regulators, research, NIH, education, American Association of Medical Colleges; a number of different groups like that. 

This conference led to some emergent concepts. One is that obesity as a diagnosis based on BMI was totally inadequate. Large employers didn't understand what the health implications were. BMI is only a height and weight; it is not even a direct measure of fat mass, and it tells you nothing about how excess adiposity is affecting health in any one individual. So, it just seems to be an inadequate term and not medically actionable. 

This has led to this adoption of a diagnostic term, not for everyday parlance, but for clinical diagnosis of adiposity-based chronic disease. Because one, it tells you what we're treating: adiposity-based, and that's abnormalities in the mass distribution and function of adipose tissue; and why we're treating it, and that's the chronic disease part. Just like any other chronic disease, obesity is associated with complications, and it's those complications that make people sick. It's those complications that confer morbidity and mortality. It's those complications that it's incumbent upon us to prevent and to treat. And of course, many of them can be treated through weight loss, per se. So, that's the idea. It's changed the way we look at obesity conceptually, away from just high BMI, to a chronic disease characterized by an abnormality in energy balance, leading to excess adiposity that impairs health through complication. So, that makes it more medically actionable and helps us a little bit in kind of messaging what is incumbent upon us as health care professionals.  

Has this changed the way patients are staged? 

Well, concomitant with a term like adiposity-based chronic disease, what now becomes the diagnostic criteria for the disease? Well, yes, we continue to need an anthropometric component, and we use BMI for that generally, even though it's not perfect. But in addition, we need a clinical component, which is really surveilling the patient for the risk, presence, and severity of complications and then individualizing therapy to greater or lesser aggressiveness based on how sick the patient is, in terms of the severity of these complications. 

So, we've got to anthropometric component and a clinical component to the disease that has to go hand in hand. AACE has a very simple paradigm for staging the disease. Stage zero if there's no complications. This could include, for example, the metabolically healthy obese that are insulin sensitive. Those patients may still be at risk of the biomechanical complications of obesity like osteoarthritis, but if they don't have those, they're kind of complication free at that point. A structured lifestyle intervention to prevent further weight gain and prevent the emergence of complications may be the suitable therapy in those; this requires clinical decision making and harmonization of goals with your patient. But that's one possible approach to therapy.

If there's mild-to-moderate complications, then that's stage one, and you really need to think about medications there, in addition to lifestyle therapy. Stage three is one or more severe complications. Then, medications are definitely in order, and patients should be considered even for bariatric surgery on a select basis. So, it's just a very simple staging paradigm. 

What advice do you have for clinicians? 

Forty percent of your patients that walk into your office have obesity. Okay? The one thing I'd like to come away with is just raise the question with your patient in an empathetic way: Would you like to discuss how a weight problem may be affecting your health? Just that simple. You don't have to use the word "fat," you don't even have to use the word "obesity." And you're asking for permission of the patient to discuss this. If they say no, the answer's no, try to bring it up maybe at the next visit. If the answer is yes, try to explain that to them and go over what the options might be for treatments. You don't have to start treatment and get everything going on the one visit, but just get the patient thinking about it. The important thing is we now have tools to really treat this disease effectively. And so, just start thinking more about diagnosing and treating adiposity-based chronic disease in your patient population, and at least discussing it with your patient, and how the weight problem again is affecting your health. 

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Disclosures: Garvey has served as on the advistory boards for Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Merck, Fractyl Health, Inogen, Alnylam Pharmaceuticals, Pfizer, and Milken Institute.

Any views expressed above are the author's own and do not necessarily reflect the views of MD /alert. This transcript was digitally generated and edited for clarity.

Implementing effective behavioral interventions for obesity remains a key challenge for the community of clinicians and patients. The topic of disseminating these interventions in diverse settings was presented at ObesityWeek® 2023.

MD /alert spoke with Susan B. Sisson, Ph.D., RDN, CHES, FACSM, director of the Behavioral Nutrition and Physical Activity Laboratory at The University of Oklahoma, about her work focused on early childhood programs in indigenous populations. 

Can you provide the background of your work and your current project? 

The context that I am specifically speaking about is my collaborative work with indigenous populations. So, that is a community, a population, groups of people, tribes, and nations, that I work with frequently and that are often considered underserved and underrepresented in just the general population. Another aspect of diverse settings is that I'm talking about bridging clinical care into community settings. So, not talking about regular doctor's offices, although there's some of that, but also bridging that into community settings. We've seen evidence that clinical obesity treatment is moderately successful. But then patients have real world things that are challenging that they might face outside the clinic. Thus, if we think about expanding obesity prevention into some of those community spaces, that diverse setting, and partner and bridge with clinicians, there might be more opportunity. I work specifically with young children. And so, thinking about the spaces that young children spend a lot of time as a diverse setting for obesity prevention. This shifting outside of the clinic is the concept behind the obesity chronic care model, which has informed a lot of my work and then the work that I'm also sharing at ObesityWeek®. 

I don't see patients. I work with clinicians; I collaborate with them. It takes a lot of people to do this work. So, [it’s] working with communities to think about where children spend time, young children spend their time. The early care and education environment, preschool, is a space where children spend a lot of time, and those caregivers, those teachers, those educators, have a great opportunity to influence the young children. There's a lot of evidence in the research literature that shows that the things that teachers do in a classroom can support or deter children's healthy eating and physical activity. Both of those are behaviors that we know are associated with disease prevention and also obesity prevention. So, [it’s] thinking about how we can bridge language and messaging, shared messaging in a collaborative way, between clinics and early care and education programs and spaces—so, a shared training, a shared language.

This is kind of novel, because the two systems don't usually work together that way. You know, doctors kind of stay in the office, and teachers kind of stay in schools. So, how do we create opportunity to bridge the spaces with shared language, focusing on those health behaviors of those young children? 

Do you have any advice for clinicians? 

You know, I think in my experience, in working with indigenous communities in particular, just the cultural practices and beliefs are really important, and the central piece of working with those communities is in relationship building. The care and the investment in building a relationship with a person is central to trust, and to then trusting what you say about my health, and then me doing what you've asked me to do for my health. That's really difficult to do in those traditional 15-minute patient visits, especially when there might be other health concerns; there might be other pressing health concerns. So, I think finding innovative ways to bring health and health care outside of its traditional walls is going to be advantageous to minority communities and honestly to all people.

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Disclosures: Susan Sisson has disclosed the following relevant financial relationships: Serve(d) as an employee for: University of Oklahoma Health Sciences Center Serve(d) as a speaker for: Obesity Week Received research grant from: USDA as PI.

Any views expressed above are the author's own and do not necessarily reflect the views of MD /alert. This transcript was digitally generated and edited for clarity.

A symposium presented at ObesityWeek® 2023 explored the connections that organs—such as the brain, liver, as well as muscle, bone, and adipose tissue—have to energy balance and metabolism. These relationships influence hormones and signaling molecules to regulate weight and are a focus of current research.

Kristin Stanford, PhD, professor at The Ohio State University College of Medicine, and Kristen Beavers, PhD, MPH, RD, professor at Wake Forest University, spoke with MD /alert about their research investigating these connections.

Can you describe your translational approach to this topic? 

Kristin Stanford

Our lab really looks at how exercise can improve whole body metabolic and cardiovascular health. We've identified some lipids that are released from adipose tissue in response to exercise that can promote whole body metabolism and have been shown to reduce adiposity and limit weight gain. 

So, we're really interested in this lipid. It's called 12,13-diHOME. It's a linoleic acid metabolite.  What we've seen is that when this lipid has increased in circulation, which we've done through non-viral overexpression or can also be done through exercise, we see that it reduces triglyceride accumulation in the liver. When we induced a sustained overexpression in mice, it contributes to reduced weight gain when these mice are on a high-fat diet, which then increases skeletal muscle triglyceride metabolism. In humans, it's correlated to reduced BMI and adiposity. 

How is this useful when talking about inter-organ involvement with weight regulation? 

KS

So, we know that it's released, at least in response to exercise or cold, it's released from brown adipose tissue, but it's talking to other tissues. It's promoting metabolism and triglyceride uptake in other tissues. So, for example, we know that when we have a sustained overexpression of this lipid in circulation in a rodent model, it's correlated to reduced adiposity. We have less weight gain, less accumulation of white adipose tissue. We also see that it talks to the heart and improves cardiac function, basically, [it] directly has a direct effect on cardiac function. We've also seen that it improves skeletal muscle metabolism, and we've seen that both in vivo and in vitro. In humans, an increase in this lipid is correlated to increased skeletal muscle respiration. So, it really seems that this lipid released from one tissue is talking to all these other tissues to improve metabolism. 

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Can you describe your interventional approach to this topic? 

Kristen Beavers

I'm interested in optimizing weight loss interventions in older adults and we have a couple of studies going on at Wake Forest focused on minimizing musculoskeletal tissue loss that happens with weight loss. People want to lose weight, they want to lose fat, but some weight they lose is not fat. For older adults, in particular, if they lose too much muscle and bone, and that exacerbates age-related risk of these tissues being lost and possible disability risk or fracture. These are things that you'd like to avoid. Our group spends a lot of time and energy thinking about ways that we might mitigate this risk.

We have a few studies, intervention trials going on right now, under that kind of umbrella theme. One is looking at wearing a weighted vest as kind of a gravitational loading mimetic. The thought here is if one of the reasons that you lose bone was weight loss is that you've unloaded yourself, but then we'll load you back. The nice thing about a weighted vest in particular is that we can sneak it into activities of daily living, which is helpful for older adults. Getting older adults to go to gym is a little bit harder of a lift than getting them to walk. That's a strategy that we're testing out in a study called INVEST right now. 

We also have a study in bariatric surgery patients. So, this is a project focused on recruiting middle aged and older, so not my typical older adults, but middle aged and older adults who are undergoing bariatric surgery, because these folks lose a lot of weight and lose a lot of bone. We are seeing if we can repurpose a medication called risedronate, which is a bisphosphonate; these medications have been on the market for a long time. [They are] used to manage and treat age-related bone loss to see if they could also be used to mitigate bone loss secondary to bariatric surgery. So, that's another study that's ongoing. 

Then the last study that we have going on right now, an intervention study, is looking at the combination of the two. So, if you have older adults who are living with overweight or obesity, so an indication for weight loss, who also have low bone mass, they have an indication perhaps for pharmacotherapy: What do you tell them? You put them in a situation where they're going to lose weight; so, we're pretty sure they'll lose some bone. Should they exercise? Should they take a medication? Should they do both? That's what the last study, it's called BEACON, is designed to try to answer.  

How is this useful when talking about inter-organ involvement with weight regulation? 

KB

There are lots of things to consider, and then it's not just the act of treating of obesity, it's thinking about the long-term effectiveness of those interventions, because weight regain isn't without consequence. That’s, again, something that I just think it's worth being aware of. I wish I could offer up a solution. But it's really something to consider when thinking about weight loss recommendations for older adults. 

There's certainly lots of benefits to weight loss. I mean, on cardio metabolic system, very well established, honestly, lots of improvements in function, which is very relevant for older adults. But I guess, you know, what we're trying to do is take a good thing and make it better and thinking specifically about what we can do to minimize bone and muscle loss, particularly with an eye on long term fracture risk for these individuals.

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Disclosures: No authors declared financial ties to drugmakers.

Any views expressed above are the author's own and do not necessarily reflect the views of MD /alert. This transcript was digitally generated and edited for clarity.