Clinical Overview Of The AACE/ACE Obesity Guidelines

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Assessment &EvaluationMONICAMonica’s BMI is 35Clinical overviewof the AACE/ACEobesity guidelinesA guide for optimizing your approach to themedical care of patients with obesityAACE, American Association of Clinical Endocrinologists; ACE, American College of Endocrinology.Rethink Obesity

Assessment and evaluationIt is important to assess each individual patient thoroughly. A complete diagnosis will include bothanthropometric and clinical considerations.Diagnostic categories1NormalPatient presentation1 Screen positive for overweight or obesity BMI 25 kg/m2 ( 23 kg/m2 in some ethnicities) Presence of obesity-related disease complication that could be improved by obesity treatmentNo obesityDiagnosis1Stage 0Stage 1Stage 2Patients who presentwith overweight(BMI 25 kg/m2–29.9 kg/m2) or obesity(BMI 30 kg/m2) buthave NO complicationsPatients with a BMI 25 kg/m2, with one ormore mild to moderatecomplications or whoare being treatedeffectively withmoderate weight lossPatients with a BMI 25 kg/m2, who haveat least one severecomplication or whorequire more significantweight loss for effectivetreatmentThe diagnosis of a patient can be achieved through the following steps:EvaluationAnthropometric diagnosisClinical diagnosis Medical history Confirm that elevated BMIrepresents excess obesity Normal weight: 25 kg/m2 or 23 kg/m2 in certain ethnicitieswith waist circumference belowregional/ethnic cutoffs Physical examination Clinical laboratory Review systems,emphasizing obesityrelated complications Measure waist circumferenceto evaluate cardiometabolicdisease risk Overweight: 25 kg/m2–29.9 kg/m2Phases of chronic disease prevention and treatment goals1NormalStage 0Stage tyPrevent progressiveweight gain or achieveweight loss to preventcomplications Obesity: 30 kg/m2 Obesity history: graphweight vs age, lifestylepatterns/preferences,previous interventionsAchieve weight loss sufficient toameliorate complications andprevent further deteriorationFor patients who are overweight or have obesity, a checklist of obesity-relatedcomplications is on page 3 of the AACE Algorithm for the Medical Care ofPatients With Obesity, ranging from: None Mild to Moderate Severe1Monica presented with:BMI, Body Mass Index; AACE, American Association of Clinical Endocrinologists. BMI of 35 kg/m2 Hypertension (140/92 mm Hg) Waist circumference of 41 inches Prediabetes (A1C level of 6.3%)Monica is considered to be in the Stage 2 obesity diagnostic category.A1C, glycated hemoglobin.2Visit RethinkObesity.com to learn more.3

Treatment recommendationsTreatment based on clinical judgment1Weight classificationTreatmentNormal weightHealthy meal plan, physical activity, health education, built environmentStage 0Lifestyle/behavioral therapy, consideration of pharmacotherapy if lifestyletherapy alone is not effectiveStage 1Lifestyle/behavioral therapy, consideration of pharmacotherapy if BMIis 27 kg/m2Stage 2Lifestyle/behavioral therapy, pharmacotherapy (if BMI is 27 kg/m2),consideration of bariatric surgery (if BMI is 35 kg/m2)Once the initial plateau for weight loss has been achieved, re-evaluate the obesity-related complications.If the complications have not been treated to target, then obesity treatment should be intensified orcomplication-specific interventions need to be employed.1Obesity is a chronic disease and the diagnostic categories for obesity may not be static.Therefore, patients require ongoing follow-up, re-evaluation, and long-term treatment1Monica is in Stage 2, which calls for a combination of lifestyle/behavioraltherapy, pharmacotherapy, and possible bariatric surgery.MONICAMonica’s BMI is 354Visit RethinkObesity.com to learn more.5

Anthropometric measurementand diagnosisThe clinical component of diagnosisPatients may present with either obesity or obesity-related complications. Since complications may oftenpresent with overweight or obesity, it’s important to check for both.For patients with BMI 25 kg/m2, anthropometric diagnosis includes the following steps1:1. Clinically interpret BMI2. Assess waist circumference3. Consider body composition measurementEvidence-based screening and diagnosis for excess adiposityin clinical settingsEvaluation criteria for obesity therapy1Patients present withoverweight or obesity(anthropometric component)Candidatesfor obesitytherapyPatients present withobesity-related disease or complication(clinical component) Prediabetes Metabolic syndromeScreening Type 2 diabetes DyslipidemiaAnnual BMI BMI 25 kg/m² BMI 23 kg/m² forsome ethnicities BMI 25 kg/m² BMI 23 kg/m² forsome ethnicitiesDiagnosis (Anthropometric Component)Patients presentwith BMI 25 kg/m2,or 23 kg/m2 incertain ethnicities,and excess adiposityEvaluate forobesity-relatedcomplications Hypertension Cardiovascular disease Nonalcoholic fatty liver disease Polycystic ovary syndrome Female infertility Male hypogonadismEvaluate foroverweightor obesity Obstructive sleep apnea Asthma/reactive airway disease Osteoarthritis Urinary stress incontinence1. Clinical interpretation of BMI: Ensure elevatedBMI is indicative of excess adiposity by assessing:age, gender, muscularity, hydration status, edema,third space fluid collection, large tumors, sarcopenia Gastroesophageal reflux disease Depression2. Waist circumference if BMI 35: Addsinformation pertaining to cardiometabolic diseaserisk; use gender- and ethnicity-specific cut-off values3. Consider body composition technologies: eg,bioelectrical impedance, air/water displacementplethysmography, or dual-energy X-rayabsorptiometry scanFor more information on how to properly screen patients for obesity-relatedcomplications, please refer to page 3 of the AACE Algorithm for Medical Care ofPatients with ObesityClinical component of diagnosis6Visit RethinkObesity.com to learn more.7

Obesity treatment optionsEvaluation-based treatment goalsAfter a patient has been diagnosed with overweight or obesity, lifestyle/behavioral modification should beimplemented to help prevent further weight gain. Adjunctive treatment with pharmacotherapy for obesitymanagement can also be considered based on clinical judgment.1Treatment goals should be based on a diagnosis that includes both anthropometric and clinical components.They should include intervention/weight loss goals and clinical goals.1Reasons to initiate anti-obesity medication include1:Associated riskWeight loss goalClinical goalMetabolic syndrome10% Prevent type 2 diabetesPrediabetes10% Prevent type 2 diabetes Failure on lifestyle therapy Weight regain on lifestyle therapy Presence of obesity-related complications Reduce A1CWhen to initiate anti-obesity medication in patients with overweight/obesity1Initiate lifestyle therapyPatients with no complicationsPatients with mild tomoderate complicationsWhen lifestyle therapy is anticipated toachieve sufficient weight loss to amelioratethe complicationInitiate anti-obesity medication asan adjunct to lifestyle therapyFailure to lose weightPatients who have progressive weight gain orwho have not achieved clinical improvementin obesity-related complications on lifestyletherapy aloneWeight regain on lifestyle therapyPatients with overweight or obesity who areexperiencing weight regain following initialsuccess on lifestyle therapy aloneType 2 diabetes5%–15% or more Reduce number and/or doses ofglucose-lowering medications Diabetes remission, especially when diabetesduration is shortDyslipidemia5%–15% or moreHypertension5%–15% or moreAsthma/reactive airway disease7%–8% or more Lower triglycerides and non-HDL-c Increase HDL-c Lower systolic and diastolic blood pressure Reduce number and/or doses ofantihypertensive medications Improve FEV1 Improve symptomatologyA1C, glycated hemoglobin; FEV1, forced expiratory volume in 1 second; HDL-c, high-density lipoprotein cholesterol.Presence of obesity-related complicationsPatients with overweight or obesity who haveobesity-related complications, particularly if severe,in order to achieve sufficient weight loss toameliorate the complicationFor more information on preferred anti-obesity medications and how to use them,see page 6 of the AACE Algorithm for the Medical Care of Patients With Obesity18Based on Monica’s diagnosis of obesity with hypertension and prediabetes, aweight loss goal of 10%–15% should be set with the goal of preventing type 2diabetes, lowering blood pressure, and reducing antihypertensive medications.Visit RethinkObesity.com to learn more.9

Diagnosing and managing obesityFor patients with overweight or obesity, the principal therapeutic target should be to improve patients’ health bypreventing or treating obesity-related complications. Evaluating patients for risk and obesity-related complicationsis critical in the development of a therapeutic plan for weight management.1Diagnosis and medical management of obesity1DiagnosisAnthropometric component (BMI kg/m2) 25 23 in certain ethnicitieswaist circumference belowregional/ethnic cutoffs25–29.923–24.9 in certain ethnicities 30 25 25 25 in certain ethnicities 23 in certain ethnicities 23 in certain ethnicitiesComplication-specific staging and treatmentClinical componentEvaluate for presence or absence ofadiposity-related complications andseverity of complications Metabolic syndrome Prediabetes Type 2 diabetes Dyslipidemia Hypertension Cardiovascular disease Nonalcoholic fatty liver disease Polycystic ovary syndrome Female infertility Male hypogonadism Obstructive sleep apnea Asthma/reactive airway disease Osteoarthritis Urinary stress incontinence Gastroesophageal reflux disease Depressiona. All patients with BMI 25 have either overweight or obesity stage 0 or higher, depending on the initial clinical evaluation for presence andseverity of complications. These patients should be followed over time and evaluated for changes in both anthropometric and clinicaldiagnostic components. The diagnoses of overweight/obesity stage 0, obesity stage 1, and obesity stage 2 are not static, and diseaseprogression may warrant more aggressive weight-loss therapy in the future. BMI values 25 have been clinically confirmed to represent excessadiposity after evaluation for muscularity, edema, sarcopenia, etc.b. Stages are determined using criteria specific to each obesity-related complication; stage 0 no complication; stage 1 mild to moderate;stage 2 severe.10Disease stageChronic diseasephase of preventionNormal weightPrimaryOverweight stage 0Secondary Lifestyle therapy:Reduced-calorie healthy meal plan/physicalactivity/behavioral interventionsSecondary Lifestyle therapy:Reduced-calorie healthy meal plan/physicalactivity/behavioral interventions Anti-obesity medications: Consider iflifestyle therapy fails to prevent progressiveweight gain (BMI 27)Tertiary Lifestyle therapy:Reduced-calorie healthy meal plan/physicalactivity/behavioral interventions Anti-obesity medications: Consider iflifestyle therapy fails to achieve therapeutictarget or initiate concurrently with lifestyletherapy (BMI 27)Tertiary Lifestyle therapy:Reduced-calorie healthy meal plan/physicalactivity/behavioral interventions Add anti-obesity medication: Initiateconcurrently with lifestyle therapy (BMI 27) Consider bariatric surgery: (BMI 35)Obesity stage 0Obesity stage 1Obesity stage 2Suggested therapy(based on clinical judgment) Healthy lifestyle:healthy meal plan/physical activityc. Treatment plans should be individualized; suggested interventions are appropriate for obtaining the sufficient degree of weight loss generallyrequired to treat the obesity-related complication(s) at the specified stage of severity.d. BMI 27 is consistent with the recommendations established by the US Food and Drug Administration for weight-loss medications.Visit RethinkObesity.com to learn more.11

Reference: 1. Reprinted with permission from American Association of Clinical Endocrinologists 2016. AmericanAssociation of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelinesfor medical care of patients with obesity. Endocr Pract. 2016;22(suppl 3):1-203.AACE does not endorse or recommend the use of any specific commercial product, process, or service. This promotional material should not beconstrued as an endorsement of a product by AACE. Under no circumstances should this material replace the diagnosis, advice, treatment orjudgment of medical professionals.Visit the AACE Obesity Resource Center at obesity.aace.com for morevaluable information, including: A complete set of resources to help you assist patients with obesity from diagnosisto treatment and management How appropriately sized equipment and furnishings can ensure patient comfort Where to purchase appropriate equipment and furnishingsRethink Obesity Rethink Obesity is a registered trademark of Novo Nordisk. RethinkObesity.com is a Novo Nordisk A/S website.Novo Nordisk is a registered trademark of Novo Nordisk A/S. 2019 Novo NordiskPrinted in the U.S.A.US19OB00039February 2019

American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocr Pract. 2016;22(suppl 3):1-203. AACE does not endorse or recommend the use of any specific commercial product,

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