Obesity medicine

Obesity medicine is a field of medicine dedicated to the comprehensive treatment of patients with obesity. Obesity medicine takes into account the multi-factorial etiology of obesity in which behavior, development, environment, epigenetic, genetic, nutrition, physiology, and psychosocial contributors play a role.^[1] As time progresses, we become more knowledgeable about the complexity of obesity, and we have ascertained that there is a certain skill set and knowledge base that is required to treat this patient population. Clinicians in the field should understand how a myriad of factors contribute to obesity including: gut microbiota diversity, regulation of food intake and energy balance through enteroendocrine and neuroregulation, and adipokine physiology.^[2] Obesity medicine physicians should be skilled in identifying factors which have contributed to obesity and know how to employ methods (behavior modification, pharmacotherapy, and surgery) to treat obesity. No person with obesity is alike, and it is important to approach each patient as an individual to determine which factors contributed to their obesity in order to effectively treat each patient.

Criticisms of the field

Some physicians do not feel as though obesity medicine should be its own sub-specialty. Rather, they feel as though obesity, as a complex disease process, should be treated by endocrinologists or physicians who have acquired additional training in the field of nutrition.^[3]

Obesity as a chronic disease

In June 2013, the American Medical Association (AMA)^[4] adopted policy that recognizes obesity as a chronic disease, a disease process which requires a range of medical interventions to prevent and treat.^[5] While professionals from different professions (US senators, congressmen and congresswomen, physicians, and medical students) applauded this decision,^[6] others were not so eager to categorize obesity as a disease.^[7] Since the initial acknowledgement of obesity as a disease by the AMA, there has been an ongoing debate about the topic.^[8]

Treatment options

In November 2013, the American College of Cardiology (ACC), the American Heart Association, and the The Obesity Society (TOS), developed the 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults.^[9][10]

In this report, they provide specific recommendations on:

1. Identifying patients who need to lose weight using body mass index (BMI)^[11] and waist circumference^[12]
2. Matching treatment benefits with risk profiles
3. Dietary strategies for weight loss
4. Lifestyle intervention and counseling
5. Selecting patients for bariatric surgical treatment for obesity

Several organizations have developed guidelines on how to manage overweight and obesity in the pediatric populations.

The Endocrine Society^[13] developed a set of clinical pediatric guidelines.^[14] In their guidelines, they provide a summary of recommendations which they outline as follows:

1. The problem with obesity
2. Diagnosis of overweight and obesity
3. Treatment of obesity- lifestyle, dietary, physical activity, psychosocial, pharmacotherapy, and bariatric surgery recommendations
4. Prevention of obesity
5. Societal barriers to implementation

The American Academy of Pediatrics (AAP)^[15] developed a robust set of guidelines which differs from those of The Endocrine Society in which they recommend the following:^[16] 1. Assessment Recommendations

• Annual assessment of weight status of all children
• Children and adolescent 2 to 18 years of age with BMI of ≥95th percentile for age and gender or BMI of >30 (whichever is smaller) should be considered obese and individuals with BMI of ≥85th percentile should be considered overweight
• Qualitative assessment of dietary patterns
• Physical activity assessment
• Thorough physical exam
• Documentation of family history of obesity related co-morbidities
• Appropriate laboratory testing for those who meet criteria for overweight or obesity

2. Treatment Recommendations

• Address weight management and lifestyle management annually
• Prevent children and adolescents in normal body mass index (BMI) range (5th to 84th percentile) from weight gain
• Children with overweight and obesity should be treated in a staged manner (taking into account their degree of risks)

3. Prevention Recommendations

• Patient Level Interventions- 1) Limit consumption of sugar-sweetened beverages, portion size, and screen time to < 2 hours/daily, and 2) Encourage breakfast daily, intake of fruits and vegetables, and family meals
• Practice and Community Level Interventions- 1) Federal and local government support to improve built environment, and 2) Encourage parents or caregivers to be good role models for children and adolescents

Education

Obesity education in medical schools and residency

Only a few medical schools and residency programs offer training and education in the field of obesity.^[17] As a result, many physicians fail to recognize obesity and are not equipped to treat it.^[18][19][20] In order to address this issue, medical schools and residency programs will need to modify their curriculum to teach their students and residents about this disease process to ensure that the large subset of the patients that they encounter in their careers receive adequate treatment.^[21]

Obesity medicine clinical fellowships

There are only a few dedicated programs which train clinicians in the field of obesity medicine:

1. Harvard Medical School Obesity Medicine and Nutrition Fellowship^[22]
2. Nemours Pediatric Obesity Fellowship^[23]
3. UTHealth Center for Obesity Medicine and Metabolic Performance

Obesity research fellowships

There are several research programs in the field of obesity:

1. University of Alabama-Birmingham^[24]
2. Johns Hopkins Obesity Research in General Internal Medicine Fellowship^[25]
3. Minnesota Obesity Prevention Training (MnOPT)^[26]
4. Yale Program for Obesity, Weight and Eating Research (POWER)^[27]
5. Centers for Disease Control & Prevention Nutrition and Obesity Fellowship^[28]
6. University of Arizona, Nutritional Sciences Graduate Program, Training Grant in Obesity Research^[29]
7. Harvard Training Program in Nutrition and Metabolism^[30]

References