Weight History in Clinical Practice: The State of the Science and Future Directions

Nutritional considerations with antiobesity medications

The improved efficacy and generally favorable safety profile of recently approved and emerging antiobesity medications (AOMs), which result in an average weight reduction of ≥15%, represent significant advancement in the treatment of obesity. This narrative review aims to provide practical evidence-based recommendations for nutritional assessment, management, and monitoring of patients treated with AOMs. Prior to treatment, clinicians can identify preexisting nutritional risk factors and counsel their patients on recommended intakes of protein, dietary fiber, micronutrients, and fluids. During treatment with AOMs, ongoing monitoring can facilitate early recognition and management of gastrointestinal symptoms or inadequate nutrient or fluid intake. Attention should also be paid to other factors that can impact response to treatment and quality of life, such as physical activity and social and emotional health. In the context of treatment with AOMs, clinicians can play an active role in supporting their patients with obesity to improve their health and well-being and promote optimal nutritional and medical outcomes.

Obesity

Obesity is a common condition and a major cause of morbidity and mortality. Fortunately, weight loss treatment can reduce obesity-related complications. This review summarizes the evidence-based strategies physicians can employ to identify, prevent, and treat obesity, including best practices to diagnose and counsel patients, to assess and address the burden of weight-related disease including weight stigma, to address secondary causes of weight gain, and to help patients set individualized and realistic weight loss goals and an effective treatment plan. Effective treatments include lifestyle modification and adjunctive therapies such as antiobesity medications and metabolic and bariatric surgery.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The relationship between weight history and psychological health-Differences related to gender and weight loss patterns

BACKGROUND

The prevalence and burden of obesity continues to grow worldwide. Psychological comorbidities may not only influence quality of life, but may also hinder successful weight loss. The causality between excess weight and mental health issues is still not fully understood. The aim of the study was to investigate whetherweight history parameters, (ie.age of onset) are related to psychological comorbidities.

METHOD

The data were derived from a representative telephone survey in Germany, collecting information on weight loss patterns and mental health outcomes among individuals with BMI>30kg/m2. Overall, 787 participants were examined in terms of depressive symptoms (Patient Health Questionnaire, PHQ-9) and anxiety (Generalized Anxiety Disorder Questionnaire, GAD7). In addition, participants were asked about different aspects of their weight history (ie. weight loss patterns and trajectories) over the lifespan. The relationship between weight history and mental health was analyzed using multivariate statistics.

RESULTS

According to regression analyses, having had more weight loss attempts, a greater weight loss being desired and being a "weight maintainer" was associated with more symptoms of depression (p < 0.001), whereas a greater desired weight loss and being categorized as a "weight maintainer" was associated with more anxiety (p < 0.001). Moroever, the prevalence of depressive symptoms was significantly higher in male individuals who desire to lose more weight or had more weight loss attempts in the past.

CONCLUSION

Gender-specific differences were observed in terms of weight history parameters, as well as mental health outcomes. Especially for men, weight loss patterns seem to be related to depressive symptoms. Concerning the overall results, it becomes clear that screening for weight history at the beginning of a multidisciplinary weight loss program in the context of gender-specific psychological comorbidities is important. The question remains why some aspects of weight history seem to be more important than others.

Baseline and longitudinal trajectories of body-mass index and all-cause mortality among patients with type 2 diabetes

AIM

To investigate the associations of baseline body mass index (BMI) and longitudinal BMI trajectories with all-cause mortality among patients with type 2 diabetes mellitus (T2DM).

METHODS,

We used data from the diabetes surveillance system of Yinzhou Health Information System with T2DM patients registered from 2010 to 2015. Participants aged ≥ 40 years were included and were followed up until September 30, 2021. The latent class growth mixture model was used to identify different changing patterns in BMI for 5 years from registration. Cox proportional hazards models were used to examine the associations of baseline BMI and 5-year BMI trajectories with all-cause mortality.

RESULTS

We observed a nonlinear association between baseline BMI and all-cause mortality (P for nonlinearity < 0.001), with an increased risk of death for low but not high BMI. However, compared with participants with medium-stable BMI for 5 years from baseline, individuals with increasing BMI had higher mortality, with adjusted hazard ratios (95% confidence intervals) 1.21 (1.02;1.43) for early-increasing and 1.47 (1.19;1.80) for late-sharp increasing groups.

CONCLUSION

These findings suggest that while obesity itself may not be associated with an increased risk for mortality, weight gain, and in particular rapid weight gain, is a risk factor for mortality among patients with T2DM.

Subtyping patients with chronic disease using longitudinal BMI patterns

Obesity is a major health problem, increasing the risk of various major chronic diseases, such as diabetes, cancer, and stroke. While the role of obesity identified by cross-sectional BMI recordings has been heavily studied, the role of BMI trajectories is much less explored. In this study, we use a machine learning approach to subtype individuals' risk of developing 18 major chronic diseases by using their BMI trajectories extracted from a large and geographically diverse EHR dataset capturing the health status of around two million individuals for a period of six years. We define nine new interpretable and evidence-based variables based on the BMI trajectories to cluster the patients into subgroups using the k-means clustering method. We thoroughly review each cluster's characteristics in terms of demographic, socioeconomic, and physiological measurement variables to specify the distinct properties of the patients in the clusters. In our experiments, the direct relationship of obesity with diabetes, hypertension, Alzheimer's, and dementia has been re-established and distinct clusters with specific characteristics for several of the chronic diseases have been found to be conforming or complementary to the existing body of knowledge.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Development of a telehealth obesity OSCE and reliable checklist for assessment of resident physicians: a pilot study

BACKGROUND

Obesity is a major public health problem, yet residents undergo little formal training and assessment in obesity-related care. Given the recent growth of telehealth, physicians must further learn to apply these skills using a virtual platform. Therefore, we aimed to develop an objective structured clinical examination (OSCE) with reliable checklists to assess resident ability to take a patient-centered obesity-focused history that was feasible over telehealth based on published obesity competencies for medical education.

METHODS

We developed a 15-minute telehealth OSCE to simulate an obesity-related encounter for residents modified from a script used to assess medical student obesity competencies. We designed three checklists to assess resident skills in history taking, communication and professionalism during the obesity-related encounter. Resident performance was assessed as the percentage of obesity-related history taking questions asked during the encounter and as the mean communication and professionalism scores on a scale of 1 through 5 with 1 representing unacceptable/offensive behavior and 5 representing excellent skills. Encounters and assessments were completed by two commissioned actors (standardized patients) and 26 internal medicine residents over a secure online platform. We assessed the reliability of each checklist by calculating the percent agreement between standardized patients and the kappa (κ) statistic on each checklist overall and by each checklist item.

RESULTS

Overall agreement between standardized patients on the history taking, communication and professionalism checklists were 83.2% (κ = 0.63), 99.5% (κ = 0.72) and 97.8% (κ =0.44), respectively. On average, residents asked 64.8% of questions on the history taking checklist and scored 3.8 and 3.9 out of 5 on the communication and professionalism checklists, respectively.

CONCLUSIONS

Results from this pilot study suggest that our telehealth obesity OSCE and checklists are moderately reliable for assessing key obesity competencies among residents on a virtual platform. Integrating obesity OSCEs and other educational interventions into residency curricula are needed to improve resident ability to take an obesity-focused history.

Association of Weight at Different Ages and All-Cause Mortality Among Older Adults in the US

Objective: Assess the association of BMI and BMI change with mortality. Methods: Using data from the Wisconsin Longitudinal Study (WLS) on participants born mainly in 1939 (n=4922), we investigated the associations between various measures of BMI across the life course (age 54 BMI; age 65 BMI; age 72 BMI; lifetime maximum BMI; BMI change between ages 54 and 65; BMI change between ages 65 and 72) and mortality. We also assessed whether these associations are mediated by late life health. Results: BMI at age 54 was more strongly associated with late life mortality than BMI at older ages. The association between BMI change and mortality varied based on the timing of weight change. Health at age 72, particularly self-rated health, diabetes, and physical functioning, mediated the observed associations. Conclusion: Knowing older people's weight at midlife and how their weight has changed may be more important in assessing late life mortality risk than their current weight.

Proposal of an obesity classification based on weight history: an official document by the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Brazilian Society for the Study of Obesity and Metabolic Syndrome (ABESO)

Obesity is a chronic disease associated with impaired physical and mental health. A widespread view in the treatment of obesity is that the goal is to normalize the individual's body mass index (BMI). However, a modest weight loss (usually above 5%) is already associated with clinical improvement, while weight losses of 10%-15% bring even further benefits, independent from the final BMI. The percentage of weight reduction is accepted as a treatment goal since a greater decrease in weight is frequently difficult to achieve due to metabolic adaptation along with environmental and lifestyle factors. In this document, the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Brazilian Society for the Study of Obesity and Metabolic Syndrome (ABESO) propose a new obesity classification based on the maximum weight attained in life (MWAL). In this classification, individuals losing a specific proportion of weight are classified as having "reduced" or "controlled" obesity. This simple classification - which is not intended to replace others but to serve as an adjuvant tool - could help disseminate the concept of clinical benefits derived from modest weight loss, allowing individuals with obesity and their health care professionals to focus on strategies for weight maintenance instead of further weight reduction. In future studies, this proposed classification can also be an important tool to evaluate possible differences in therapeutic outcomes between individuals with similar BMIs but different weight trajectories.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

BMI Trajectories from Childhood to Midlife are Associated with Subclinical Kidney Damage in Midlife

OBJECTIVE

This study aimed to investigate the relationship of BMI trajectories from childhood with subclinical kidney damage (SKD) in midlife, a surrogate measure for chronic kidney disease.

METHODS

The study followed up 1,442 participants from the 1985 Australian Schools Health and Fitness Survey who were between 7 and 15 years old at the time the survey was conducted and who had BMI measurements in childhood and at least two follow-ups in adulthood. Measures of kidney function for participants 36 to 50 years old were also included. Latent class growth mixture modeling was used to identify the BMI trajectories. Log-binomial regression determined the associations of BMI trajectories with SKD defined as either 1) an estimated glomerular filtration rate (eGFR) of 30 to 60 mL/min/1.73 m² or 2) an eGFR > 60 mL/min/1.73 m² with a urine albumin-creatinine ratio ≥ 2.5 mg/mmol (males) or 3.5 mg/mmol (females), adjusting for childhood age, sex, and duration of follow-up.

RESULTS

Relative to the persistently low trajectory (n = 534, 37.0%), being in higher BMI trajectories was associated with greater risk of SKD in midlife (relative risk [RR] = 1.89, 95% CI = 1.10-3.25 for progressing to moderate [n = 633, 43.9%]; RR = 1.91, 95% CI = 0.95-3.81 for progressing to moderate/high [n = 194, 13.5%]; RR = 2.86, 95% CI = 1.03-7.99 for progressing to high/very high [n = 39, 2.7%]; and RR = 2.47, 95% CI = 0.77-7.94 for adult-onset high [n = 35, 2.4%]).

CONCLUSIONS

Participants with increasing BMI trajectories from childhood had an increased risk of SKD in midlife.

Controlled obesity status: a rarely used concept, but with particular importance in the COVID-19 pandemic and beyond

Obesity is a chronic disease that causes and aggravates several other diseases, and early reports suggest it is an important risk factor for COVID-19 severity. Although a deeper understanding of this relationship is vital, it is also important to inform the general public about the risks and, ideally, offer strategies to mitigate the risks. As "resolution" of obesity in the short-term is not feasible, it is indeed possible that smaller weight losses and increase in physical activity can actually reduce the risks. In this context, we propose that a term called "controlled obesity" be more often used and studied, in which those who have lost over 10% of their maximal weight and, ideally, are physically active are considered healthier. This context can have much broader usefulness, beyond the pandemics, as evidence points that weight loss over 10% can significant reduce overall health risks, irrespective of final BMI.

8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Best Practices in the Management of Overweight and Obesity

Obesity is a chronic disease caused by dysregulated energy homeostasis pathways that encourage the accumulation of adiposity, which in turn results in the development or exacerbation of weight-related comorbidities. Treatment of obesity relies on a foundation of lifestyle modification; weight loss pharmacotherapy, bariatric surgery and devices are additional tools to help patients achieve their health goals. Appropriate management of patients with obesity provides multiple metabolic benefits beyond weight loss.

Disparities in Nutrition Counseling at Pediatric Wellness Visits in South Carolina

Background: In 2007, an Expert Committee recommended that dietary patterns be assessed at each wellness visit and that counseling on diet and nutrition be provided to all children. Few studies have examined the "uptake" of obesity prevention practices into pediatric primary care. This study aimed to describe patterns of nutrition counseling among children at wellness visits in South Carolina between 2008 and 2017 and determine whether sociodemographic disparities existed. Methods: The sample included 123,864 children 2-18 years of age who had a wellness visit at one of South Carolina's four major health care systems between January 1, 2008, and December 31, 2017. Documentation of nutrition counseling was defined by the International Classification of Diseases (ICD)-9/10 codes. A matched sample design and conditional logistic regression were used to examine sociodemographic disparities in children who did and did not receive nutrition counseling. Results: Nutrition counseling was documented at 3.55% of wellness visits. Significant sociodemographic disparities were found, including that African American and Hispanic children were less likely to receive counseling than white or non-Hispanic children. Differences were also found by urban/rural residence, health insurance, and BMI. Despite guidelines, ICD 9/10 code indicating diagnosis of overweight or obesity was documented for only 12.2% of children. Conclusions: Nutrition counseling was rarely documented in a large sample of electronic medical record (EMR) data from pediatric wellness visits in South Carolina-a state heavily burdened by childhood obesity. Children's BMIs were infrequently recorded, which may be a barrier to tracking BMI over time. Sociodemographic and geographic differences in nutrition counseling may exacerbate disparities in childhood obesity.

Who's a good boy? Effects of dog and owner body weight on veterinarian perceptions and treatment recommendations

Background:

Weight bias against persons with obesity impairs health care delivery and utilization and contributes to poorer health outcomes. Despite rising rates of pet obesity (including among dogs), the potential for weight bias in veterinary settings has not been examined.

Subjects/Methods:

In two online, 2×2 experimental studies, the effects of dog and owner body weight on perceptions and treatment recommendations were investigated in 205 practicing veterinarians (Study 1) and 103 veterinary students (Study 2). In both studies, participants were randomly assigned to view one of four vignettes of a dog and owners with varying weight statuses (lean vs. obesity). Dependent measures included emotion/liking ratings toward the dog and owners; perceived causes of the dog’s weight; and treatment recommendations and compliance expectations. Other clinical practices, such as terms to describe excess weight in dogs, were also assessed.

Results:

Veterinarians and students both reported feeling more blame, frustration, and disgust toward dogs with obesity and their owners than toward lean dogs and their owners (p values<0.001). Interactions between dog and owner body weight emerged for perceived causes of obesity, such that owners with obesity were perceived as causing the dog with obesity’s weight, while lean owners were perceived as causing the lean dog’s weight. Participants were pessimistic about treatment compliance from owners of the dog with obesity, and weight loss treatment was recommended for the dog with obesity when presenting with a medical condition ambiguous in its relationship to weight. Veterinarians and students also reported use of stigmatizing terms to describe excess weight in dogs.

Conclusions:

Findings from this investigation, with replication, have implications for training and practice guidelines in veterinary medicine.