Why does type 2 diabetes mellitus impair weight reduction in patients with obesity? A review

Background

A common adiposopathic complication of obesity is type 2 diabetes mellitus. Healthful weight reduction in patients with obesity can improve glucose metabolism and potentially promote remission of type 2 diabetes mellitus. However, weight-reduction in patients with increased adiposity is impaired among patients with type 2 diabetes mellitus compared to patients without diabetes mellitus.

Methods

Data for this review were derived from PubMed and applicable websites.

Results

Among patients with increased body fat, the mechanisms underlying impaired weight reduction for those with type 2 diabetes mellitus are multifactorial, and include energy conservation (i.e., improved glucose control and reduced glucosuria), hyperinsulinemia (commonly found in many patients with type 2 diabetes mellitus), potential use of obesogenic anti-diabetes medications, and contributions from multiple body systems. Other factors include increased age, sex, genetic/epigenetic predisposition, and obesogenic environments.

Conclusions

Even though type 2 diabetes mellitus impairs weight reduction among patients with increased adiposity, clinically meaningful weight reduction improves glucose metabolism and can sometimes promote diabetes remission. An illustrative approach to mitigate impaired weight reduction due to type 2 diabetes mellitus is choosing anti-diabetes medications that increase insulin sensitivity and promote weight loss and deprioritize use of anti-diabetes medications that increase insulin exposure and promote weight gain.

Artificial intelligence and obesity management: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of Artificial Intelligence, focused on the management of patients with obesity.

Methods

The perspectives of the authors were augmented by scientific support from published citations and integrated with information derived from search engines (i.e., Chrome by Google, Inc) and chatbots (i.e., Chat Generative Pretrained Transformer or Chat GPT).

Results

Artificial Intelligence (AI) is the technologic acquisition of knowledge and skill by a nonhuman device, that after being initially programmed, has varying degrees of operations autonomous from direct human control, and that performs adaptive output tasks based upon data input learnings. AI has applications regarding medical research, medical practice, and applications relevant to the management of patients with obesity. Chatbots may be useful to obesity medicine clinicians as a source of clinical/scientific information, helpful in writings and publications, as well as beneficial in drafting office or institutional Policies and Procedures and Standard Operating Procedures. AI may facilitate interactive programming related to analyses of body composition imaging, behavior coaching, personal nutritional intervention & physical activity recommendations, predictive modeling to identify patients at risk for obesity-related complications, and aid clinicians in precision medicine. AI can enhance educational programming, such as personalized learning, virtual reality, and intelligent tutoring systems. AI may help augment in-person office operations and telemedicine (e.g., scheduling and remote monitoring of patients). Finally, AI may help identify patterns in datasets related to a medical practice or institution that may be used to assess population health and value-based care delivery (i.e., analytics related to electronic health records).

Conclusions

AI is contributing to both an evolution and revolution in medical care, including the management of patients with obesity. Challenges of Artificial Intelligence include ethical and legal concerns (e.g., privacy and security), accuracy and reliability, and the potential perpetuation of pervasive systemic biases.

Obesity medicine as a subspecialty and United States certification - A review

Background

Certification of obesity medicine for physicians in the United States occurs mainly via the American Board of Obesity Medicine (ABOM). Obesity medicine is not recognized as a subspecialty by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). This review examines the value of specialization, status of current ABOM Diplomates, governing bodies involved in ABMS/AOA Board Certification, and the advantages and disadvantages of an ABMS/AOA recognized obesity medicine subspecialty.

Methods

Data for this review were derived from PubMed and appliable websites. Content was driven by the expertise, insights, and perspectives of the authors.

Results

The existing ABOM obesity medicine certification process has resulted in a dramatic increase in the number of Obesity Medicine Diplomates. If ABMS/AOA were to recognize obesity medicine as a subspecialty under an existing ABMS Member Board, then Obesity Medicine would achieve a status like other ABMS recognized subspecialities. However, the transition of ABOM Diplomates to ABMS recognized subspecialists may affect the kinds and the number of physicians having an acknowledged focus on obesity medicine care. Among transition issues to consider include: (1) How many ABMS Member Boards would oversee Obesity Medicine as a subspecialty and which physicians would be eligible? (2) Would current ABOM Diplomates be required to complete an Obesity Medicine Fellowship? If not, then what would be the process for a current ABOM Diplomate to transition to an ABMS-recognized Obesity Medicine subspecialist (i.e., "grandfathering criteria")? and (3) According to the ABMS, do enough Obesity Medicine Fellowship programs exist to recognize Obesity Medicine as a subspecialty?

Conclusions

Decisions regarding a transition to an ABMS recognized Obesity Medicine Subspecialty versus retention of the current ABOM Diplomate Certification should consider which best facilitates medical access and care to patients with obesity, and which best helps obesity medicine clinicians be recognized for their expertise.

Obesity, diabetes mellitus, and cardiometabolic risk: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of type 2 diabetes mellitus (T2DM), an obesity-related cardiometabolic risk factor.

Methods

The scientific support for this CPS is based upon published citations and clinical perspectives of OMA authors.

Results

Topics include T2DM and obesity as cardiometabolic risk factors, definitions of obesity and adiposopathy, and mechanisms for how obesity causes insulin resistance and beta cell dysfunction. Adipose tissue is an active immune and endocrine organ, whose adiposopathic obesity-mediated dysfunction contributes to metabolic abnormalities often encountered in clinical practice, including hyperglycemia (e.g., pre-diabetes mellitus and T2DM). The determination as to whether adiposopathy ultimately leads to clinical metabolic disease depends on crosstalk interactions and biometabolic responses of non-adipose tissue organs such as liver, muscle, pancreas, kidney, and brain.

Conclusions

This review is intended to assist clinicians in the care of patients with the disease of obesity and T2DM. This CPS provides a simplified overview of how obesity may cause insulin resistance, pre-diabetes, and T2DM. It also provides an algorithmic approach towards treatment of a patient with obesity and T2DM, with "treat obesity first" as a priority. Finally, treatment of obesity and T2DM might best focus upon therapies that not only improve the weight of patients, but also improve the health outcomes of patients (e.g., cardiovascular disease and cancer).

Stress, psychiatric disease, and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

Previous Obesity Medicine Association (OMA) Clinical Practice Statements (CPS) included topics such as behavior modification, motivational interviewing, and eating disorders, as well as the effect of concomitant medications on weight gain/reduction (i.e., including psychiatric medications). This OMA CPS provides clinicians a more focused overview of stress and psychiatric disease as they relate to obesity.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics in this CPS include the relationship between psychological stress and obesity, including both acute and chronic stress. Additionally, this CPS describes the neurobiological pathways regarding stress and addiction-like eating behavior and explores the relationship between psychiatric disease and obesity, with an overview of psychiatric medications and their potential effects on weight gain and weight reduction.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on stress and psychiatric disease is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Knowledge of stress, addiction-like eating behavior, psychiatric disease, and effects of psychiatric medications on body weight may improve the care obesity medicine clinicians provide to their patients with obesity.

Obesity Pillars Roundtable: Body mass index and body composition in Black and Female individuals. Race-relevant or racist? Sex-relevant or sexist?

Background

Body mass index (BMI or weight in kilograms/height in meters2) is the most common metric to diagnose overweight and obesity. However, a body composition analysis more thoroughly assesses adiposity, percent body fat, lean body mass (i.e., including skeletal muscle), and sometimes bone mineral density. BMI is not an accurate assessment of body fat in individuals with increased or decreased muscle mass; the diagnostic utility of BMI in individuals is also influenced by race and sex.

Methods

Previous Obesity Pillars Roundtables addressed the diagnostic limitations of BMI, the importance of android and visceral fat (especially among those with South and East Asian ancestry), and considerations of obesity among individuals who identify as Hispanic, diverse in sexual-orientation, Black, Native American, and having ancestry from the Mediterranean and Middle East regions. This roundtable examines considerations of BMI in Black and female individuals.

Results

The panelists agreed that body composition assessment was a more accurate measure of adiposity and muscle mass than BMI. When it came to matters of race and sex, one panelist felt: "race is a social construct and not a defining biology." Another felt that: "BMI should be a screening tool to prompt further evaluation of adiposity that utilizes better diagnostic tools for body composition." Regarding bias and misperceptions of resistance training in female individuals, another panelist stated: "I have spent my entire medical career taking care of women and have never seen a woman unintentionally gain 'too much' muscle mass and bulk up from moderate strength training."

Conclusions

Conveying the importance of race and sex regarding body composition has proven challenging, with the discussion sometimes devolving into misunderstandings or misinformation that may be perceived as racist or sexist. Body composition analysis is the ultimate diagnostic equalizer in addressing the inaccuracies and biases inherent in the exclusive use of BMI.

Obesity Pillars roundtable: Excessive weight reduction with highly effective anti-obesity medications (heAOMs)

Background

Historically, many anti-obesity medications (AOMs) were withdrawn from development and/or the market due to safety concerns. Another challenge was that, with some exceptions, most of these AOMs had limited weight reducing efficacy. Approved AOMs often did not meet the weight reduction expectations of either clinicians, or their patients. Currently, newer approved and investigational AOMs achieve greater weight reduction than older AOMs. This has prompted an emerging new challenge of "too much weight loss" with some of these highly effective anti-obesity medications (heAOM) - something many did not think possible prior to year 2020.

Methods

This roundtable review includes perspectives from 3 obesity specialists with experience in the clinical use of AOMs. The intent is to provide perspectives and guidance in managing patients with obesity who experience "too much weight loss" with heAOM.

Results

The panelists generally agreed that before treatment with heAOMs, patients with obesity are best informed about the importance of healthful nutrition, adequate hydration, routine physical activity, behavior modification techniques, goals of treatment, and anticipated changes not only from a medical standpoint, but also from a psychosocial standpoint. Clinicians might best recognize that the definition of "excessive weight reduction" may have both objective and subjective considerations, with body composition analyses often essential to accurately assess adiposity.

Conclusions

The consensus of the panelists is reflected in a proposed structured and algorithmic approach to the patient with excessive weight reduction. Once properly evaluated, if the excessive weight reduction is determined most likely due to the heAOM hyper-responders, then this should prompt the clinician to educate the patient (and possibly family and friends) on the health and psychosocial aspects of weight reduction, and engage in a shared decision-making process that determines if the heAOM is best kept at the same dose, decreased in dose, temporarily held, or rare cases, best discontinued.

Sleep-disordered breathing, sleep apnea, and other obesity-related sleep disorders: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of sleep-disordered breathing, (e.g., sleep-related hypopnea, apnea), and other obesity-related sleep disorders.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Obesity contributes to sleep-disordered breathing, with the most prevalent manifestation being obstructive sleep apnea. Obesity is also associated with other sleep disorders such as insomnia, primary snoring, and restless legs syndrome. This CPS outlines the evaluation, diagnosis, and treatment of sleep apnea and other sleep disorders, as well as the clinical implications of altered circadian system.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on "Sleep-Disordered Breathing, Sleep Apnea, and Other Obesity-Related Sleep Disorders" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.

Obesity pillars roundtable: Phentermine - Past, present, and future

Background

Phentermine is a sympathomimetic amine, approved for "short-term"treatment of patients with obesity. Among phentermine contraindications include use in patients with cardiovascular disease or patients with uncontrolled hypertension.

Methods

This roundtable discussion includes perspectives from 3 obesity specialists with experience in the clinical use of phentermine. The questions asked of the panelists were derived from publications regarding phentermine safety and efficacy.

Results

While the panelists generally agreed upon core principles of phentermine use, each obesity specialist had their own priorities and style regarding the administration of phentermine. Among the variances in perceptions (based upon their individual "real world" clinical experiences) included the degree of efficacy and degree of clinical benefit of phentermine, degree of concern regarding phentermine use in patients with cardiovascular disease risk factors, the advisability of a screening electrocardiogram, and the role of telehealth in prescribing phentermine and monitoring for the efficacy and safety of phentermine.

Conclusions

Providing universal guidance regarding phentermine treatment for obesity is challenging because of the lack of long-term, prospective, randomized, placebo-controlled, health outcomes data. Such data is unlikely forthcoming any time soon. Also challenging are the substantial variances in governmental restrictions on phentermine use. Therefore, clinicians are left to rely on the best available evidence, their individual practical clinical experience, as well as the collective clinical experiences of others - as reflected by this roundtable.

Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides clinicians an overview of nonalcoholic fatty liver disease (NAFLD), potential progression to nonalcoholic steatohepatitis (NASH), and their application to obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics of this CPS include the prevalence of NAFLD and NASH, the prevalence of NAFLD and NASH among patients with obesity, as well as NAFLD and NASH definitions, diagnosis, imaging, pathophysiology, differential diagnosis, role of high fructose corn syrup and other simple sugars, and treatment (e.g., nutrition, physical activity, medications).

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding NAFLD and obesity is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Patients with obesity are at increased risk for NAFLD and NASH. Patients may benefit when clinicians who manage obesity understand the etiology, diagnosis, and optimal treatment of NAFLD with a goal to prevent NASH.

Cancer and Obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides an overview of cancer and increased body fat.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics include the increased risk of cancers among patients with obesity, cancer risk factor population-attributable fractions, genetic and epigenetic links between obesity and cancer, adiposopathic and mechanistic processes accounting for increased cancer risk among patients with obesity, the role of oxidative stress, and obesity-related cancers based upon Mendelian randomization and observational studies. Other topics include nutritional and physical activity principles for patients with obesity who either have cancer or are at risk for cancer, and preventive care as it relates to cancer and obesity.

Conclusions

Obesity is the second most common preventable cause of cancer and may be the most common preventable cause of cancer among nonsmokers. This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on cancer is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Patients with obesity are at greater risk of developing certain types of cancers, and treatment of obesity may influence the risk, onset, progression, and recurrence of cancer in patients with obesity.

Thirty Obesity Myths, Misunderstandings, and/or Oversimplifications: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of 30 common obesity myths, misunderstandings, and/or oversimplifications.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS discusses 30 common obesity myths, misunderstandings, and/or oversimplifications, utilizing referenced scientific publications such as the integrative use of other published OMA CPSs to help explain the applicable physiology/pathophysiology.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on 30 common obesity myths, misunderstandings, and/or oversimplifications is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Knowledge of the underlying science may assist the obesity medicine clinician improve the care of patients with obesity.

Obesity pillars roundtable: Obesity and individuals from the Mediterranean region and Middle East

Background

The rates of obesity in Mediterranean and Middle East regions are increasing. This may be related to worsening physical inactivity, and gravitation away from more healthful nutrition.

Methods

This roundtable discussion includes 4 obesity specialists with experience in the clinical management of obesity. Included in this discussion are citations regarding obesity and populations from the Mediterranean and Middle East regions.

Results

Among the most studied nutritional dietary pattern having evidence-based data supporting improved cardiometabolic health is the Mediterranean Diet. Prospective studies such as the PREvención con DIeta MEDiterránea (PREDIMED) study support the cardiometabolic benefits of dietary consumption of plant-based, higher fiber foods having a relatively high proportion of unsaturated fats. Cuisine from the Middle East has both similarities and some differences compared to the Mediterranean Diet. Interim analyses of the PREDIMED-Plus study suggest the Mediterranean Diet plus caloric restriction and physical activity intervention reduces body weight and improves cardiometabolic risk factors. As with any dietary intake, Mediterranean and Middle Eastern food choices and preparation affect their nutritional healthfulness.

Conclusion

The panelists of this roundtable discussion describe their practical diagnostic processes and treatment plans for patients with obesity from the Mediterranean Region and Middle East.

Concomitant medications, functional foods, and supplements: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of the body weight effects of concomitant medications (i.e., pharmacotherapies not specifically for the treatment of obesity) and functional foods, as well as adverse side effects of supplements sometimes used by patients with pre-obesity/obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS outlines clinically relevant aspects of concomitant medications, functional foods, and many of the more common supplements as they relate to pre-obesity and obesity. Topics include a discussion of medications that may be associated with weight gain or loss, functional foods as they relate to obesity, and side effects of supplements (i.e., with a focus on supplements taken for weight loss). Special attention is given to the warnings and lack of regulation surrounding weight loss supplements.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on concomitant medications, functional foods, and supplements is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of pre-obesity/obesity. Implementation of appropriate practices in these areas may improve the health of patients, especially those with adverse fat mass and adiposopathic metabolic consequences.

Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of bariatric surgery (i.e., bariatric procedures that improve metabolic disease are often termed "metabolic and bariatric surgery"), gastrointestinal hormones, and the microbiome as they relate to patients with obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS includes the pros and cons of the most common types of bariatric procedures; the roles of gastrointestinal (GI) hormones in regulating hunger, digestion, and postabsorptive nutrient metabolism; and the microbiome's function and relationship with body weight. This CPS also describes patient screening for bariatric surgery, patient care after bariatric surgery, and treatment of potential nutrient deficiencies before and after bariatric surgery. Finally, this CPS explores the interactions between bariatric surgery, GI hormones, and the microbiome.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding bariatric surgery, gastrointestinal hormones, and the microbiome is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Implementation of appropriate care before and after bariatric surgery, as well as an awareness of GI hormones and the microbiome, may improve the health of patients with obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.

Obesity Pillars Roundtable: Obesity and East Asians

Background

Individuals from East Asia make up about 1/5th of the world's population. Individuals from South Asia with obesity are well-described to have increased susceptibility to cardiovascular disease (CVD) risk factors and increased risk of CVD events. Less well described are the adiposopathic effects of the disease of obesity among East Asians.

Methods

This roundtable discussion includes 3 obesity medicine specialists with experience in the clinical management of obesity among patients of East Asian descent. Included are citations regarding obesity and East Asians.

Results

In general, East Asians are at decreased risk for CVD compared to Whites and South Asians. However, compared to Whites, for the same body mass index, East Asians are at increased risk for metabolic diseases such as type 2 diabetes mellitus. Both obesity and type 2 diabetes mellitus are epidemics in East Asian countries. In this Roundtable, the panelists discuss East Asian nutrition and physical activity, with special attention given to Asian foods, especially rice. The panelists also discuss East Asian genetic predispositions for development of visceral adiposity, type 2 diabetes mellitus, as well as genetic predisposition to drug metabolism and potential drug and herbal interactions, as commonly encountered in patients with obesity. Finally, the panelists give summary tips for managing East Asian patients with obesity.

Conclusion

The three panelists of this roundtable describe their practical diagnostic processes and treatment plans for patients from East Asia, with an emphasis on a patient-centered approach to obesity in this unique population.

Behavior, motivational interviewing, eating disorders, and obesity management technologies: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of "Behavior, Motivational Interviewing, Eating Disorders, and Obesity Management Technologies."

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS outlines important components of behavior, motivational interviewing, eating disorders, and obesity management technologies as they relate to pre-obesity and obesity. Topics include eating behavior disorder evaluation, the motivations behind eating and physical activity behaviors (including underlying neurophysiology, eating disorders, environmental factors, and personal prioritization), motivational interviewing techniques, and technologies that may assist with pre-obesity/obesity management.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on "Behavior, Motivational Interviewing, Eating Disorders, and Obesity Management Technologies" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of pre-obesity/obesity. Implementation of appropriate clinical practices in these areas may improve the health of patients, especially those with adverse fat mass and adiposopathic metabolic consequences.

Obesity Pillars Roundtable: Obesity and Diversity

Background

The clinical implications of obesity differ, depending on race, ethnicity, and sexual orientation.

Methods

This roundtable discussion included 4 obesity specialists with expertise in the clinical management of obesity among diverse populations including Blacks, Hispanics/Latinos, Lesbian-Gay-Bisexual-Transgender-Questioning (LGBTQ) individuals, and Native-Americans.

Results

One of the first obstacles towards overcoming disparities in managing obesity and its complications among diverse populations is understanding applicable terminology. This includes categorization terminology relative to Native Americans (for the purpose of assessing culture and possibly genetic predispositions), understanding the differences between Black African Americans and Black Africans, understanding the differences between the terms Hispanic and Latinx, and basic concepts behind different pronouns applicable to Lesbian-Gay-Bisexual-Transgender-Questioning (LGBTQ) individuals. After being better able to grasp the input from patients with diverse backgrounds, universal obesity assessment and management principles can be then tailored utilizing a patient-centered approach.

Conclusion

Understanding the unique genetic, culture, and terminology regarding patients of different races, ethnicities, and sexual orientation may help clinicians better engage patients in managing obesity via utilizing a more patient-centered approach.

Obesity Pillars Roundtable: Obesity and South Asians

Background

Compared to other races/ethnicities, individuals from South Asia with obesity are strikingly susceptible to the presence of CVD risk factors and onset of CVD events - in part due to adiposopathic anatomic and metabolic responses to positive caloric balance. Pathogenic endocrine and immune effects of adipocyte hypertrophy and visceral fat accumulation both directly and indirectly promote among the most common metabolic diseases encountered in clinical practice - many being major cardiovascular disease (CVD) risk factors. This is especially applicable to those from South Asia - largely due to genetics, epigenetics, unhealthful nutrition, and physical inactivity.

Methods

This roundtable discussion included 4 obesity specialists engaged in the clinical management of obesity among patients of South Asian descent.

Results

Patients with obesity from South Asia have increased adipocyte size, fewer (functional) adipocytes, and increased visceral adiposity accompanied by functional endocrine and immune abnormalities. This helps explain the increased CVD risk factors and increased CVD risk among this unique population. These CVD risk factors include increased prevalence of metabolic syndrome (even at lower body mass index relative to other races), insulin resistance, type 2 diabetes mellitus, increased lipoprotein (a), and adiposopathic dyslipidemia [(i.e., elevated triglyceride levels, reduced high density lipoprotein cholesterol levels, increased low density lipoprotein (LDL) particle number, and increased prevalence of smaller and denser LDL particles].

Conclusion

The four panelists of this roundtable discussion describe their practical diagnostic processes and treatment plans for patients from South Asia, with an emphasis on a patient-centered approach to obesity in this unique population.

Nutrition and physical activity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on Nutrition and Physical Activity provides clinicians an overview of nutrition and physical activity principles applicable to the care of patients with increased body fat, especially those with adverse fat mass and adiposopathic metabolic consequences.

Methods

The scientific information and clinical guidance is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA CPS on Nutrition and Physical Activity provides basic clinical information regarding carbohydrates, proteins, fats (including trans fats, saturated fats, polyunsaturated fats, and monounsaturated fats), general principles of healthful nutrition, nutritional factors associated with improved health outcomes, and food labels. Included are the clinical implications of isocaloric substitution of refined carbohydrates with saturated fats and vice-versa, as well as definitions of low-calorie, very low-calorie, carbohydrate-restricted, and fat-restricted dietary intakes. Specific dietary plans discussed include carbohydrate-restricted diets, fat-restricted diets, very low-calorie diets, the Mediterranean diet, Therapeutic Lifestyle diet, Dietary Approaches to Stop Hypertension (DASH), ketogenic (modified Atkins) diet, Ornish diet, Paleo diet, vegetarian or vegan diet (whole food/plant-based), intermittent fasting/time restricted feeding, and commercial diet programs. This clinical practice statement also examines the health benefits of physical activity and provides practical pre-exercise medical evaluation guidance as well as suggestions regarding types and recommended amounts of dynamic (aerobic) training, resistance (anaerobic) training, leisure time physical activity, and non-exercise activity thermogenesis (NEAT). Additional guidance is provided regarding muscle physiology, exercise prescription, metabolic equivalent tasks (METS), and methods to track physical activity progress.

Conclusion

This Obesity Medicine Association Clinical Practice Statement on Nutrition and Physical Activity provides clinicians an overview of nutrition and physical activity. Implementation of appropriate nutrition and physical activity in patients with pre-obesity and/or obesity may improve the health of patients, especially those with adverse fat mass and adiposopathic metabolic consequences.

Ten things to know about ten cardiovascular disease risk factors ("ASPC Top Ten - 2020")

Preventive cardiology involves understanding and managing multiple cardiovascular disease (CVD) risk factors. Given the rapid advancements in medical science, it may be challenging for the busy clinician to remain up-to-date on the multifaceted and fundamental aspects of CVD prevention, and maintain awareness of the newest applicable guidelines. The "American Society for Preventive Cardiology (ASPC) Top Ten 2020" summarizes ten essential things to know about ten important CVD risk factors, listed in tabular formats. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and gender), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten 2020" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

P5364Safety profile of bempedoic acid: pooled analysis of 4 phase 3 clinical trials

Background/Introduction

Bempedoic acid (BA), an oral, first-in-class, ATP-citrate lyase inhibitor, lowers low-density lipoprotein cholesterol (LDL-C) in patients who do not achieve sufficient lipid lowering with guideline-recommended first-line therapies.

Purpose

We evaluated the safety profile of BA in phase 3 trials.

Methods

Data were pooled from 4 randomised, double-blind, placebo-controlled studies that enrolled patients with hyperlipidaemia who were receiving stable lipid-lowering therapy (LLT; maximally tolerated statins +/− nonstatin therapies) and required additional LDL-C lowering. Patients were randomised (2:1) to BA 180 mg or placebo daily for 12 to 52 weeks.

Results

Median exposure for 3621 patients (2424 BA, 1197 placebo) was 363 days. Background LLT included a statin +/− other LLT (83.8%), nonstatin LLT alone (9.4%), or none (6.8%). Adverse event (AE) and serious AE rates were similar between groups (Table). The most common AEs in the BA and placebo groups were nasopharyngitis (7.4% vs 8.9%), myalgia (4.9% vs 5.3%), and urinary tract infection (4.5% vs 5.5%). Rates of new-onset/worsening diabetes were 4.0% for BA and 5.6% for placebo. No AEs leading to discontinuation differed by ≥0.5% between treatments. All fatal AEs were judged by the investigator as unrelated to treatment. A trend was observed for a lower 3-component major adverse cardiac event rate with BA vs placebo (hazard ratio, 0.85; 95% confidence interval: 0.53 to 1.37). Changes in uric acid, creatinine, and haemoglobin were apparent at week 4, stable over time, and reversible after stopping BA. Gout occurred in 1.4% and 0.4% of patients in the BA and placebo groups, respectively. The safety profile of BA was consistent across background therapies, demographics, and disease characteristics.

Table 1. Safety summary Placebo (n=1197) BA (n=2424) Any AE / SAE, % (n) 72.5 (868) / 13.3 (159) 73.1 (1171) / 14.1 (341) Drug discontinuation due to an AE, % (n) 7.8 (93) 11.3 (273) AE with a fatal outcome, % (n) 0.3 (4) 0.8 (19) Aminotransferase elevation >3 x ULN, % (n) 0.3 (3) 0.7 (18) Aminotransferase elevation >5 x ULN, % (n) 0.2 (2) 0.2 (6) Creatine kinase elevation >5 x ULN, % (n) 0.2 (2) 0.3 (8) Creatinine, mean change at week 12, mg/dL −0.002±0.11 0.046±0.12 Uric acid, mean change at week 12, mg/dL −0.02±0.82 0.82±0.97 Haemoglobin, mean change at week 12, g/dL 0.06±0.69 −0.31±0.71

Conclusion(s)

BA added to LLT was well tolerated, with a safety profile comparable to placebo.

Rate and risk predictors for development of self-reported type-2 diabetes mellitus over a 5-year period: the SHIELD study

AIMS

This investigation determined the proportion of adults newly diagnosed as having type-2 diabetes mellitus (T2DM), and ascertained risk predictors for development of self-reported T2DM.

METHODS

The US Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) survey was a 5-year longitudinal study of adults with and without diabetes mellitus. Adults completed a baseline health questionnaire in 2004 and ≥1 annual follow-up survey through 2009. Respondents with no self-reported diagnosis of diabetes at baseline were followed to measure rate of and assess risk factors for development of T2DM over 5 years.

RESULTS

Among 8582 respondents without diabetes at baseline, 622 (7.2%) reported a diagnosis of T2DM over the subsequent 5 years. Increasing age, family history of T2DM, body mass index ≥30 kg/m(2), abdominal obesity, excessive thirst, asthma, gestational diabetes and 'high blood sugar without diabetes' significantly increased the risk of developing T2DM (p < 0.05 for each). Good to excellent health status and self-reported circulatory problems decreased the risk (p < 0.05 for each).

CONCLUSIONS

Among this representative US adult population, the rate of developing T2DM was 7.2% over 5 years. Predictors of T2DM diagnosis identified in this analysis were readily obtainable via self-report.

The Bile Acid Sequestrant Acceptability scale validation study

AIMS

The primary objective of this study was to validate a novel Bile Acid Sequestrant Acceptability (BASA) Scale intended to assess the acceptability and/or tolerability of bile acid sequestrant (BAS) beverage preparations. A secondary objective was to assess the utility of weightings based on subjective clinical importance for the BASA scale individual components and its composite score.

METHODS

This was a randomised, single-blind, single site, controlled study of oral administration of 4 g of orange-flavoured generic cholestyramine powder, 12 g of orange-flavoured generic cholestyramine powder and an orange-flavoured sweetened control drink powder, each mixed with water.

RESULTS

The study sample included 42 subjects; 26 men and 16 women. Participants were non-Hispanic white (76.2%) or black/African American (23.8%), with a mean age of 51.4 years and body mass index of 30.1 kg/m(2). The components of the BASA scale were taste, texture, appearance and mixability; the possible total BASA scores ranged being 4-20; the higher the BASA scale score, the better the acceptability/tolerability. Composite BASA scale scores were significantly lower for the 4 g (mean BASA score = 10.3) and 12 g (mean BASA score = 9.4) cholestyramine compared with the control drink powder (mean BASA score = 16.7) (p < 0.001). BASA scale scores did not significantly differ between the 4 and 12 g of cholestyramine. (p = 0.215). Weighting of the components did not materially alter the results. Findings for the individual components of the BASA scale were similar to the composite values.

CONCLUSION

The BASA scale effectively distinguished between an orange-flavoured BAS powder and a commercial orange-flavour control powder.

Adiposopathy and bariatric surgery: is 'sick fat' a surgical disease?

OBJECTIVE

To review how bariatric surgery in obese patients may effectively treat adiposopathy (pathogenic adipose tissue or 'sick fat'), and to provide clinicians a rationale as to why bariatric surgery is a potential treatment option for overweight patients with type 2 diabetes, hypertension, and dyslipidaemia.

METHODS

A group of clinicians, researchers, and surgeons, all with a background in treating obesity and the adverse metabolic consequences of excessive body fat, reviewed the medical literature regarding the improvement in metabolic disease with bariatric surgery.

RESULTS

Bariatric surgery improves metabolic disease through multiple, likely interrelated mechanisms including: (i) initial acute fasting and diminished caloric intake inherent with many gastrointestinal surgical procedures; (ii) favourable alterations in gastrointestinal endocrine and immune responses, especially with bariatric surgeries that reroute nutrient gastrointestinal delivery such as gastric bypass procedures; and (iii) a decrease in adipose tissue mass. Regarding adipose tissue mass, during positive caloric balance, impaired adipogenesis (resulting in limitations in adipocyte number or size) and visceral adiposity are anatomic manifestations of pathogenic adipose tissue (adiposopathy). This may cause adverse adipose tissue endocrine and immune responses that lead to metabolic disease. A decrease in adipocyte size and decrease in visceral adiposity, as often occurs with bariatric surgery, may effectively improve adiposopathy, and thus effectively treat metabolic disease. It is the relationship between bariatric surgery and its effects upon pathogenic adipose tissue that is the focus of this discussion.

CONCLUSIONS

In selective obese patients with metabolic disease who are refractory to medical management, adiposopathy is a surgical disease.

Does nicotinic acid (niacin) lower blood pressure?

Nicotinic acid (niacin) is a well-established treatment for dyslipidaemia - an important cardiovascular disease (CVD) risk factor. However, niacin may also reduce blood pressure (BP), which is another important CVD risk factor. This review examines the limited publicly available data on niacin's BP effects. Acute administration of immediate-release niacin may lower BP because of niacin's acute vasodilatory effects. Although not always supported by clinical trial data, the package insert of a prescription, extended-release niacin describes niacin-induced acute hypotension. From a chronic standpoint, larger studies, such as the Coronary Drug Project, suggest that niacin may lower BP when administered over a longer period of time. Post hoc analyses of some of the more recent niacin clinical trials also support a more chronic, dose-dependent, BP-lowering effect of niacin. Because laropiprant [a prostaglandin D(2) (PGD(2)) type 1 (DP1) receptor antagonist] does not attenuate niacin's BP-lowering effects, it is unlikely that any chronic lowering of BP by niacin is due to dilation of dermal vessels through activation of the DP1 receptor by PGD(2.) Further research is warranted to evaluate the extent and mechanisms of niacin's effects on BP.

Lipid-modifying efficacy and tolerability of extended-release niacin/laropiprant in patients with primary hypercholesterolaemia or mixed dyslipidaemia

BACKGROUND

Improving lipids beyond low-density lipoprotein cholesterol (LDL-C) lowering with statin monotherapy may further reduce cardiovascular risk. Niacin has complementary lipid-modifying efficacy to statins and cardiovascular benefit, but is underutilised because of flushing, mediated primarily by prostaglandin D(2) (PGD(2)). Laropiprant (LRPT), a PGD(2) receptor (DP1) antagonist that reduces niacin-induced flushing has been combined with extended-release niacin (ERN) into a fixed-dose tablet.

METHODS AND RESULTS

Dyslipidaemic patients were randomised to ERN/LRPT 1 g (n = 800), ERN 1 g (n = 543) or placebo (n = 270) for 4 weeks. Doses were doubled (2 tablets/day; i.e. 2 g for active treatments) for 20 weeks. ERN/LRPT 2 g produced significant changes vs. placebo in LDL-C (-18.4%), high-density lipoprotein cholesterol (HDL-C; 20.0%), LDL-C:HDL-C (-31.2%), non-HDL-C (-19.8%), triglycerides (TG; -25.8%), apolipoprotein (Apo) B (-18.8%), Apo A-I (6.9%), total cholesterol (TC; -8.5%), TC:HDL-C (-23.1%) and lipoprotein(a) (-20.8%) across weeks 12-24. ERN/LRPT produced significantly less flushing than ERN during initiation (week 1) and maintenance (weeks 2-24) for all prespecified flushing end-points (incidence, intensity and discontinuation because of flushing). Except for flushing, ERN/LRPT had a safety/tolerability profile comparable with ERN.

CONCLUSION

Extended-release niacin/LRPT 2 g produced significant, durable improvements in multiple lipid/lipoprotein parameters. The improved tolerability of ERN/LRPT supports a simplified 1 g-->2 g dosing regimen of niacin, a therapy proven to reduce cardiovascular risk.

Is adiposopathy (sick fat) an endocrine disease?

OBJECTIVE

To review current consensus and controversy regarding whether obesity is a 'disease', examine the pathogenic potential of adipose tissue to promote metabolic disease and explore the merits of 'adiposopathy' and 'sick fat' as scientifically and clinically useful terms in defining when excessive body fat may represent a 'disease'.

METHODS

A group of clinicians and researchers, all with a background in endocrinology, assembled to evaluate the medical literature, as it pertains to the pathologic and pathogenic potential of adipose tissue, with an emphasis on metabolic diseases that are often promoted by excessive body weight.

RESULTS

The data support pathogenic adipose tissue as a disease. Challenges exist to convince many clinicians, patients, healthcare entities and the public that excessive body fat is often no less a 'disease' than the pathophysiological consequences related to anatomical abnormalities of other body tissues. 'Adiposopathy' has the potential to scientifically define adipose tissue anatomic and physiologic abnormalities, and their adverse consequences to patient health. Adiposopathy acknowledges that when positive caloric balance leads to adipocyte hypertrophy and visceral adiposity, then this may lead to pathogenic adipose tissue metabolic and immune responses that promote metabolic disease. From a patient perspective, explaining how excessive caloric intake might cause fat to become 'sick' also helps provide a rationale for patients to avoid weight gain. Adiposopathy also better justifies recommendations of weight loss as an effective therapeutic modality to improve metabolic disease in overweight and obese patients.

CONCLUSION

Adiposopathy (sick fat) is an endocrine disease.

Measuring flushing symptoms with extended-release niacin using the flushing symptom questionnaire: results from a randomised placebo-controlled clinical trial

INTRODUCTION

Niacin is underutilised because of flushing. Lack of a quantitative tool to assess niacin-induced flushing has precluded the objective evaluation of flushing associated with extended-release (ER) niacin formulations. We developed the Flushing Symptom Questionnaire((c)) (FSQ), a quantitative tool to assess patient-reported flushing, and assessed its ability to characterise ER niacin-induced flushing.

METHODS

This study focused on the responses to one question in the FSQ, the Global Flushing Severity Score (GFSS), reported on a 0-10 scale (none = 0, mild = 1-3, moderate = 4-6, severe = 7-9 and extreme = 10) to assess flushing during ER niacin initiation (week 1) and maintenance (weeks 2-8).

RESULTS

Flushing severity with ER niacin was greatest during week 1 and remained greater than placebo for the study duration. During weeks 2-8, 40% of patients on ER niacin vs. 8% of those on placebo had > 1 day/week with 'moderate or greater' GFSS.

CONCLUSIONS

In conclusion, the GFSS component of the FSQ was a sensitive and responsive quantitative measure of ER niacin-induced flushing that will aid in the objective comparison of novel strategies intended to improve tolerability and adherence to niacin, an agent proven to reduce cardiovascular risk.

The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys

The objectives of this study were to explore the relation between body mass index (BMI) and prevalence of diabetes mellitus, hypertension and dyslipidaemia; examine BMI distributions among patients with these conditions; and compare results from two national surveys. The Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) 2004 screening questionnaire (mailed survey) and the National Health and Nutrition Examination Surveys (NHANES) 1999-2002 (interview, clinical and laboratory data) were conducted in nationally representative samples>or=18 years old. Responses were received from 127,420 of 200,000 households (64%, representing 211,097 adults) for SHIELD, and 4257 participants for NHANES. Prevalence of diabetes mellitus, hypertension and dyslipidaemia was estimated within BMI categories, as was distribution of BMI levels among individuals with these diseases. Mean BMI was 27.8 kg/m2 for SHIELD and 27.9 kg/m2 for NHANES. Increased BMI was associated with increased prevalence of diabetes mellitus, hypertension and dyslipidaemia in both studies (p<0.001). For each condition, approximately [corrected] 75% or more [corrected] of patients had BMI>or=25 kg/m2. Estimated prevalence of diabetes mellitus and hypertension was similar in both studies, while dyslipidaemia was substantially higher in NHANES than SHIELD. In both studies, prevalence of diabetes mellitus, hypertension and dyslipidaemia occurred across all ranges of BMI, but increased with higher BMI. However, not all overweight or obese patients had these metabolic diseases and not all with these conditions were overweight or obese. Except for dyslipidaemia prevalence, SHIELD was comparable with NHANES. Consumer panel surveys may be an alternative method to collect data on the relationship of BMI and metabolic diseases.

Effectiveness and tolerability of ezetimibe in patients with primary hypercholesterolemia: pooled analysis of two phase II studies

BACKGROUND

Ezetimibe (SCH 58235) is a novel cholesterol absorption inhibitor that selectively and potently blocks intestinal absorption of dietary and biliary cholesterol.

OBJECTIVE

Data from 2 multicenter, placebo-controlled, double-blind, randomized, parallel-group, 12-week studies of ezetimibe were pooled to evaluate the drug's effect on lipid parameters in patients with primary hypercholesterolemia.

METHODS

After dietary stabilization (National Cholesterol Education Program Step I diet or a stricter diet), washout of lipid-altering drugs, and a 6-week placebo lead-in period, patients with baseline plasma low-density lipoprotein cholesterol (LDL-C) levels > or = 130 and < or = 250 mg/dL and plasma triglyceride (TG) levels < or = 300 mg/dL were randomized to receive either ezetimibe 0.25, 1, 5, or 10 mg, or placebo administered once daily before the morning meal in study A (dose-response study) or ezetimibe 5 or 10 mg or placebo administered once daily before the morning meal or at bedtime in study B (dose-regimen study).

RESULTS

A total of 432 patients were included in this pooled analysis, 243 in study A and 189 in study B. The 5- and 10-mg doses of ezetimibe significantly reduced LDL-C levels by 15.7% and 18.5%, respectively (P < 0.01 vs placebo) and significantly increased high-density lipoprotein cholesterol (hDL-C) levels by 2.9% and 3.5%, respectively (P < 0.05 vs placebo). A reduction in plasma TG levels was observed (P = NS). With the 10-mg dose of ezetimibe, 67.8% of patients achieved > or = 15% reduction in plasma LDL-C levels, and 22.0% achieved > or = 25% reduction. With the 5-mg dose, 54.0% of patients achieved > or = 15% reduction in plasma LDL-C levels, and 15.3% achieved > or = 25% reduction. The decrease in plasma LDL-C levels was significantly greater with ezetimibe 10 mg compared with ezetimibe 5 mg (P < 0.05). Ezetimibe was well tolerated, with an adverse event profile similar to that of placebo.

CONCLUSIONS

In these two 12-week studies, ezetimibe significantly decreased plasma LDL-C levels and increased plasma HDL-C levels, with a tolerability profile similar to that of placebo.

Lipid-altering drugs in development

Although currently available lipid lowering therapies are effective and well tolerated, the search continues for additional treatments with even better efficacy and tolerability profiles. As well as refinements to existing strategies (new HMG-CoA reductase inhibitors, fibrates and combination therapies) new avenues are being explored. These include inhibitors of enzymes other than HMG-CoA reductase involved in cholesterol regulation and drugs which affect absorption of lipids from the gastrointestinal tract. In the case of the latter, it has been shown that the new antiobesity treatment orlistat can favourably affect the blood lipid profile. In line with an increasing emphasis on improving high density lipoprotein-cholesterol (HDL-C) levels, the potential therapeutic roles of niacin and drugs which inhibit enzymes involved in the metabolism of HDL-C are also being researched.

Drug interactions of lipid-altering drugs

The use of lipid-altering drugs has been shown to reduce the progression of atherosclerotic lesions and reduce the risk of atherosclerotic events (such as myocardial infarction and stroke). In general, these lipid-altering drugs are well tolerated but there is the potential for drug interactions. For example, HMG-CoA reductase inhibitors may interact with macrolides, azalides, azole antifungals and cyclosporin. Resins (such as cholestyramine and colestipol) may impair the absorption of many concurrent medications. Fibrates have potential drug interactions with warfarin, furosemide (frusemide), oral hypoglycaemics and probenecid. Nicotinic acid (niacin) may have potential drug interactions with high dose aspirin (acetylsalicylic acid), uricosuric agents (such as sulfapyrazone) and alcohol (ethanol). Finally, probucol may have potential drug interactions with antidysrhythmics, tricyclic antidepressants and phenothiazines. In addition, lipid-altering drugs, used in combination, may have the potential for drug interactions, enhancing some of the risks of adverse effects, such as myositis and hepatotoxicity. Therefore, in order to use lipid-altering drugs in the most effective, and safest manner, it is important for the clinician to have an understanding of the mechanisms of potential drug interactions, which drug interactions may theoretically occur, and specifically, which spe cific drug interactions have already been described.

Drug therapy for hyperlipidemia. When reducing cardiovascular risk is a priority

If you are confused about the plethora of lipid-lowering agents now available and have not been able to read all the latest studies, you are not alone. It is almost impossible for busy physicians to keep up with this rapidly growing area of research. Drs Bays and Dujovne provide an update of the major antihyperlipidemics, along with a discussion of how to select patients for this therapy and the relative cost-effectiveness of the different types of therapy.

Peripheral diabetic neuropathy

Diabetic neuropathy is a common complication of diabetes mellitus with significant morbidity and mortality. Hyperglycemia with its secondary metabolic, vascular, and enzymatic consequences is most likely to be the predominant cause. The clinical manifestations includes a wide range of somatic and autonomic syndromes. Painful diabetic neuropathy may require symptomatic treatment. The precise role of therapies such as continuous subcutaneous insulin therapy and aldose reductase inhibitors remains to be clarified.