In part 4 of this Exclusive Interview, Dr. W. Timothy Garvey talks with Diabetes in Control Publisher Steve Freed during the AACE 2018 convention in Boston, MA about the differences between the varied obesity guidelines from which a practitioner has to choose.
W. Timothy Garvey, MD, FACE is a professor and Director of the University of Alabama Diabetes Research Center in Birmingham.
Transcript of this video segment:
Freed: You’ve been very active in writing the AACE guidelines for obesity. What difference from the TOS/AHA/ACC [The Obesity Society, American Heart Association, American College of Cardiology] guidelines, endocrine guidelines, and the ADA guidelines, OMA guidelines — have you seen? There are so many guidelines and it can make it very confusing for a physician to know which one to follow.
Garvey: Yes. It is confusing and they’re all valuable for certain reasons and I will just briefly go through this. The American Heart Association, American College of Cardiology, and the Obesity Society guidelines were really the first out there. They proposed five questions to address around which there were randomized clinical trials upon which to base their recommendations. The five medications approved for chronic therapy that I mentioned weren’t even approved at that point so they really dealt with a lifestyle and the bariatric surgery issues and came up with recommendations that are pretty reasonable there. But they weren’t really comprehensive in that sense that medications were not part of the overall guidelines. The Endocrine Society have focused on pharmacotherapy and they have reviewed the evidence and basically confirmed the FDA prescribing information is grounded in science. I think their biggest contribution was pointing out iatrogenic obesity. In other words, medications we used for other kinds of comorbidities that really produce more weight gain and make the problem worse and suggest other alternatives for blood pressure medicines or anti-depression type medicines that are associated with less weight gain. So, I think that brought that into the picture very clearly and I think they are very valuable for that reason. The Obesity Medical Association has some guidelines that I think are very good, they are kind of expert opinion, they weren’t subjected a rigorous peer-review process, they are not published in a journal, they’re on their website, but they are very practical and are evidence-based in the final analysis. In fact, they’re kind of similar to the AACE guidelines which I am familiar with because I was a lead author on those. When AACE does the guidelines, they ask all of the questions that are relevant to real-world patient care. Not just questions around which there are randomized clinical trials to address. So what are all the issues that we have to address when a patient walks in the door and we engage them in a long-term therapeutic plan. And then we bring the best level of evidence that there is to address all of those questions and then grade the strength of the recommendations based on the strength of the evidence. But at least we come up with the recommendation based on, again, the totality of the evidence and the best level of evidence there is to help clinicians navigate their way through obesity management. So we had like 123 questions relevant to screening, diagnosis, evaluation, disease staging, therapeutic decision-making, goals of therapy for long-term follow-up, and so I think they are more comprehensive and evidence-based from that perspective. And so, we really kind of look at the goals of therapy to improve the health of the patient, not to get X number of pounds off, but to lose sufficient weight to improve the health of the patient, which we define as the prevention and treatment of weight-related complications. We do this because those are what make the patient sick – it’s the complications that produce the morbidity and mortality of the disease and here I am talking about prediabetes, diabetes, dyslipidemia, hypertension, nonalcoholic fatty liver disease, NASH, those are kind of cardiometabolic related diseases. In addition, what I call the biomechanical complications that are due to kind of carrying around excess body weight over a number of years – obstructive sleep apnea, stress incontinence, osteoarthritis, these are very important complications as well. Those are the things we want to prevent or ameliorate with weight-loss therapy. So, AACE’s kind of strategy for care is really to address the patient from that perspective to improve their health. It’s not a cosmetic in that sense, it’s not to get X number of pounds off, but it’s more of a disease-oriented approach I think.