Speaker 1:

Welcome to AACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the latest episodes on aace.com/podcasts. And now let's meet the endocrine experts who will be talking with us today.

Jaime Almandoz, MD, MBA, FTOS:

Hi everyone, and welcome to another AACE podcast. I'm Jaime Almandoz and I'm excited to welcome you to this podcast to discuss the recent Lancet Diabetes and Endocrinology Commission on the definition and diagnostic criteria of clinical obesity. To introduce myself briefly, I'm an Associate Professor of Medicine in the Division of Endocrinology at UT Southwestern Medical Center in Dallas, where I'm also Medical Director of the Weight Wellness Obesity Medicine Program.

For this episode, I'm honored to be joined by one of the true pioneers in the field of obesity medicine Dr. Robert Kushner. Dr. Kushner is a Professor of Medicine and Medical Education at Northwestern University Feinberg School of Medicine, where he previously served as the Director for the Center for Lifestyle Medicine.

He's internationally recognized for his work in clinical obesity, medicine, lifestyle medicine, and education. Dr. Kushner has authored more than 250 scientific articles, book chapters and books, including the groundbreaking Primary Care Evaluation and Management of Obesity, and is a past President of the Obesity Society.

In addition to his academic and clinical work, Dr. Kushner has played a pivotal role in advancing the field through certification and education. He's a founding member and former chair of the American Board of Obesity Medicine, helping to establish professional standards and promote excellence in obesity care across the country. His work has fundamentally shaped how we approach obesity, recognizing it as a chronic complex disease that deserves evidence-based, compassionate and patient-centered treatment. Dr. Kushner, welcome to the show. It's truly a pleasure to have you here.

Robert F. Kushner, MD:

Jaime, thank you for that gracious introduction. I really appreciate it and I'm so happy to be here with you.

Jaime Almandoz, MD, MBA, FTOS:

All right, well let's get down to today's discussion. Okay, so what I want to start with is to get an idea of what inspired the need for Lancet Commission to take a fresh look at how obesity is defined and what problem was the commission primarily aiming to solve?

Robert F. Kushner, MD:

Yeah, great opening question. It's time to move beyond BMI, and that's what the commission actually did. We've used BMI for decades to do two things, kind of double duty. One is to define excess body fat and second is to define obesity as a disease. And you and I know there's multiple limitations and flaws with that. First of all, BMI does not measure body fat. It's just a height-weight relationship, so you could be measuring body muscle mass that doesn't measure distribution of body fat, so there's a lot of errors there.

And second of all, you and I know there's cut points needed depending upon the age span, the sex, race, ethnicity and so forth.

Lastly, which is probably the most problematic area is that we never define a disease based on height and weight. So you're looking at someone and you see their BMIs, let's say 32, you have a disease, well, that sounds ridiculous, so we need to move beyond BMI.

Jaime Almandoz, MD, MBA, FTOS:

Can you take me behind the scenes a little bit? You have 58 experts from around the world working on this. I'm sure there were some strong opinions. How did you manage to bring together so many different views on obesity to agree on this definition?

Robert F. Kushner, MD:

Not easy as you can imagine, we met every other month virtually. There was 58 commissioners from around the world. I was one of the commissioners and we met monthly for two and a half years. You can imagine that it was led beautifully by Francisco Rubino, who I think many people know. He was the chair, he's at London, he's a bariatric surgeon. He really prepared every single month with a different topic in which we worked through different concepts, different frameworks tackled one topic at a time. It was an iterative process as you could imagine, right? So it's like a straw man. You throw it out, you get reaction, you do anonymous voting and polling, and we used the Delphi consensus technique. I think most clinicians know what that is. You do series of voting until you finally get to a final answer. The bottom line is it was very successful. We had 82 statements that came out of the commission. You had to have a consensus of two out of three or 67% of the commissioners had to agree to it. So 60% of these statements were unanimous, which is really, really important, and 40% were near unanimous. So even though the threshold was two out of three, we surpassed that when it came to actually recommending these statements.

Jaime Almandoz, MD, MBA, FTOS:

Oh, wow. That's great insight. From a practical perspective, how is this new definition of clinical and preclinical obesity different from the old BMI focus model and what does this mean for clinicians working with patients day to day?

Robert F. Kushner, MD:

Yeah, it's a really good question. There was two fundamental outcomes from the report. The first is, using BMI to identify body fat. We can get back to that, but to answer your question directly, the two new terms, which really changes the framework quite a bit from this report is to designate preclinical obesity from clinical obesity. And here's why, Jaime, we know that over 40% of US adults have obesity by BMI of over 30, but do they all have a disease? Do they all need treatment? How many of them just have extra muscle, not enough body fat? Versus how many have a low BMI? Yet they really have obesity and have harm to their health. So it's very important to be more clearly identify who may have extra body fat, but there's no harm to their health.

No signs or symptoms, which is something new we identified with this report. How do you even obesity? We included signs or symptoms or limitation daily activity. So if you have no harm to your health, no limitations of daily activity. We said you have pre-clinical obesity. If however, you have excess body fat, but you have identified harm to your health by having a sign or a symptom of obesity, which we could talk about later or limitations of daily activity, you now have clinical obesity and that separates out for the first time who should we allocate treatment to more aggressively? And who should we perhaps we could back off on and just provide counseling if they don't have a high risk of developing harm to their health as time goes on?

Jaime Almandoz, MD, MBA, FTOS:

Gotcha. One of the things we talk about about lived experiences of people with obesity is weight stigma and bias and that negative lived experience for people living with obesity. And one concern that's come up is whether labeling people with having clinical obesity could actually increase stigma. How do you respond to worries about reinforcing weight bias with this new model?

Robert F. Kushner, MD:

Well, it would be an unintended consequence if somehow bias went up. The whole idea is to reduce bias. Now we know that stigma and bias is prevalent in our society, and I have no deep understanding that this commission is going to change everything. It really takes much more to it. But by hopefully identifying when harm can affect one's body weight by signs and symptoms, that there's an underlying biological nature to this and it's very clear. We're hoping that we'll reduce the stigma or bias if you can identify, I am being harmed by this versus people who may have extra body fat, but there's no harm. Now, we hope the reduced bias of course goes to both groups, but it's really going to, I think hopefully shed more understanding that this can be a disease and we can identify it when it's a disease.

Jaime Almandoz, MD, MBA, FTOS:

I think that's a great point. It's one of the main reasons or one reason why we want to consider obesity as a disease because we're trying to decrease weight stigma and bias around it. Some critics have said that calling obesity disease might make people overlook the role of lifestyle factors. How do you approach concerns about balancing what some people are calling personal responsibility with recognizing obesity as a disease?

Robert F. Kushner, MD:

I've heard this argument many times, if you call it disease, people say, "Well, there's nothing I can do. I don't have to take care of myself. My genes and my disease will carry forward." And that's not true with other chronic diseases we deal with all the time. And diabetes, a great example. This is an AACE podcast, right? We never just give someone medication, "Say, you could eat anything you want. You don't have to be physically active. It doesn't matter what your body weight is, you just take this medication." No endocrinologist would say that. So I can't think of hardly any other chronic disease that we don't have a layer of a cornerstone of treatment, of lifestyle modification or how to take better care of yourself. So we hope that by identifying people with clinical obesity, that we will increase our attention to those individuals, which includes lifestyle modification and taking good care of yourself, but also we need to be more aggressive and use evidence-based treatments that are available for those individuals.

Jaime Almandoz, MD, MBA, FTOS:

Yeah, I think that's such a wonderful point that lifestyle change is foundational for so many of the treatments we recommend, but unfortunately, for many people it may not be enough to treat their obesity and to bring about the meaningfully clinical outcomes that we want to see. We touched on this a little bit earlier, that the new definition of obesity goes beyond BMI and includes other anthropometric measurements to assess adiposity. How realistic is it for most healthcare providers to start using these in day-to-day practice, and do you think the system is ready for this kind of shift?

Robert F. Kushner, MD:

I hope it's ready. I think we need a lot of work. I will say that waist circumference has been recommended as in obesity guidelines going back to 1998. I'll also point out that the AACE obesity guidelines talk about doing waist circumference for BMI of 35 or lower when you're doing your staging and so forth. But I'll also recognize that is not routinely done as part of a physical examination. Even in my own institution where I'm the obesity champion, right? I'm out there really holding the flag that we need to do more regarding screening and evaluation. It's hard for even our medical students and our preceptors to do it.

It's interesting because it's probably one of the lowest skilled procedures. It's much more complex to take a blood pressure and teach that the stethoscope in here, the Korotkoff sounds and so on. It's not hard to do a waist circumference. You have to be sensitive. You're putting a tape measure around someone who's not going to like that perhaps, but you have to explain it. You have to learn how to do it. But it's very important. And we know, as I said in that first question, Jaime, that BMI is insufficient in a large group of individuals to really diagnose obesity or risk of a high BMI, and we know where the body fat is distributed, particularly that visceral, that abdominal compartment increases that risk estimate significantly, not only for having obesity, but also the disease of obesity with signs and symptoms and heart disease. The Commission and this is important to also mention, took a very pragmatic approach. We had 58 commissioners from around the world. So when someone on the virtual meeting says, "Let's do body composition, everyone." Someone from a Third World country or less resourced country around the world says, "We're not going to do bioimpedance and DEXA and bod pod on people. That's ridiculous."

So we took a pragmatic approach and we came up with three reasonable additional anthropometric measurements beyond BMI, waist circumference, waist to height ratio, and waist to hip ratio. The data from my point of view, shows waist to height ratio probably has the greatest predictability, and you don't have to change it based on age, and gender, and ethnicity about 0.5 is probably reasonable.

So I think we're a long way off to really get it to be part of clinical care. Perhaps it could be added if it's added as a performance measure that may help. We do need to start teaching in medical schools, but we have to tell them why we're not just adding a procedure. We need to tell why is it important with someone with a high BMI you don't just start treatment? You want to add another measurement that's very pragmatic, simple to do and has value.

Jaime Almandoz, MD, MBA, FTOS:

Absolutely. I think that's such a great point about being pragmatic and practical on this. I'm always a fan of practical more than perfection, and I agree with you that what we need are accessible measures for all clinicians across the spectrum, not just obesity specialists and endocrinologists with primary care and public health clinicians to be able to do this effectively. I'm going to shift gears a little bit and talk about some other concerns that those of us who work in the clinical sphere have around these definitions for obesity. Are you worried that health insurers or health systems might jump on this classification as an excuse to cut off coverage or deny treatment for patients labeled with pre-clinical obesity just because they don't have complications yet? And what's your kind of view on how these should be used from a prevention perspective?

Robert F. Kushner, MD:

Yeah, that would be under that category of unintended consequence, which I used earlier about increasing stigma and bias. It would be an unintended consequence if the insurance companies use that as a barrier as if we don't have enough barriers, right? If they use it as a barrier to not treat someone, I think of it and we have to push back and we have to explain that. But two points I want to make Jaime, one is, that we think of this as resource allocation. We have a lot of individuals in this country that have obesity, excess body fat, but not all of them probably have harm to their body. So if we could start allocating resources more effectively to individuals with clinical obesity, that would hopefully free up funds for one thing, because it really comes down to money is we can put our efforts towards those individuals.

However, there are individuals with, we use the term pre-clinical obesity, meaning there's no harm to their body that do need treatment now because of increased family risk, high risk of type two diabetes for other reasons as examples, and we do need to treat them as well. And the guidelines by the way, say that it's not that you don't treat people with pre-clinical obesity, it's just that not all of them may need to be treated as intensely at this point, but if they are high risk, they should be. So we need to make that point very clear. When we're working with insurance companies, we need to probably document those individuals that do need more aggressive care, even though they don't have what we would call clinical obesity. So we have to be on the lookout for that, that we don't have insurance companies denying treatment in those that do need treatment.

Jaime Almandoz, MD, MBA, FTOS:

I agree with you. I think the cost of current evidence-based obesity care is quite high. Do you think if the costs were lower, that, that may kind of change the framing of the discussion?

Robert F. Kushner, MD:

I think it would. When we see patients in the clinic, we could do a whole obesity-focused encounter. When we get down to treatment, our eyes go right to the EMR and say, "What's the insurance?" How sad is that? So if cost does come down, and I think it will in a market cost typically comes down and competition and so on, I think that will help allocate our resources. I don't think it'll be changed definitions, but it may change how we allocate our resources to those individuals.

Jaime Almandoz, MD, MBA, FTOS:

In talking about resource allocation, what kind of steps is The Commission recommending to ensure that rolling out this classification doesn't end up making health inequities worth, especially for under-resourced communities or in countries that already stretched them from this perspective?

Robert F. Kushner, MD:

Well, it kind of gets down to what I was just saying is that we have a resource-limited, let's say, pool of money or health professionals and community resources. And if we can identify those in the community that need treatment, and that would be, I would say those with clinical obesity, we could take those limited resources and apply it to those individuals almost in a tiered system. So I'm not ignoring individuals with pre-clinical obesity by all, it's just that not all of them need the same aggressive treatment today if they have no designated harm to their body. We define that by signs and symptoms of the disease or limitations of daily activity. So if you have a low-resource community, you could actually tailor your treatment for those that really need treatment today.

Jaime Almandoz, MD, MBA, FTOS:

That's great. Thank you. Overall, how do you think the response has been to The Commission's report?

Robert F. Kushner, MD:

Overall, the response has been very positive. On the launch day that Francisco Rubino had back in January, I think it was covered in most countries around the world. Personally, I was on both national and international news. I think it was very positive. It was a fresh story, a fresh look at what obesity is. I think a first step forward to move beyond BMI, which all of us have been talking about the limitations of BMI and we need to move forward. And I think this starts to do that. However, you're pointing out in this podcast that there are concerns, there are gaps between insurance and how do we allocate resources to the right person? Is our healthcare professionals ready to do this? So we still have work to do, but I am really looking forward to academic discourse in viewpoints and comments and other articles that are coming out that will build upon it. None of the commissioners felt we were done and we shake hand and we go home for the day. All of us felt this was the first step in starting a conversation to move beyond just BMI. You have excess body fat, you have obesity, you need treatment.

Jaime Almandoz, MD, MBA, FTOS:

I'm sure there were a lot of interesting discussions as part of this process. What are some of your most memorable takeaways or thoughts that made you pause with regards to your approach to this?

Robert F. Kushner, MD:

Yeah, you can imagine after two and a half years of talking to expert commissioners around the world, this was not a slam by all. There was no shouting matches. There was no fist to fist. We were all virtual and so on. But I would say probably the two areas that had the greatest discussion was what do you include as a sign or symptom of obesity? And the two that jumped out at me in which we had to go round after round is diabetes, which is good for this AACE podcast and depression or mental health. A lot of the commissioners felt that diabetes, we've talked about di-obesity for so long, but yet now you're cutting out diabetes as a natural progression of obesity. And the argument that really won the day, not only with that but with mental health, is that you had to connect the dots directly from dysfunctional fat to the sign, or symptom or disorder.

And the argument was, if we start with mental health, let's say depression, that depression can cause obesity and obesity can cause depression, it goes both ways. So how can you have that as a natural progression of obesity? If you could have depression first, then you develop obesity. So there's other things going on here. When it came to diabetes, there was a little more nuanced, and the argument was that yes, dysfunctional fat causes insulin resistance, and actually one of the signs or symptoms is high triglycerides, low HDL and dysglycemia, which are insulin resistant signs, but you needed beta cell failure or other factors to actually go on and cause diabetes. So the fact that there was another factor in there, it didn't make it to the list of a direct complication of obesity that could be argued, and I think it will be in the scientific community.

Jaime Almandoz, MD, MBA, FTOS:

Thank you. As we look towards the future, what would you say are some of the highest priority research errors or knowledge gaps that we need to advance to ensure that this new classification is really effective and equitable?

Robert F. Kushner, MD:

Yeah, I thought a lot about that. When you're done with the... Every time you write an article, God, if I had to write another article, I would add this or that. I've thought a lot about that, and I'll just list some of the questions that need to be answered. We don't know the prevalence of preclinical obesity and clinical obesity in the population. I said that 40% of American adults have obesity by BMI. How many are preclinical obesity? How many have a clinical obesity? Should the new designation be used in clinical trials? Should the goal be remission of signs and symptoms as an outcome? Should treatment outcomes include only individuals with clinical obesity? Should we include preclinical obesity? What's the timeline? If someone has preclinical obesity, how many of them develop clinical obesity? And what is that timeline? How many more signs and symptoms are there? What about the ICD-United coding? It doesn't have anything about this. So we have a lot of work to do before this is ready for clinical care. And so many questions are raised by these new recommendations.

Jaime Almandoz, MD, MBA, FTOS:

So a lot of work to be done here, but I think wonderful kind of progress with regards to, as you say, moving beyond BMI. And so that brings us to the end of today's episode. I really want to thank my wonderful guest, Dr. Bob Kushner today, and to thank our listeners for listening. We look forward to continuing the conversation with you as through this series of podcasts. Thank you so much for joining us. We hope that you're walking away with some fresh ideas and plenty to think about.

Speaker 1:

Thanks for listening to another great AACE podcast. Join us for another episode at aace.com/podcasts and help us in our mission to elevate clinical endocrinology. Together we are AACE.