SPECIAL ARTICLE

A framework for physician assistant intervention for overweight and obesity Lawrence Herman, MPA, PA-C, DFAAPA; John G. McGinnity, MS, PA-C, DFAAPA; Michael Doll, MPAS, PA-C, DFAAPA; Eric D. Peterson, EdM, FACEHP, CHCP; Amanda Russell, MS, PA-C; Joseph Largay, PA-C, CDE. American Academy of Physician Assistants Overweight and Obesity Task Force

ABSTRACT Overweight and obesity compose a chronic disease process of epidemic proportions that presents on a continuum, likely affecting nearly two out of every three patients treated by physician assistants (PAs). However, meaningful and actionable definitions, including but not limited to anthropometric and clinical descriptors, are needed. The effective treatment of overweight and obesity requires an efficient and timely process of screening, diagnosis, evaluation of complications, staging, and clear algorithmic management. PAs are trained as primary care providers and can diagnose and treat overweight and obese patients regardless of practice setting and across the spectrum of the disease and patient’s age. Keywords: obesity, overweight, physician assistants, BMI, chronic care model, AAPA

Lawrence Herman is an associate professor and chair of the Department of Physician Assistant Studies at the New York Institute of Technology in Old Westbury, N.Y. He is the chair of the AAPA Overweight and Obesity Task Force. John G. McGinnity is program director and clinical associate professor at the Department of Healthcare Sciences PA Program at Wayne State University in Detroit, Mich. Michael Doll is the chief physician assistant in the cardiothoracic surgery service at Geisinger Medical Center in Danville, Pa. Eric D. Peterson is a fellow of the Alliance for Continuing Education and a certified continuing healthcare development professional. Amanda Russell practices orthopedics at OrthoVirginia in Midlothian, Va. At the time this article was written, Joseph Largay was a clinical instructor in the Department of Medicine, Division of Endocrinology, at the University of North Carolina at Chapel Hill, and practiced in the outpatient clinic of the Diabetes Care Center. He has since joined AstraZeneca as a full-time employee. Mr. Herman discloses that he is a consultant for Boehringer Ingelheim, Novo Nordisk, and Sanofi Aventis. Mr. Largay discloses that he is a consultant for AstraZeneca, Sanofi, Takeda, and Vivus; and receives grants and research funding from Amylin, Andromeda, Boehringer Ingelheim, GI Dynamics, Halozyme, Hoffmann-LaRoche, Immune Tolerance Network, Jaeb Center For Health Research Inc., Johnson & Johnson, Lexicon, Lilly, Medtronic, Merck, Novo-Nordisk, Orexigen, Phase Bio, National Institute of Allergy and Infectious Diseases, National Institutes of Health/National Heart, Lung & Blood Institute, Sanofi Aventis, and Tolerx. The other authors disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000466594.30788.a6 Copyright © 2015 American Academy of Physician Assistants

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he American Academy of Physician Assistants (AAPA) convened a six-member expert panel including five practicing PAs (with nearly a century of combined experience) to develop a framework that can be used by physician assistants (PAs) and other medical providers to effectively combat overweight and obesity. The expert panel members represent a broad array of medical and surgical specialties that often treat conditions related to overweight and obesity: family practice, internal medicine, endocrinology, interventional and general cardiology, sports medicine, occupational medicine, emergency medicine, hospitalist medicine, and general, orthopedic, and cardiothoracic surgery. This broad experience is critical background to support an effective action plan. In addition to bringing its own expertise and experience to the matter, the panel reviewed

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SPECIAL ARTICLE

Key points Overweight and obesity compose a chronic disease process of epidemic proportions that presents on a continuum, likely affecting nearly two out of every three patients treated by PAs. The effective treatment of overweight and obesity requires an efficient and timely process of screening, diagnosis, evaluation of complications, staging, and clear algorithmic management. This article proposes a new framework for treating overweight and obesity using a chronic disease process. PAs can diagnose and treat overweight and obese patients regardless of practice setting and across the spectrum of the disease and patient’s age.

the work of other expert groups on this topic, focusing on recent position papers from the American Association of Clinical Endocrinologists and the American College of Endocrinology.1,2 The panel also reviewed a selected bibliography of more than 30 articles reflecting the current knowledge of overweight and obesity. The panel concluded that the pathogenesis of overweight and obesity conforms to the chronic disease model. Overweight and obesity as diseases arise from a complex interaction of genetics, environment, and individual and population behaviors that influence disease severity and affect patient health and the development of complications. Even in patients with healthful behaviors, the highly obesogenic environment in the United States places most patients at some level of risk. Therefore, we advocate for a strategy to attack these societal issues in meaningful ways, while clinicians concurrently adopt a chronic care model for the treatment of overweight and obesity. Validating the behaviors of patients with healthful weights also is important. This article addresses the current lack of diagnostic management clarity surrounding overweight and obesity, which serves as an impediment to clear, concerted, and comprehensive action. We propose a new framework for a more meaningful diagnosis of overweight and obesity as a chronic disease that translates emerging concepts into actionable recommendations. Finally, we endorse for PAs a diagnostic algorithm that is mapped to evidence-based, risk-stratified patient subsets and complications-centric management. The framework has been built on the following key findings: • All patients should be screened for overweight and obesity using BMI and other measures that more directly quantify adipose tissue mass, including adjustments for ethnic differences in risk thresholds individualized for patients. • The use of population health techniques, such as registries and electronic health record flags, will help identify patients who are at risk and will enhance their management. 30

• Screening, diagnosis, and staging are important to the development and implementation of disease management options. The goal of weight loss therapy should be to minimize or reduce complications, rather than lower BMI. • The diagnosis of overweight and obesity, diseases of excess adiposity, requires linking complications and comorbidities as disease markers and disease severity. • Associating overweight and obesity and its complications will increase awareness of patient populations appropriate for interventions aimed at maintaining healthful weight, halting or reversing weight gain, and addressing weightrelated complications for the prevention and treatment of complications. • A patient-centered approach to diagnosis and treatment is needed to prevent and treat complications with increasingly aggressive therapeutic approaches to optimize outcomes, the risk/benefit ratio of intervention, and costeffectiveness. • Engaging patients as full partners in their own care is an essential component of treatment, as patient selfmanagement is critical to successful outcomes. The framework has been developed with an eye toward ensuring that it is practical, easily implemented by busy clinicians, and effective in helping patients address the underlying causes of a variety of medical conditions. Because PAs are generalists in spite of practicing in virtually every medical specialty, and an estimated two-thirds of patients seen by PAs are overweight or obese, PAs are uniquely positioned to spearhead an enhanced focus on overweight and obesity. AAPA will make this document available to its membership and appropriate outside constituencies with the intent of marshalling support for more effective, evidence-based interventions for the prevention and treatment of overweight and obesity. CURRENT TREATMENT Traditionally, medical practice has noted anthropomorphic measures in the patient record, usually in the form of a body mass index (BMI) calculated on the patient’s height and weight. Obesity has only recently been identified as a unique medical condition deserving a formal diagnosis and treatment plan, but clinicians do no not necessarily do so using a chronic care model. Complications that arise from overweight and obesity are generally managed within separate medical specialties, often without addressing the root cause. Given the relationship of overweight and obesity to a wide array of serious conditions, this paradigm must shift in a way that emphasizes prevention, rather than the treatment of overweight and obesity-related complications as separate medical problems. Equally important, many clinicians in the US healthcare system have not yet embraced the concept of overweight and obesity using a chronic care disease process. As a result, the system ignores the inevitable long-term consequences of overweight and obesity until after the disease has

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A framework for physician assistant intervention for overweight and obesity

progressed and complications have developed. The added failure to associate the complications of overweight and obesity with their root cause has created a number of negative consequences: • Clinicians are discouraged from treating overweight and obesity early. • Policymakers, researchers, and payers are deterred from providing appropriate funding, care models, and public policy to address the problem. A NEW DIAGNOSTIC ALGORITHM Overweight and obesity are a multidimensional chronic disease process characterized by complicated and intertwined pathophysiological processes. These processes ultimately cause increased body mass and increased adipose tissue that likely results in increased morbidity and mortality. A BMI of 25 kg/m2 or greater is associated with increased incidence of obesity-related complications and risk of progressive obesity.3-7 Although BMI provides a simple, efficient method of screening for overweight and obesity, BMI alone is not sufficient to establish a diagnosis. Factors such as ethnicity, sex, age, waist circumference, and muscularity all have the potential to shift diagnostic thresholds. We propose a new overweight and obesity diagnostic algorithm incorporating two key components: • an assessment of at-risk patients using BMI and ethnicity-adjusted anthropometrics to identify patients with increased adipose tissue • identification of obesity-related complications in these patients (Table 1).1 A comprehensive and actionable diagnosis cannot rely solely on BMI, but must also consider the effect of excess weight on health. Patients with a BMI of 25 kg/m2 or greater (or in certain populations, a BMI of 23 to 25 kg/m2 with increased waist circumference) require concurrent evaluation for specific obesity-related complications to complete the diagnostic process. These complications are listed in Table 2. After diagnosis, the comprehensive interventions to treat overweight or obesity must be individualized and must include primary, secondary, and tertiary interventions: • Patients with a BMI less than 25 kg/m2 (and waist circumference is not increased) are considered normal weight TABLE 1.

Screening and diagnosis of overweight and obesity2

Diagnosis

BMI (kg/m2)

Clinical evaluation

Overweight

25-29.9

No obesity-related complications

Obesity

≥30

No obesity-related complications

Overweight or obesity with complications

≥25

One or more obesity-related complications

and are candidates for healthful lifestyle education to prevent overweight and obesity. In most populations, a waist circumference less than or equal to 40 in (101.6 cm) in men and less than or equal to 35 in (88.9 cm) in women is considered normal.8 • Patients who are overweight or obese and have no obesity-related complications are candidates for secondary intervention to reverse weight gain and prevent obesityrelated complications. • Patients with BMIs of 25 kg/m2 or greater and obesityrelated complications require tertiary interventions to prevent continued weight gain and to treat complications. A BROAD-BASED DIAGNOSTIC AND TREATMENT MODEL Intensive and collaborative action across the entire spectrum of healthcare providers is essential for achieving any significant reduction in the prevalence of overweight and obesity. Our conclusion is clear: Overweight and obesity must be recognized by all healthcare providers and treated as chronic diseases with significant downstream complications. This reverses the traditional approach to diagnosis and treatment, which has focused on the complications of overweight and obesity, without reference to their underlying cause. The proposed diagnostic and treatment model consists of the four steps (Table 2): • Screen all patients using BMI (taking into account ethnically adjusted anthropomorphic measures), including automatic calculation of BMI with pop-ups and stop points in electronic health records (EHRs). • Evaluate and document the presence or absence of obesity-related complications. • Assign an appropriate stage of obesity and complications based on the clinical evaluation. • Initiate appropriate interventions. Patient education, which often is overlooked, must be a key component in the treatment of overweight and obesity, and, much like tobacco addiction, must be addressed at each and every visit. Clinicians may need to intervene repeatedly, and patients may need to make multiple attempts to control and reverse overweight or obesity. OTHER ISSUES We offer the following additional observations about the adoption of this proposed framework and treatment of patients with overweight or obesity: • The link between the diagnosis of overweight and obesity and its complications must be clearly recognized in order to improve clinicians’ understanding of what they are treating and why they are treating it. • The phrase morbid obesity should be eliminated because it may further stigmatize patients and act as a barrier to clinicians initiating a discussion with patients. The terms overweight and obesity are understood by patients and the medical community and should be retained.

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SPECIAL ARTICLE TABLE 2.

Diagnosing and treating overweight and obesity2

Diagnosis

Complications-specific staging and treatment

Step 1

Step 2

Step 3

Step 4

BMI (kg/m2)

Clinical assessment of overweight/ obesity-related complications

Complicationsspecific staging

Suggested therapeutic interventions (based on clinical judgment)

25-29.9

• Prediabetes, metabolic syndrome, type 2 diabetes • Dyslipidemia or hypertriglyceridemia • Hypertension • Coronary artery disease • Peripheral arterial disease • Carotid arterial disease • Cerebrovascular accident or transient ischemic attack • Sleep apnea • Osteoarthritis • Disability or immobility • Polycystic ovary syndrome • Stress and urge urinary incontinence • Nonalcoholic fatty liver disease • Gastroesophageal reflux disease • Gallbladder disease • Depression • Cancer including recurrences • Psychologic disorder or stigmatization

Overweight

• Nutrition: healthful meal pattern • Exercise: physical activity • Behavioral therapist: lifestyle modification • Sleep hygiene

Obesity

• Nutrition: healthful meal pattern • Exercise: physical activity • Intensive behavioral therapist: lifestyle modification • Sleep hygiene • Consider adding weight loss medication if BMI ≥27

Overweight/obesity with complications

• Nutrition: healthful meal pattern • Exercise: physical activity • Intensive behavioral therapist: lifestyle modification • Sleep hygiene • Weight loss medication if BMI ≥27 • Consider bariatric surgery in patients with type 2 diabetes and BMI of 35-39.9 • Consider bariatric surgery in patients with BMI ≥ 40

≥30

≥25

• Special populations, such as Asian patients, warrant an individualized diagnostic approach, which may include waist circumference and body fat analysis.8 Clinicians should understand that overweight is analogous to prehypertension or prediabetes, and cannot be ignored. Although patient with overweight and complications may not be classified as obese under BMI standards, they need treatment including weight loss management. • Any framework for diagnosis and treatment of overweight and obesity must provide an economically viable global model for care that focuses on primary prevention and secondary treatment. The most aggressive weight loss interventions should be initiated for patients with complications, who will derive the greatest benefit. By focusing on the highest benefit interventions, cost-effectiveness will improve over time. The process should not divert limited healthcare resources from high-risk patients who require aggressive interventions to lower-morbidity patient populations. • Finally, the diagnostic and disease management paradigm for obesity may need to be modified for older patients.

a focus on prevention. In fact, unlike any other clinician, to practice all PAs certify in primary care and subsequently recertify every 10 years. With a grounding in primary care, PAs practice along the whole spectrum of medical and surgical specialties, and most PAs change their area of practice at least once during their career. This means that patients are likely to encounter a PA at many points throughout the medical system. Indeed, PAs often address patients’ primary care needs on behalf of a specialty care team, and the vast majority of PAs treat patients with overweight or obesity each day in their practice, regardless of their area of practice. Because of the generalist training that allows lifelong flexibility in their practice patterns, PAs are accustomed to acquiring new skills and competencies. With a professional commitment to interprofessional, team-based care instilled in PAs from their earliest training, PAs are uniquely positioned to lead and coordinate a broad-based effort to change the way the medical community diagnoses, manages, and treats patients with overweight or obesity.

THE ROLE OF PHYSICIAN ASSISTANTS The PA profession is in a unique position to affect the diagnosis and management of overweight and obesity. PAs are trained and certified as primary care generalists with

ISSUES AND OPPORTUNITIES Given the magnitude of the overweight and obesity crisis in the United States, and consistent with AAPA’s policy encouraging PAs to address issues of weight, obesity, and

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physical activity, AAPA is prepared to undertake the following actions on behalf of the PA profession: 1. Develop an interprofessional credential for clinicians who demonstrate competency in providing care to patients with overweight or obesity. For clinicians who want to specialize in this area, important areas in which to demonstrate competency include: • Applying population medicine approaches { Identifying the at-risk population through appropriate systematic screening and proactively offering appropriate preventive services • Making a diagnosis of overweight or obesity { Assessing for obesity-related complications { Assigning a clinical stage based on the presence or absence of complications • Communicating with patients using motivational interviewing techniques about their health concerns and desire to implement change • Constructing and implementing an obesity management program { Managing obesity-related complications { Determining behavioral interventions  Assessing level of physical activity  Prescribing a program of physical activity  Assessing dietary habits and meal pattern preferences  Prescribing appropriate medical nutrition therapy  Promoting good sleep hygiene { Recommending and prescribing pharmacotherapy when appropriate { Recommending and employing surgical interventions when appropriate { Identifying and addressing psychologic disorders that may affect weight { Establishing a referral network for additional services 2. Work with the Physician Assistant Education Association to identify and implement modifications to the PA training program to ensure that PAs develop these competencies in during training.

3. Work with accountable care organizations and other organizations with responsibility for patient care across multiple settings to develop special services for patients with overweight or obesity. These services would be offered to at-risk patients and aimed at reducing downstream mortality, morbidity, and costs related to overweight and obesity-related complications. JAAPA REFERENCES 1. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/ TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63(25 Pt B):2985-3023. 2. Garvey WT, Garber AJ, Mechanick JI, et al. American Association of Clinical Endocrinologists and American College of Endocrinology position statement on the 2014 advanced framework for a new diagnosis of obesity as a chronic disease. Endocr Pract. 2014;20(9):977-989. 3. Bogers RP, Bemelmans WJ, Hoogenveen RT, et al. Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300,000 persons. Arch Intern Med. 2007;167(16): 1720-1728. 4. Wormser D, Kaptoge S, Di Angelantonio E, et al. Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies. Lancet. 2011;377(9771): 1085-1095. 5. Owen CG, Whincup PH, Orfei L, et al. Is body mass index before middle age related to coronary heart disease risk in later life? Evidence from observational studies. Int J Obes (Lond). 2009;33(8):866-877. 6. Whitlock G, Lewington S, Mhurchu CN. Coronary heart disease and body mass index: a systematic review of the evidence from larger prospective cohort studies. Semin Vasc Med. 2002;2(4): 369-381. 7. Hartemink N, Boshuizen HC, Nagelkerke NJ, et al. Combining risk estimates from observational studies with different exposure cutpoints: a meta-analysis on body mass index and diabetes type 2. Am J Epidemiol. 2006;163(11):1042-1052. 8. International Diabetes Foundation. The IDF consensus worldwide definition of the metabolic syndrome. http://www.idf. org/webdata/docs/IDF_Meta_def_final.pdf. Accessed April 9, 2015.

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A framework for physician assistant intervention for overweight and obesity.

Overweight and obesity compose a chronic disease process of epidemic proportions that presents on a continuum, likely affecting nearly two out of ever...
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