By Eva Kneepkens of Medical Contact [1].
After fifteen years, the obesity guideline for adults has finally been updated. Guideline chair and internist-endocrinologist Liesbeth van Rossum explains some of the new recommendations.
The adult obesity guideline dated back to 2008 and was quite outdated. Since then, so much has happened in science. It was high time for a new one,’ says Liesbeth van Rossum, internist-endocrinologist and guideline chair. After such a rigorous update, there are many new insights and recommendations. Below is a selection.
Comorbidities
As before, weight-related health risk (GGR) is a key pillar of the guideline. ‘But that has been simplified. The GGR now consists of three components: BMI, abdominal circumference and obesity-related comorbidities. The outcome of those three determines which GGR category the patient falls into’. Moreover, the list of obesity-related comorbidities has grown considerably. ‘Previously, the focus was on type 2 diabetes, cardiovascular disease, osteoarthritis and obstructive sleep apnea syndrome (OSAS). The list is now much longer and includes, for example, asthma, 13 forms of cancer, infertility and depression. It is important for physicians to be alert to obesity in these conditions. For one thing, they can cause or perpetuate obesity. ‘For example, we see many people who have a psychosocial cause or a medication side effect with a weight-increasing effect. Just a lifestyle intervention is then often not enough.’ On the other hand, obesity often gets in the way of treating these conditions. Take asthma. ‘First look at what type it is. Research showed that half of the people with the combination of obesity and asthma in adulthood have inflammatory asthma and are wrongly using corticosteroids with a potential weight-increasing effect. Then you have to treat the obesity first, and that can also improve the obesity-related inflammatory asthma.
Fat mass
In addition, comorbidities have won a place on the list of outcome measures in the treatment of obesity. ‘Fat is an organ and in obesity it is literally sick. If you tackle the fat, the obesity-related comorbidities also improve, and they are also part of the outcome measures. That is new,” says Van Rossum. What is also new is that BMI still only has a modest role in the consultation room. ‘BMI is still there, but it is less important in the whole story. We now mainly look at fat mass. Ideally, you want to measure that with a body composition meter, but not every doctor has one. A simpler way then is to measure abdominal circumference as a surrogate marker for visceral fat.’ In addition, quality of life is also important. ‘Suppose someone loses very little weight after a lifestyle intervention, but the quality of life goes up. That is often related to body composition and the decrease in chronic inflammation. Feeling fitter and better in your own skin is also important for the patient’.
Making negotiable
‘All the doctor really has to do is be alert and discuss obesity in a non-judgmental way. “You come in for knee problems, are you OK with talking about your obesity as well?” We know from research that 99 percent of patients are okay with that. For the few who don’t, you’ve planted a seed anyway. But it is important that you link a warm conduit to it. So ask permission to talk about it, discuss the causes, if there is time, by systematically going through the list, which also leads to a more open conversation, and provide a warm referral by saying: “Do you agree to do something about it?” This can be done through the doctor’s assistant, POH or, in an increasing number of municipalities, the central care coordinator. As a result, discussing obesity need not take up much of the physician’s time.
There are developments at play here that will help the physician. For example, Van Rossum and her colleagues are finalizing a website on which patients themselves can determine their lifestyle and numerous underlying causes of obesity. That website will also be available in Turkish and Moroccan, among other languages. Moreover, the network approach is emerging and is part of the obesity guideline. ‘Within a year, 25 hospitals already have a lifestyle care counter that can refer people to appropriate help in their own neighborhood, and more and more municipalities have a central care coordinator.’
[1] Kneepkens, E. (2023, July 13). ‘Discuss obesity in a nonjudgmental way’. Medical Contact.
