You have the power! Implementing the POWER guidelines in everyday practice

The obesity epidemic in the U.S. is no longer a new problem; however, despite continued emphasis on disease burden, more than two-thirds of Americans are considered overweight or obese.1 Gastroenterologists are uniquely positioned to take the lead in managing the disease considering their extensive training in the pathophysiology of the digestive tract, management of common obesity-related comorbidities like gastroesophageal reflux disease (GERD) and nonalcoholic fatty liver disease (NAFLD), as well as emerging endoscopic therapeutic options for obesity. National societies recognize this opportunity and have published documents guiding gastroenterologists/hepatologists involvement, including the ACG’s Obesity Action Plan in 2008, the AASLD Diagnosis and Management of NAFLD in 2012, the ASGE’s Position Statement on Endobariatric Therapies in Clinical Practice in 2015, and, more recently, AGA’s Practice Guide on Obesity and Weight Management, Education, and Resources (POWER) in 2017.2-5

Considering the significant impact of obesity and the growing clinical opportunities, gastroenterologists should familiarize themselves with these documents, which address assessment, management, and follow-up of obesity and its complications. The AGA POWER guidelines provide a framework for the provision of comprehensive care of patients who are obese. These guidelines emphasize the need for a collaborative approach with a multidisciplinary team of dietitians, exercise therapists, nurse educators, psychologists and physicians. Initial consultation focuses on assessing patient readiness for intervention and overall disease burden. This includes dietary and physical activity analysis, medical assessment of both risk factors for obesity, as well as complications of disease, and a psychological evaluation. This assessment is followed by an intense intervention phase that relies on dietary manipulation, physical activity and behavioral counseling. For select patients, weight loss is augmented with pharmacotherapy followed by endoscopic therapy, surgical management, or both, when indicated. Weight loss maintenance and weight gain–regain prevention is the focus of follow-up care.

Learn more about the AGA POWER guidelines, a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management.

Although obesity management requires a multidisciplinary approach, gastroenterologists are equipped to assume the lead role in the care of these patients. Longitudinal care of comorbidities, especially GERD, NAFLD, and nonalcoholic steatohepatitis, allow for routine, office visits, as does complication management of medical and surgical weight loss therapy itself (altered bowel habits, nausea and vomiting, small intestinal bacterial overgrowth, nutritional deficiencies) and need for diagnostic and therapeutic endoscopy. If expertise in endobariatrics is available, then this service is an additional resource that may augment overall care.

Consistent with this framework, our practice at the University of Pennsylvania has developed a gastrointestinal (GI) Weight Management and Obesity Program that cares for patients from referral for medically supervised weight loss through maintenance and management of complications related to obesity. Patients are initially identified by a partnering health care professional, who recognizes the patient’s need and desire to lose weight in the presence of a GI comorbidity or complaint. This diagnosis of obesity is crucial in building a patient panel and highlights the importance of advertising our GI Weight Management and Obesity Program to high-impact users such as primary care physicians, endocrinologists and cardiologists.6 A patient’s first visit to our center includes a medical assessment with a gastroenterologist, who focuses on readiness for change, obesity disease burden, and GI-related comorbidities and complaints. The patient is also seen by a registered dietitian, who analyzes current practices and physical activity level. Patients can be referred for psychosocial and/or exercise therapy assessments as appropriate.

If a patient subsequently enrolls in the program, they are asked to maintain a close relationship through interval follow-up with team members that 1) reflects the nature of obesity as a chronic illness (similar to how patients with diabetes are seen for periodic blood measurements) and 2) emphasizes shared decision-making. This occurs through both electronic communication via the medical system’s patient portal as well as in-person visits at specified intervals where food and activity diaries are reviewed, goals are refined, and progress is documented. In our program, patients are seen monthly in the first quarter of the program and then transitioned to quarterly visits depending on their clinical status. Close follow-up ensures doctor–patient rapport and accountability. Select patients are offered adjunctive pharmacotherapy in addition to assessment and referral for bariatric procedures. A working collaboration between our gastroenterologists and bariatric surgeons has therefore become vital to our program’s success.

Once weight loss has been achieved during the intervention phase, patients continue with follow-up intervals that increase over time. Complications of therapy and recidivism are addressed and managed during this period. As part of preventive care, patients are encouraged to keep up with routine colorectal cancer screenings, especially considering the increased malignancy rates in this adult population.7 Although patients may “graduate” from the intervention phase, follow-up is maintained and patients are re-enrolled in the intervention phase if/when weight recidivism occurs.

Overall, obesity continues to be a leading driver in medical disease and health care utilization.8 Gastroenterologists are uniquely positioned to lead diverse teams of medical professionals, offering medically supervised weight-loss programs as a part of comprehensive GI care. The success of the program relies on working within multispecialty collaboratives, and the ability of a practice to support frequent patient encounters. Although obesity is not a new problem in this country, gastroenterologists can offer a new comprehensive approach to obesity care, ultimately changing the famous CDC weight charts from red back to blue.

Drs. Newberry and Pickett-Blakely have no conflicts to disclose.

References
1. Ogden, C.L., Carroll, M.D., Fryar, C.D., Flegal, K.M. Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS Data Brief. 2015;219:1.
2. American College of Gastroenterology. Obesity: a growing & dangerous public health challenge. Published 2018. http://gi.org/wp-content/uploads/2011/07/ institute-ACG_Obesity_Physician_Resource_Guide.pdf. Accessed July 12, 2018.
3. Chalasani, N., Younossi, Z., Lavine, J.E. et al, American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association. The diagnosis and management of nonalcoholic fatty liver disease: practice guideline. Hepatology. 2012;55:2005-2023.
4. Sullivan, S., Kumar, N., Edmundowicz, S.A. et al, AASGE position statement on endoscopic bariatric therapies in clinical practice. Gastrointest Endosc. 2015;82:767-772.
5. Acosta, A., Streett, S., Kroh, M.D. et al, POWER — practice guide on obesity and weight management, education, and resources. Clin Gastroenterol Hepatol. 2017;15:631-649.e10.
6. Bleich, S.N., Pickett-Blakely, O., Cooper, L.A., Physician practice patterns of obesity diagnosis and weight related counseling. Pat Educ Counsel. 2010;82:123-129.
7. Bardou, M., Barkun, A.N., Martel, M. Obesity and colorectal cancer. Gut. 2013;62:933-947.
8. Finkelstein, E.A., Trogdon, J.G., Cohen, J.W., Dietz, W. Annual medical spending attributable to obesity: payer- and service-specific estimates. Health Affairs. 2009;28:w822.

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