Challenges with Current Staging Systems for Obesity

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Hello, and thank you for joining this HCPLive® MEDcast series titled: “Updates in the Standards of Care in Diabetes in 2023: Obesity and Weight Management.” I’m Diana Isaacs, an endocrine clinical pharmacy specialist and the continuous glucose monitoring coordinator at the Cleveland Clinic Diabetes Center in Cleveland, Ohio.

Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES: I’m Natalie Bellini, a nurse practitioner specializing in diabetes management with the R&B Medical Group in Williamsville, New York. Today we’re going to discuss the latest updates to the ADA [American Diabetes Association] Standards of Care in Diabetes—2023, focusing on weight management and obesity treatment.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: To discuss this, we’re joined by Dr Scott Kahan, the director of the National Center for Weight and Wellness in Washington, DC. He is a member of leadership committees at the Endocrine Society, the Obesity Treatment Foundation, and the American Diabetes Association, where he serves on the Professional Practice Committee, which creates the Standards of Care in Diabetes guidelines. We’re excited to have you with us. To start, tell us why weight management has become such an integral part of diabetes care.

Scott Kahan, MD, MPH: Weight management has always been an integral part of diabetes care. Unfortunately, many physicians and other health care providers didn’t get the message or didn’t have the training to put much attention to it. But it’s been a good movement forward in the last few years and certainly in the last decade or 2. Now, you’d be hard-pressed to find a health care provider who doesn’t associate obesity and diabetes and who doesn’t attend to the importance of weight management and obesity. They don’t always know exactly what to do. That’s understandable because traditionally obesity isn’t taught in medical schools; it’s given short shrift. But the focus has changed, the attention has changed, and we’ll see more movement making weight management and diabetes management almost indistinguishable going forward.

Natalie Bellini, DNP, FNP-BC, BC-ADM, CDCES: That’s amazing. You’re right. When we started screening for obesity in the chart, BMI [body mass index] would pop up. It was a diagnosis code that came in. You’d say, “Discussed weight with patient”—period. That didn’t address weight, but that’s what’s happened. With the new medications out to treat obesity, there are other opportunities. Can we talk about the role of genetics and social determinants of health in obesity before we jump into treatment?

Scott Kahan, MD, MPH: All health care providers appreciate that, in most cases, driving type 2 diabetes and obesity are health behaviors—physical activity, what we eat, how much we move. What patients don’t often appreciate, however, is a range of things influence whether they’ll engage in those health behaviors and how successful they are. For one, genetics and, secondarily, biology play a strong role in what we do and how successful we are, and social determinants of health are also important.

For example, if you live in an area where there’s minimal healthy food available, if the few food options you have are corner stores and bodegas as opposed to large grocery stores with lots of produce and other healthful options, it’s going to be more challenging to eat according to healthful guidelines. If you live in an area where it’s difficult to find safe places to be outside and be active, where it’s not the norm to be playing in sports or being active outdoors or elsewhere, it’s less likely that that’s going to be a part of your day-to-day life. There are many more examples, but genetics and social determinants of health are 2 important things that influence the things we do for health.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I’m curious, what’s the consensus about staging or diagnosing obesity? We have the BMI, but is that what we’re currently using? Are there other emerging ways to diagnose or classify?

Scott Kahan, MD, MPH: Structurally, nothing on the ground has changed. Still, the most basic way of diagnosing obesity and secondarily determining treatment options is based on someone’s size—ie, their BMI. There’s some benefit of that. It’s quick and easy. Everybody knows what BMI is. It’s easy to calculate. We usually don’t even have to do it. Our electronic medical records do it for us. It’s ingrained in our society and our health care system as the routine way of doing things.

The problem with that is there are lots of drawbacks to using BMIs solely. For 1, there’s a lot of misclassification. Someone who’s muscular will look like they have a high BMI, even if they’re objectively thin and fit. What’s even more common is the opposite: individuals who are sarcopenic and osteopenic. Individuals who are frail tend to look like they have a healthy BMI, even though their fat mass is high and their risk from being overweight is likely high. That’s 1 of many drawbacks of using BMI solely.

There have been a number of staging systems developed for obesity that allow us, in a sense, to try to stage the obesity. It’s somewhat similar to how oncologists use staging systems to stage a cancer—not just whether it’s present or absent but also the degree, extent, and severity of the cancer, or of the obesity in this case. It’s largely driven by the presence of various weight-associated comorbidities. A number of staging systems have been developed, and they continue to be studied at length.

Studies show that, almost exclusively, these staging systems are better ways of determining risk than simply an individual’s size or BMI at baseline. Unfortunately, they haven’t become standard in medicine. In practices like mine that focus exclusively on obesity, they’re more common to be considered, but in a primary care setting, they’re not frequently used. That’s OK for now, as long as clinicians consider—in addition to BMI—patients’ comorbidities and weight-related health. That includes comorbidities like diabetes, hypertension, sleep apnea, fatty liver, and so forth, as well as functional status—limitations on mobility, for example, and other ways the weight may get in the way of the individual’s quality of life. If we consider those things to better stratify patients beyond size, that goes a long way, even in the absence of a formal staging system. On the other hand, that we’ll see more consideration of staging systems in the next several years.

Transcript Edited for Clarity