Last month, the American Association of Clinical Endocrinologists and American College of Endocrinology published a position statement introducing “ABCD,” for Adiposity-based Chronic Disease, as a new diagnostic term. The concept of using this paradigm stems from their previously published Advanced Framework for a New Diagnosis of Obesity as a Chronic Disease following their 2014 Consensus Conference on Obesity. This followed AACE/ACE clinical practice guidelines on the comprehensive medical care of patients with obesity released earlier in 2016 that gave recommendations for a clinical diagnosis of obesity as a chronic disease. Going beyond (but including screening and classification via) BMI, an exam to confirm excess adiposity, waist circumference to refine cardiometabolic risk of adiposity, advanced modalities, and emphasis on a complications-centric staging approach were outlined in order to treat patients based upon the pathophysiologic hostility of adiposity versus weight per se. Lifestyle changes and therapies were reviewed with evidence-based recommendations in the clinical practice guideline and are a cornerstone for proposing the model of “ABCD.”
“Positioning lifestyle medicine in the promotion of overall health, not only as the first algorithmic step, but as the central, pervasive action” was listed as the number one key element in the document. The authors state that lifestyle medicine framed “positively as promoting ‘health'” should be promoted throughout healthcare teams and applied to all patients with any disease which, as first line therapy, is supported by a variety of other clinical practice recommendations. The role of lifestyle medicine is described for the chronic disease model including primordial, primary, and secondary prevention as highlighted in the clinical practice guideline. For obesity, lifestyle medicine has always been known to be the fundamental constituent of prevention and treatment and is contextually even more valuable when treating/preventing “adiposity-based” disease. As pointed out in the treatment guidelines, the goal is to improve the complications of obesity via weight loss versus the weight loss itself. Even without “weight loss,” implementing optimal dietary patterns, physical activity (aerobic, resistance training, and non-exercise activity) along with other healthful behaviors is crucial for health. For example, physical fitness has been noted to be a vital factor in discerning the so-called “metabolically healthy obesity,” which per the AACE/ACE guideline and ABCD model would be “stage 0” assuming true clinical obesity or excess adiposity.
Lifestyle medical prescription remains elusive and we agree with the position statement that “optimal application of lifestyle medicine in clinical practice requires scientific study and validation, much more effort in HCP education and training for standardized evidence-based protocols, and clinical implementation and monitoring with fair reimbursement strategies.”
While changing the nomenclature of diagnosis may be a step in the right direction for stigmatization, we will still need better ways to implement the treatment into clinics. We have written before how lifestyle medicine is first line treatment for most chronic diseases and yet it is underutilized for multiple reasons. Two of the biggest reasons stated by healthcare providers are time and resources.
Healthcare providers tend to have too little time with each patient to go over lifestyle in detail. The way around this is having a multidisciplinary approach with dietitians, exercise physiologists/trainers, and health coaches. However, the resources for these is often lacking. Even if we change how obesity is diagnosed (and named), the treatment part still needs work by devoting more time and resources to patients as stated.
Once screened, patients should have the option to be put into such a multidisciplinary program overseen by an obesity specialist. The patient should go through dietary counseling with a dietitian, exercise counseling with an exercise physiologist, possibly a psych evaluation with a psychologist, and social support with a patient led support group. The obesity specialist overseeing can determine whether additional treatment with pharmacotherapy and/or a bariatric procedure is needed per the obesity treatment guidelines available.