The CDC estimates approximately 39 percent of adults in the United States are obese. As cases of NASH and NAFLD continue to approach epidemic levels, hepatologists are now managing more patients with liver disease as a comorbidity of obesity. With this issue becoming more prevalent in hepatology clinics, many AASLD members have sought advanced training on obesity management.
“Dual board certification in obesity medicine and Gastroenterology is an emerging trend and is likely to help patients suffering from obesity and obesity-related GI and liver conditions to benefit from targeted therapies for obesity,” said Rohit Loomba, MD, chair of AASLD’s NAFLD Special Interest Group.
We caught up with several AASLD members who are currently working toward certification in obesity medicine and asked them to share their thoughts on the importance of managing obesity within their practices.
Monica Konerman, MD
University of Michigan
“Given that lifestyle interventions are the primary therapy for NAFLD, as a hepatologist I thought it would be extremely helpful to get additional training in obesity medicine since that is not a primary focus of our traditional training in gastroenterology and hepatology. I knew that a certification program would provide me with more information and training in the use of medications for obesity and evidence-based practices to help patients achieve weight loss.
The types of clinical problems, patient population and logistical barriers have dramatically changed in the past five years largely as a reflection of the shift from HCV to NAFLD as the largest disease focus. Given the other associated metabolic diseases seen in NAFLD, hepatologists are more routinely interfacing and collaborating with other disciplines like endocrinology, cardiology and nutrition. Identifying the best approach to this multidisciplinary, complex care is an important question that will ultimately facilitate delivery of high quality care.”
Sonali Paul, MD
Director, Metabolic and Fatty Liver Clinic
University of Chicago
“I used to think the role of hepatologist was mainly in treating diseases as in viral hepatitis or autoimmune conditions. However, in addition to disease treatment, I currently see my role in disease prevention as well. The cross section of liver disease and obesity medicine allows me to keep my patients healthy and prevent cirrhosis progression and its complications and obviate the need for liver transplantation. And, in those who do get transplanted, I am better equipped in treating their metabolic profile and preventing recurrent or denovo NAFLD.
Certification in obesity medicine will allow me to offer several things to my patients with known NAFLD, and also help those with risk factors for NAFLD. Although there are currently no FDA recommended medications that can treat NAFLD, we do know that weight loss and risk factor modification can help with histological improvement. To this end, knowledge in obesity medicine has allowed me to obtain more detailed weight histories, know which common medications can cause weight gain (such as metoprolol, which I had never known before), know when to prescribe – and the indications for –weight loss medications, and have a more nuanced understanding of when to refer to bariatric surgery.”
Sujit Janardhan, MD
Rush University Medical Center
“I feel that comprehensive care of a patient with chronic liver disease includes management of relevant co-morbidities including being overweight and obesity. This applies to not only patients with NAFLD, but also patients with other chronic liver diseases. It is important to remember that the major source of morbidity and mortality even in NAFLD patients is due to cardiovascular or metabolic complications that are directly related to obesity. Liver disease may have brought them in to my office, but treating their obesity will help improve both their liver-related and global metabolic health.
Training in obesity medicine has not only taught me how to more effectively discuss weight loss with patients, but also how to provide the motivational support to facilitate behavioral change. In addition, I have received expert training in the multidisciplinary approach to obesity management that includes dietary, exercise, pharmacologic and/or surgical interventions as well as management of both obesity-related and weight loss-related complications. Finally, I have begun to understand the gravity of the obesity epidemic and have shed outdated beliefs regarding the pathophysiology of obesity in favor of the far more complex hormonal, neurologic, environmental and genetic interplay that mediates this disease. By empowering patients with a true understanding of why they gain or lose weight, they are ultimately better prepared to achieve their weight loss goals.
As NAFLD becomes the forefront of the hepatology landscape, the hepatologist will need to adjust his/her skill set to becoming more adept at treating global metabolic disease through a multidisciplinary approach. Specialized training in obesity management is invaluable to this end.”
Rush University Medical Center
“Obesity is a problem that links all aspects of medicine. Each of us should be comfortable counseling our patients in weight management. However, liver patients are unique. Cirrhosis changes all aspects of metabolism, and NASH is an obesity-induced liver disease.
I think that patients will trust my recommendations if I have formal certification. When I counsel them, it helps to know I have society guidelines behind my recommendations. As providers, we frequently tell patients to lose weight but do not always provide the tools for success. Lifestyle modification is difficult, and it’s important for my patient to trust what I say and the certification adds to my credibility.”
The AASLD members featured in this article are pursuing their obesity medicine certifications through the American Board of Obesity Medicine. How are you preparing for, or already treating, obesity in your practice? Share your thoughts about this topic and more on facebook.com/aasld or @aasldtweets on Twitter.