Implementation of Obesity Science Into Clinical Practice: A Scientific Statement From the American Heart Association
将肥胖科学应用于临床实践：美国心脏协会的科学声明
Author Info & Affiliations
Deepika Laddu，博士，FAHA，主席，Ian J. Neeland，医学博士，FAHA，副主席，Mercedes Carnethon，博士，FAHA，Fatima C.斯坦福，医学博士，MPH，MPA，MBA，FAHA，Morgana Mongraw-Chaffin，博士， FAHA、Bethany Barone Gibbs 博士、FAHA、Chiadi E. Ndumele 医学博士、博士、FAHA、Chris T. Longenecker 医学博士、FAHA、Misook L. Chung 博士、注册护士、FAHA 和 Goutham Rao 医学博士、FAHA 代表美国心脏协会生活方式和心脏代谢健康委员会肥胖委员会的成员；流行病学和预防委员会；临床心脏病学委员会；高血压委员会；心血管疾病肾脏委员会；和心血管和中风护理委员会作者信息和附属机构
Deepika Laddu，博士，FAHA，主席，Ian J. Neeland，医学博士，FAHA，副主席，Mercedes Carnethon，博士，FAHA，Fatima C.斯坦福，医学博士，MPH，MPA，MBA，FAHA，Morgana Mongraw-Chaffin，博士， FAHA、Bethany Barone Gibbs 博士、FAHA、Chiadi E. Ndumele 医学博士、博士、FAHA、Chris T. Longenecker 医学博士、FAHA、Misook L. Chung 博士、注册护士、FAHA 和 Goutham Rao 医学博士、FAHA 代表美国心脏协会生活方式和心脏代谢健康委员会肥胖委员会的成员；流行病学和预防委员会；临床心脏病学委员会；高血压委员会；心血管疾病肾脏委员会；和心血管和中风护理委员会作者信息和附属机构
Abstract 抽象的
Obesity is a recognized public health epidemic with a prevalence that continues to increase dramatically in nearly all populations, impeding progress in reducing incidence rates of cardiovascular disease. Over the past decade, obesity science has evolved to improve knowledge of its multifactorial causes, identifying important biological causes and sociological determinants of obesity. Treatments for obesity have also continued to develop, with more evidence-based programs for lifestyle modification, new pharmacotherapies, and robust data to support bariatric surgery. Despite these advancements, there continues to be a substantial gap between the scientific evidence and the implementation of research into clinical practice for effective obesity management. Addressing barriers to obesity science implementation requires adopting feasible methodologies and targeting multiple levels (eg, clinician, community, system, policy) to facilitate the delivery of obesity-targeted therapies and maximize the effectiveness of guideline-driven care to at-need patient populations. This scientific statement (1) describes strategies shown to be effective or promising for enhancing translation and clinical application of obesity-based research; (2) identifies key gaps in the implementation of obesity science into clinical practice; and (3) provides guidance and resources for health care professionals, health care systems, and other stakeholders to promote broader implementation and uptake of obesity science for improved population-level obesity management. In addition, advances in implementation science that hold promise to bridge the know-do gap in obesity prevention and treatment are discussed. Last, this scientific statement highlights implications for health research policy and future research to improve patient care models and optimize the delivery and sustainability of equitable obesity-related care.
肥胖是一种公认的公共卫生流行病，其患病率在几乎所有人群中持续急剧增加，阻碍了降低心血管疾病发病率的进展。在过去的十年中，肥胖科学不断发展，以提高对其多因素原因的认识，确定肥胖的重要生物学原因和社会学决定因素。肥胖症的治疗方法也在不断发展，有更多基于证据的生活方式改变计划、新的药物疗法以及支持减肥手术的可靠数据。尽管取得了这些进步，科学证据与有效肥胖管理的临床实践研究的实施之间仍然存在很大差距。解决肥胖科学实施的障碍需要采用可行的方法并针对多个层面（例如临床医生、社区、系统、政策），以促进针对肥胖的治疗的提供，并最大限度地提高对有需要的患者群体的指南驱动的护理的有效性。该科学声明 (1) 描述了被证明对加强肥胖研究的转化和临床应用有效或有前途的策略； (2) 确定肥胖科学在临床实践中的关键差距； (3) 为医疗保健专业人员、医疗保健系统和其他利益相关者提供指导和资源，以促进更广泛地实施和采用肥胖科学，以改善人口水平的肥胖管理。此外，还讨论了有望弥补肥胖预防和治疗方面知识差距的实施科学进展。 最后，这份科学声明强调了对健康研究政策和未来研究的影响，以改善患者护理模式并优化公平肥胖相关护理的提供和可持续性。
肥胖是一种公认的公共卫生流行病，其患病率在几乎所有人群中持续急剧增加，阻碍了降低心血管疾病发病率的进展。在过去的十年中，肥胖科学不断发展，以提高对其多因素原因的认识，确定肥胖的重要生物学原因和社会学决定因素。肥胖症的治疗方法也在不断发展，有更多基于证据的生活方式改变计划、新的药物疗法以及支持减肥手术的可靠数据。尽管取得了这些进步，科学证据与有效肥胖管理的临床实践研究的实施之间仍然存在很大差距。解决肥胖科学实施的障碍需要采用可行的方法并针对多个层面（例如临床医生、社区、系统、政策），以促进针对肥胖的治疗的提供，并最大限度地提高对有需要的患者群体的指南驱动的护理的有效性。该科学声明 (1) 描述了被证明对加强肥胖研究的转化和临床应用有效或有前途的策略； (2) 确定肥胖科学在临床实践中的关键差距； (3) 为医疗保健专业人员、医疗保健系统和其他利益相关者提供指导和资源，以促进更广泛地实施和采用肥胖科学，以改善人口水平的肥胖管理。此外，还讨论了有望弥补肥胖预防和治疗方面知识差距的实施科学进展。 最后，这份科学声明强调了对健康研究政策和未来研究的影响，以改善患者护理模式并优化公平肥胖相关护理的提供和可持续性。
The prevalence of obesity in the United States and globally has been escalating for decades, with recent estimates that >40% of US adults are living with obesity.1,2 The continued rise in obesity has inevitably slowed the decline in rates of cardiovascular disease (CVD) despite improvements in other population risk factors.3 Moreover, forecasted trends in global obesity prevalence underscore the significant impact that obesity will continue to have on CVD incidence, especially among people of underrepresented races and ethnicities.4–6 Over the past decade, significant progress made in obesity science has contributed to the discovery of knowledge cutting across the domains of basic, translational, and biobehavioral science; epidemiology; and clinical studies/trials. Treatment of obesity also continues to evolve, with more empirical evidence supporting the efficacy of lifestyle modification programs, new pharmacotherapies, and robust outcomes data for bariatric surgery.
几十年来，美国和全球的肥胖患病率一直在上升，最近估计超过 40% 的美国成年人患有肥胖症。 1,2 尽管其他人口危险因素有所改善，但肥胖率的持续上升不可避免地减缓了心血管疾病（CVD）发病率的下降。 3 此外，全球肥胖患病率的预测趋势强调了肥胖将继续对心血管疾病发病率产生重大影响，特别是在代表性不足的种族和民族人群中。 4–6 在过去的十年中，肥胖科学取得的重大进展有助于发现跨越基础科学、转化科学和生物行为科学领域的知识；流行病学；和临床研究/试验。肥胖的治疗也在不断发展，越来越多的经验证据支持生活方式改变计划、新药物疗法和减肥手术的可靠结果数据的有效性。
几十年来，美国和全球的肥胖患病率一直在上升，最近估计超过 40% 的美国成年人患有肥胖症。 1,2 尽管其他人口危险因素有所改善，但肥胖率的持续上升不可避免地减缓了心血管疾病（CVD）发病率的下降。 3 此外，全球肥胖患病率的预测趋势强调了肥胖将继续对心血管疾病发病率产生重大影响，特别是在代表性不足的种族和民族人群中。 4–6 在过去的十年中，肥胖科学取得的重大进展有助于发现跨越基础科学、转化科学和生物行为科学领域的知识；流行病学；和临床研究/试验。肥胖的治疗也在不断发展，越来越多的经验证据支持生活方式改变计划、新药物疗法和减肥手术的可靠结果数据的有效性。
Despite the ubiquity of these advancements, effective implementation of obesity science into routine clinical practice for prevention and treatment of obesity remains suboptimal. There are major gaps between our knowledge of the science of obesity and the clinical implementation of that science for ideal patient care. The lack of sufficient implementation exemplifies important gaps that exist between our biological and sociological understanding of obesity, interventions that target obesity (eg, lifestyle, pharmacological, and surgical), and the application of evidence-based research into clinical practice for improved management of obesity.7–9 These gaps are sustained by structural, societal, and cultural barriers that are pervasive in real-world clinical practice and require a redoubling of efforts and alternative strategies for resolution and advancement. Therefore, prioritizing implementation of obesity science will be instrumental in informing evidence-based practice and consequently guiding delivery and maintenance of contextually appropriate care to diverse, underrepresented populations with obesity.10,11 Bridging the gap in obesity implementation science requires a multitargeted approach that addresses long-standing implementation challenges across various levels (eg, clinician, community, system, policy) and applies effective implementation strategies based on core frameworks11,12 to advance the integration of novel, empirically supported obesity science into routine clinical care (Figure 1).
尽管这些进步无处不在，但将肥胖科学有效实施到预防和治疗肥胖的常规临床实践中仍然不够理想。我们对肥胖科学的了解与理想患者护理科学的临床实施之间存在重大差距。缺乏足够的实施说明了我们对肥胖的生物学和社会学理解、针对肥胖的干预措施（例如生活方式、药物和手术）以及将循证研究应用于临床实践以改善肥胖管理之间存在的重要差距。 7–9 这些差距是由现实临床实践中普遍存在的结构、社会和文化障碍所维持的，需要加倍努力和替代策略来解决和进步。因此，优先实施肥胖科学将有助于为循证实践提供信息，从而指导向多样化、代表性不足的肥胖人群提供和维持因地制宜的护理。 10,11 缩小肥胖实施科学方面的差距需要采取多目标方法，解决各个层面（例如临床医生、社区、系统、政策）长期存在的实施挑战，并应用基于核心框架的有效实施策略 11,12 推动将新颖的、经经验支持的肥胖科学纳入常规临床护理（图 1）。
尽管这些进步无处不在，但将肥胖科学有效实施到预防和治疗肥胖的常规临床实践中仍然不够理想。我们对肥胖科学的了解与理想患者护理科学的临床实施之间存在重大差距。缺乏足够的实施说明了我们对肥胖的生物学和社会学理解、针对肥胖的干预措施（例如生活方式、药物和手术）以及将循证研究应用于临床实践以改善肥胖管理之间存在的重要差距。 7–9 这些差距是由现实临床实践中普遍存在的结构、社会和文化障碍所维持的，需要加倍努力和替代策略来解决和进步。因此，优先实施肥胖科学将有助于为循证实践提供信息，从而指导向多样化、代表性不足的肥胖人群提供和维持因地制宜的护理。 10,11 缩小肥胖实施科学方面的差距需要采取多目标方法，解决各个层面（例如临床医生、社区、系统、政策）长期存在的实施挑战，并应用基于核心框架的有效实施策略 11,12 推动将新颖的、经经验支持的肥胖科学纳入常规临床护理（图 1）。
图 1.肥胖科学的实施流程。肥胖知识和治疗方面的科学进步始于实验室，用基础研究工具（例如肥胖的临床前生物学和遗传模型）对想法和假设进行测试。在这个阶段，缺乏适当的模型和人群的异质性限制了基础研究的成功和应用，并阻碍了人类研究的进展。在人类研究阶段，观察性研究、随机试验和卫生服务研究告知并确认如何将基础研究的知识应用于人类临床环境。在此阶段，将测试新的肥胖诊断工具和治疗策略的有效性和安全性。这一阶段实施的障碍包括缺乏经过证实的治疗有效性、研究人群的异质性/缺乏普遍性以及与肥胖的生物社会学联系的崩溃。在下一阶段的实施中，医疗保健政策和实践对于在正确的时间向正确的患者提供护理、提供公平的新疗法以及向广大人群实施经过验证的策略和指南建议至关重要。此阶段使用实施科学来评估、衡量和修改临床方法，以提高经过验证的干预措施的采用率和有效性。患者和社区的结果进一步推动了这一实施，表明患者受到护理变化的积极影响，并有可能通过传播研究成果惠及有需要的人，从而产生额外的公共卫生影响。 在此阶段，政策与实践之间往往存在差距，突出表现在护理系统、护理报销、及时和公平地获取资源以及缺乏成本效益的证明方面的局限性。克服并缩小知识/科学与临床实施之间的差距可以为所有肥胖患者带来更好的健康和更好的健康结果。
The purposes of this scientific statement are to (1) describe strategies shown to be effective or promising for enhancing clinical application of obesity-based research; (2) identify key gaps in the implementation of obesity science into clinical practice; and (3) provide guidance and resources for clinical and community health care professionals, health care systems, and other stakeholders to facilitate improved population-level management of obesity. This scientific statement also discusses additional implications for policy, as well as future research to improve patient care models and optimize the delivery and sustainability of equitable obesity-related care.
本科学声明的目的是 (1) 描述被证明对加强肥胖研究的临床应用有效或有前途的策略； (2) 找出将肥胖科学应用于临床实践的关键差距； (3) 为临床和社区卫生保健专业人员、卫生保健系统和其他利益相关者提供指导和资源，以促进改善人口层面的肥胖管理。该科学声明还讨论了对政策的其他影响，以及改善患者护理模式和优化公平肥胖相关护理的提供和可持续性的未来研究。
本科学声明的目的是 (1) 描述被证明对加强肥胖研究的临床应用有效或有前途的策略； (2) 找出将肥胖科学应用于临床实践的关键差距； (3) 为临床和社区卫生保健专业人员、卫生保健系统和其他利益相关者提供指导和资源，以促进改善人口层面的肥胖管理。该科学声明还讨论了对政策的其他影响，以及改善患者护理模式和优化公平肥胖相关护理的提供和可持续性的未来研究。
METHODS FOR SUCCESSFUL IMPLEMENTATION OF OBESITY SCIENCE INTO CLINICAL PRACTICE
将肥胖科学成功应用于临床实践的方法
Successful implementation of obesity science into clinical practice requires a methodological framework that moves scientific knowledge from bench to bedside and addresses gaps in the implementation pipeline. Obesity science is well established, and emerging therapeutic options for obesity based on scientific discoveries have become increasingly prevalent in the past several years. Education on the complex origins and clinical consequences of obesity, a framework for the successful delivery of obesity care, and health policy interventions to enhance provision of obesity care are examples of implementation priorities that are essential to the success of obesity science.
将肥胖科学成功应用于临床实践需要一个方法框架，将科学知识从实验室转移到临床，并解决实施过程中的差距。肥胖科学已经十分成熟，基于科学发现的新兴肥胖治疗方案在过去几年中变得越来越普遍。关于肥胖的复杂起源和临床后果的教育、成功提供肥胖护理的框架以及加强提供肥胖护理的卫生政策干预措施是对肥胖科学成功至关重要的实施重点的例子。
将肥胖科学成功应用于临床实践需要一个方法框架，将科学知识从实验室转移到临床，并解决实施过程中的差距。肥胖科学已经十分成熟，基于科学发现的新兴肥胖治疗方案在过去几年中变得越来越普遍。关于肥胖的复杂起源和临床后果的教育、成功提供肥胖护理的框架以及加强提供肥胖护理的卫生政策干预措施是对肥胖科学成功至关重要的实施重点的例子。
To address the growing obesity epidemic and successfully implement obesity science, health care professionals must first be equipped with the proper knowledge and implementation skills. Yet, numerous studies have demonstrated that obesity education is lacking. For example, although the American Board of Medical Specialties certification examinations influence medical knowledge and practice for physicians throughout the United States, only 25% of the 24 general certification content outlines (ie, preparatory material for examinations) mention obesity. This gap indicates a need for translating the complexity of obesity science into practice with an increased emphasis on the diagnosis, prevention, and treatment of obesity.13 In a comprehensive international systematic review on obesity education across varying levels of medical training, Mastrocola and colleagues14 determined that there is a paucity of obesity education programs for medical students, residents, and fellow physicians in training programs throughout the world despite high obesity prevalence. Still, they note that these programs often improve outcomes when administered.
为了解决日益严重的肥胖流行问题并成功实施肥胖科学，医疗保健专业人员必须首先具备适当的知识和实施技能。然而，大量研究表明缺乏肥胖教育。例如，虽然美国医学专业委员会认证考试影响全美医生的医学知识和实践，但24个通用认证内容大纲（即考试准备材料）中只有25%提到肥胖。这一差距表明需要将肥胖科学的复杂性转化为实践，并更加重视肥胖的诊断、预防和治疗。 13 在对不同级别医学培训的肥胖教育进行全面的国际系统审查中，Mastrocola 及其同事 14 确定，针对医学生、住院医师和医疗人员的肥胖教育计划很少。尽管肥胖症患病率很高，但世界各地的医生都参加了培训计划。不过，他们指出，这些计划在实施后通常会改善结果。
为了解决日益严重的肥胖流行问题并成功实施肥胖科学，医疗保健专业人员必须首先具备适当的知识和实施技能。然而，大量研究表明缺乏肥胖教育。例如，虽然美国医学专业委员会认证考试影响全美医生的医学知识和实践，但24个通用认证内容大纲（即考试准备材料）中只有25%提到肥胖。这一差距表明需要将肥胖科学的复杂性转化为实践，并更加重视肥胖的诊断、预防和治疗。 13 在对不同级别医学培训的肥胖教育进行全面的国际系统审查中，Mastrocola 及其同事 14 确定，针对医学生、住院医师和医疗人员的肥胖教育计划很少。尽管肥胖症患病率很高，但世界各地的医生都参加了培训计划。不过，他们指出，这些计划在实施后通常会改善结果。
One increasingly successful method for improving health care professional education and subsequent implementation is the certification program in obesity medicine offered by the American Board of Obesity Medicine (ABOM). Studies show that physicians certified in obesity medicine tend to deliver more effective evidence-based care such as lifestyle and behavioral counseling, pharmacotherapy, and care for patients who undergo metabolic and bariatric surgery.15 In a cross-sectional analysis of the ABOM-certified physicians, certified physicians’ practices were likely to be concordant with published guidelines, including the American College of Cardiology/American Heart Association/The Obesity Society, American Association of Clinical Endocrinologists/American College of Endocrinology, and Obesity Medicine Association guidelines. However, although health care practitioners may be confident that ABOM-certified physicians will deliver evidence-based care, access to these physicians is often unavailable because of the high prevalence of obesity and the relative shortage of certified professionals. Although all states in the United States have at least 1 ABOM-certified adult physician, there are geographic disparities in physician availability relative to obesity prevalence, leading to widened health care disparities. This is even more pronounced in the pediatric population, with fewer ABOM-certified physicians.
改善医疗保健专业教育和后续实施的一种日益成功的方法是美国肥胖医学委员会 (ABOM) 提供的肥胖医学认证计划。研究表明，获得肥胖医学认证的医生往往会为接受代谢和减肥手术的患者提供更有效的循证护理，例如生活方式和行为咨询、药物治疗以及护理。 15 在对 ABOM 认证医生的横断面分析中，认证医生的做法可能与已发布的指南一致，包括美国心脏病学会/美国心脏协会/肥胖协会、美国协会临床内分泌学家/美国内分泌学院和肥胖医学协会指南。然而，尽管医疗保健从业者可能相信 ABOM 认证的医生将提供循证护理，但由于肥胖症患病率高且认证专业人员相对短缺，因此往往无法接触到这些医生。尽管美国所有州都至少有 1 名获得 ABOM 认证的成年医生，但与肥胖患病率相关的医生数量存在地域差异，导致医疗保健差距扩大。这在儿科人群中更为明显，因为获得 ABOM 认证的医生较少。
改善医疗保健专业教育和后续实施的一种日益成功的方法是美国肥胖医学委员会 (ABOM) 提供的肥胖医学认证计划。研究表明，获得肥胖医学认证的医生往往会为接受代谢和减肥手术的患者提供更有效的循证护理，例如生活方式和行为咨询、药物治疗以及护理。 15 在对 ABOM 认证医生的横断面分析中，认证医生的做法可能与已发布的指南一致，包括美国心脏病学会/美国心脏协会/肥胖协会、美国协会临床内分泌学家/美国内分泌学院和肥胖医学协会指南。然而，尽管医疗保健从业者可能相信 ABOM 认证的医生将提供循证护理，但由于肥胖症患病率高且认证专业人员相对短缺，因此往往无法接触到这些医生。尽管美国所有州都至少有 1 名获得 ABOM 认证的成年医生，但与肥胖患病率相关的医生数量存在地域差异，导致医疗保健差距扩大。这在儿科人群中更为明显，因为获得 ABOM 认证的医生较少。
The next step in implementation requires a framework for successful delivery of obesity medicine care. The Society for Behavioral Medicine has an evidence-based model for primary care obesity management based on the 5As counseling framework (assess, advise, agree, assist, and arrange),16 which can be used to promote the implementation of obesity treatments in clinical practice settings (Figure 2). Two recent American Heart Association statements provide a comprehensive summary of how to implement the 5A model for health behavior change in primary care and community-based settings for CVD prevention and risk management.17,18 There is a particular focus on guiding primary health care professional efforts to offer or refer patients for behavioral counseling beyond what can be done during brief, episodic office visits.17 Best-practice approaches for enhancing the adoption and implementation of behavior change programs in clinical or community-based health care settings, including the use of team-based care, reimbursement and referral models, and practical national resources, are described in detail.17,19 Although more studies are needed on the effectiveness of health care professional–delivered behavior counseling interventions on the maintenance of behavioral outcomes, promoting a healthy lifestyle and assisting patients in achieving health behavior goals presents a feasible strategy that health care professionals in clinical and community-linked settings can use to proactively maximize impact on obesity care and reduce the burden of subsequent CVD risk at every visit.18 It is important to note that building solid, sustainable clinic-community linkages is necessary to facilitate the implementation of obesity/weight management programs. Indeed, increasing clinician education and self-efficacy in obesity science, along with the workforce of specialized ABOM-certified diplomates, while building straightforward treatment workflows that are evidence based with expanded and adequate clinician reimbursement also appears to be the logical next step to the successful implementation of obesity science into clinical practice.20
下一步的实施需要一个成功提供肥胖医学护理的框架。行为医学协会有一个基于5A咨询框架（评估、建议、同意、协助和安排）的初级保健肥胖管理循证模型， 16 可用于促进实施肥胖治疗在临床实践中的应用（图2）。美国心脏协会最近的两份声明全面总结了如何在初级保健和社区环境中实施 5A 健康行为改变模型，以预防 CVD 和风险管理。 17,18 特别注重指导初级卫生保健专业人士为患者提供或转介进行行为咨询，而这些咨询超出了短暂、不定期的办公室就诊所能完成的范围。 17 在临床或社区医疗保健环境中加强行为改变计划的采用和实施的最佳实践方法，包括使用基于团队的护理、报销和转诊模式以及实用的国家资源，都有详细描述。 17,19 虽然需要更多的研究来了解医疗保健专业人员提供的行为咨询干预措施对维持行为结果的有效性，但促进健康的生活方式和帮助患者实现健康行为目标提供了一种可行的策略，医疗保健临床和社区相关环境中的专业人员可以使用它来主动最大限度地提高对肥胖护理的影响，并减少每次就诊时后续心血管疾病风险的负担。 18 值得注意的是，建立牢固、可持续的临床与社区联系对于促进肥胖/体重管理计划的实施是必要的。 事实上，提高临床医生在肥胖科学方面的教育和自我效能，以及专业的 ABOM 认证外交官队伍，同时建立以证据为基础的简单的治疗工作流程，并扩大和充分的临床医生报销似乎也是成功的下一步逻辑将肥胖科学应用于临床实践。 20
下一步的实施需要一个成功提供肥胖医学护理的框架。行为医学协会有一个基于5A咨询框架（评估、建议、同意、协助和安排）的初级保健肥胖管理循证模型， 16 可用于促进实施肥胖治疗在临床实践中的应用（图2）。美国心脏协会最近的两份声明全面总结了如何在初级保健和社区环境中实施 5A 健康行为改变模型，以预防 CVD 和风险管理。 17,18 特别注重指导初级卫生保健专业人士为患者提供或转介进行行为咨询，而这些咨询超出了短暂、不定期的办公室就诊所能完成的范围。 17 在临床或社区医疗保健环境中加强行为改变计划的采用和实施的最佳实践方法，包括使用基于团队的护理、报销和转诊模式以及实用的国家资源，都有详细描述。 17,19 虽然需要更多的研究来了解医疗保健专业人员提供的行为咨询干预措施对维持行为结果的有效性，但促进健康的生活方式和帮助患者实现健康行为目标提供了一种可行的策略，医疗保健临床和社区相关环境中的专业人员可以使用它来主动最大限度地提高对肥胖护理的影响，并减少每次就诊时后续心血管疾病风险的负担。 18 值得注意的是，建立牢固、可持续的临床与社区联系对于促进肥胖/体重管理计划的实施是必要的。 事实上，提高临床医生在肥胖科学方面的教育和自我效能，以及专业的 ABOM 认证外交官队伍，同时建立以证据为基础的简单的治疗工作流程，并扩大和充分的临床医生报销似乎也是成功的下一步逻辑将肥胖科学应用于临床实践。 20
图 2. 在初级保健中实施肥胖治疗的 5A（评估、建议、同意、协助和安排）模型。
For example, beginning in 2014, the National Academy of Medicine established the Roundtable on Obesity Solutions and has convened workshops and related activities to address key issues related to obesity prevention, evaluation, and treatment. These have included assessing training needs and defining competencies.21 The roundtable’s work is a valuable resource in filling important gaps in knowledge and skills among health care professionals.
例如，从2014年开始，美国国家医学院成立了肥胖解决方案圆桌会议，并举办了研讨会和相关活动，以解决与肥胖预防、评估和治疗相关的关键问题。其中包括评估培训需求和定义能力。 21 圆桌会议的工作是填补医疗保健专业人员知识和技能方面的重要差距的宝贵资源。
例如，从2014年开始，美国国家医学院成立了肥胖解决方案圆桌会议，并举办了研讨会和相关活动，以解决与肥胖预防、评估和治疗相关的关键问题。其中包括评估培训需求和定义能力。 21 圆桌会议的工作是填补医疗保健专业人员知识和技能方面的重要差距的宝贵资源。
Health policy interventions that can enhance the provision of obesity care are emerging globally. One example is Life’s Essential 8, the key measures for improving and maintaining cardiovascular health as defined by the American Heart Association.22 The goal of Life’s Essential 8 is to link science to implementation. Many of the Life’s Essential 8 health behaviors and habits affect body weight, and the Life’s Essential 8 advisory contains important methods for implementing cardiovascular health assessment and longitudinal monitoring, as well as potential data sources and tools to promote widespread adoption in policy, public health, clinical, institutional, and community settings.
可以加强肥胖护理服务的卫生政策干预措施正在全球范围内出现。 Life's Essential 8 就是一个例子，这是美国心脏协会定义的改善和维持心血管健康的关键措施。 22 Life’s Essential 8 的目标是将科学与实施联系起来。 《Life's Essential 8》的许多健康行为和习惯都会影响体重，《Life's Essential 8》建议包含实施心血管健康评估和纵向监测的重要方法，以及促进政策、公共卫生、医疗保健等领域广泛采用的潜在数据源和工具。临床、机构和社区环境。
可以加强肥胖护理服务的卫生政策干预措施正在全球范围内出现。 Life's Essential 8 就是一个例子，这是美国心脏协会定义的改善和维持心血管健康的关键措施。 22 Life’s Essential 8 的目标是将科学与实施联系起来。 《Life's Essential 8》的许多健康行为和习惯都会影响体重，《Life's Essential 8》建议包含实施心血管健康评估和纵向监测的重要方法，以及促进政策、公共卫生、医疗保健等领域广泛采用的潜在数据源和工具。临床、机构和社区环境。
IDENTIFYING GAPS IN OBESITY SCIENCE: CLINICIAN KNOWLEDGE, COMFORT, AND SENSITIVITY; PATIENT AVOIDANCE; CONNECTION TO RESOURCES; AND COST-EFFECTIVENESS
识别肥胖科学的差距：临床知识、舒适度和敏感性；患者回避；连接资源；和成本效益
A critical gap to implementing obesity science into practice is the central focus on ascertaining a particular body weight. Obesity, as traditionally defined by body mass index (BMI), is remarkably heterogeneous, and use of the BMI alone leads to confusion about when and how to initiate targeted obesity interventions. It is well known that BMI cannot distinguish between lean and fat mass and that it fails to discriminate between adipose tissue depots in different anatomic regions. For example, a BMI-centric approach has spawned a debate about metabolically healthy obesity, referring to populations with lower cardiovascular risk due to lower visceral abdominal adiposity and higher levels of cardiorespiratory fitness despite an elevated BMI.23,24 Moreover, debate about the potential dangers of weight loss and the concept of the obesity paradox—whereby patients with symptomatic CVD (eg, heart failure) who maintain higher body weight (overweight or class I obesity) experience improved survival—has led to controversies, particularly in cardiovascular medicine, and skepticism of the merits in prescribing weight loss interventions to patients with existing cardiac conditions.24,25 These weight-centric approaches to obesity management, rather than a focus on obesity-related complications and adverse health outcomes, can be confusing and may discourage some clinicians from even considering obesity management interventions. Therefore, it is clear that we need better tools to assess the degree of obesity and its relationship to associated health risks. Furthermore, overreliance on BMI may paradoxically hinder efforts by clinicians in many settings to address obesity. The net effect is that the vast majority of patients whom clinicians encounter may benefit from weight management. Therefore, BMI adds little useful information for most clinicians in terms of how to prioritize care for obesity based on the risk of obesity-related conditions. There is evidence that waist circumference may be useful in this regard; however, implementing routine measurement and actionable steps to address waist circumference in the context of BMI remains a challenge in clinical practice.
将肥胖科学付诸实践的一个关键差距在于确定特定体重的中心重点。传统上根据体重指数 (BMI) 定义的肥胖具有显着的异质性，单独使用 BMI 会导致人们对何时以及如何启动有针对性的肥胖干预措施产生困惑。众所周知，BMI 无法区分瘦肉量和脂肪量，也无法区分不同解剖区域的脂肪组织库。例如，以 BMI 为中心的方法引发了关于代谢健康肥胖的争论，即尽管 BMI 较高，但由于内脏腹部脂肪含量较低而心肺健康水平较高，因此心血管风险较低的人群。 23,24 此外，关于减肥的潜在危险和肥胖悖论的概念的争论——有症状的CVD（例如心力衰竭）患者在保持较高体重（超重或I级肥胖）的情况下会得到改善生存率引起了争议，特别是在心血管医学领域，以及对对患有心脏病的患者进行减肥干预措施的优点的怀疑。 24,25 这些以体重为中心的肥胖管理方法，而不是关注肥胖相关的并发症和不良健康结果，可能会令人困惑，甚至可能阻止一些临床医生考虑肥胖管理干预措施。因此，很明显，我们需要更好的工具来评估肥胖程度及其与相关健康风险的关系。此外，过度依赖体重指数可能会自相矛盾地阻碍临床医生在许多情况下解决肥胖问题的努力。 最终效果是临床医生遇到的绝大多数患者可能会从体重管理中受益。因此，BMI 对于大多数临床医生在如何根据肥胖相关疾病的风险优先考虑肥胖护理方面几乎没有提供任何有用的信息。有证据表明腰围在这方面可能有用；然而，在 BMI 的背景下实施常规测量和可行的步骤来解决腰围问题仍然是临床实践中的一个挑战。
将肥胖科学付诸实践的一个关键差距在于确定特定体重的中心重点。传统上根据体重指数 (BMI) 定义的肥胖具有显着的异质性，单独使用 BMI 会导致人们对何时以及如何启动有针对性的肥胖干预措施产生困惑。众所周知，BMI 无法区分瘦肉量和脂肪量，也无法区分不同解剖区域的脂肪组织库。例如，以 BMI 为中心的方法引发了关于代谢健康肥胖的争论，即尽管 BMI 较高，但由于内脏腹部脂肪含量较低而心肺健康水平较高，因此心血管风险较低的人群。 23,24 此外，关于减肥的潜在危险和肥胖悖论的概念的争论——有症状的CVD（例如心力衰竭）患者在保持较高体重（超重或I级肥胖）的情况下会得到改善生存率引起了争议，特别是在心血管医学领域，以及对对患有心脏病的患者进行减肥干预措施的优点的怀疑。 24,25 这些以体重为中心的肥胖管理方法，而不是关注肥胖相关的并发症和不良健康结果，可能会令人困惑，甚至可能阻止一些临床医生考虑肥胖管理干预措施。因此，很明显，我们需要更好的工具来评估肥胖程度及其与相关健康风险的关系。此外，过度依赖体重指数可能会自相矛盾地阻碍临床医生在许多情况下解决肥胖问题的努力。 最终效果是临床医生遇到的绝大多数患者可能会从体重管理中受益。因此，BMI 对于大多数临床医生在如何根据肥胖相关疾病的风险优先考虑肥胖护理方面几乎没有提供任何有用的信息。有证据表明腰围在这方面可能有用；然而，在 BMI 的背景下实施常规测量和可行的步骤来解决腰围问题仍然是临床实践中的一个挑战。
Implementation Gaps in Lifestyle Interventions
生活方式干预措施的实施差距
In a recent study, few health care practitioners (16%) could identify evidence-based lifestyle treatments for obesity, and there was a high level of heterogeneity by practice type.26 This included low levels of working knowledge about diet and nutrition specialists (ie, when to refer and identification of barriers to specialist referral), intensive behavioral therapy, and physical activity. This gap in recognition may help explain the low rates of referrals to clinical weight management programs and other weight reduction systems for those who are eligible. Further barriers include a lack of clinician comfort in initiating and conducting discussions about obesity with patients; hesitancy to reduce trust or offend patients who may be seen, incorrectly or not, as wanting to avoid these interactions; assumptions about patient interest in weight management strategies and access to them; and structural issues such as poor coverage or low levels of reimbursement for obesity-related care.
在最近的一项研究中，很少有医疗保健从业者 (16%) 能够识别出基于证据的生活方式治疗肥胖症，而且不同实践类型之间存在高度异质性。 26 这包括对饮食和营养专家的工作知识水平较低（即何时转诊和识别专家转诊的障碍）、强化行为治疗和体育活动。这种认知上的差距可能有助于解释符合资格的人转诊至临床体重管理计划和其他减肥系统的比例较低的原因。进一步的障碍包括临床医生在与患者发起和进行有关肥胖问题的讨论时缺乏舒适度；犹豫是否要减少信任或冒犯患者，无论是否正确，这些患者可能会被视为想要避免这些互动；关于患者对体重管理策略和获得这些策略的兴趣的假设；以及结构性问题，例如肥胖相关护理的覆盖率低或报销水平低。
在最近的一项研究中，很少有医疗保健从业者 (16%) 能够识别出基于证据的生活方式治疗肥胖症，而且不同实践类型之间存在高度异质性。 26 这包括对饮食和营养专家的工作知识水平较低（即何时转诊和识别专家转诊的障碍）、强化行为治疗和体育活动。这种认知上的差距可能有助于解释符合资格的人转诊至临床体重管理计划和其他减肥系统的比例较低的原因。进一步的障碍包括临床医生在与患者发起和进行有关肥胖问题的讨论时缺乏舒适度；犹豫是否要减少信任或冒犯患者，无论是否正确，这些患者可能会被视为想要避免这些互动；关于患者对体重管理策略和获得这些策略的兴趣的假设；以及结构性问题，例如肥胖相关护理的覆盖率低或报销水平低。
Not surprisingly, 23% of patients never speak to a clinician about their weight or lifestyle interventions for weight management. When discussions did occur, almost 60% of respondents reported that clinicians never asked for permission before discussing sensitive issues related to obesity, and only about half (52%) thought that their clinician understood the challenges of overweight or obesity.27 Thirty percent of respondents reported that their clinician did not discuss resources for weight management. Last, >15% of patients reported not seeking care to avoid being weighed or having discussions about weight, with a higher prevalence for those with more severe obesity.27 This is a major gap in implementation, given that there is clear evidence that intensive lifestyle therapy is considerably more effective than brief advice, and general educational information is provided far more often by physicians than connection or referral to classes, programs, or tangible resources for lifestyle change.19,27
毫不奇怪，23% 的患者从未与临床医生谈论他们的体重或体重管理的生活方式干预措施。当讨论确实发生时，近 60% 的受访者表示，临床医生在讨论与肥胖相关的敏感问题之前从未征求许可，只有约一半 (52%) 认为他们的临床医生了解超重或肥胖的挑战。 27 30% 的受访者表示，他们的临床医生没有讨论体重管理的资源。最后，超过 15% 的患者表示没有寻求护理以避免称重或讨论体重，其中肥胖较严重的患者患病率更高。 27 这是实施中的一个重大差距，因为有明确的证据表明强化生活方式疗法比简短的建议更有效，并且医生提供的一般教育信息比连接或转介课程的频率要高得多、项目或改变生活方式的有形资源。 19,27
毫不奇怪，23% 的患者从未与临床医生谈论他们的体重或体重管理的生活方式干预措施。当讨论确实发生时，近 60% 的受访者表示，临床医生在讨论与肥胖相关的敏感问题之前从未征求许可，只有约一半 (52%) 认为他们的临床医生了解超重或肥胖的挑战。 27 30% 的受访者表示，他们的临床医生没有讨论体重管理的资源。最后，超过 15% 的患者表示没有寻求护理以避免称重或讨论体重，其中肥胖较严重的患者患病率更高。 27 这是实施中的一个重大差距，因为有明确的证据表明强化生活方式疗法比简短的建议更有效，并且医生提供的一般教育信息比连接或转介课程的频率要高得多、项目或改变生活方式的有形资源。 19,27
Clinicians need to adopt effective and sensitive ways to initiate discussions about weight. As part of a 2017 roundtable workshop,21 Rao describes the “opening the door” approach to initiating discussions, which seeks permission to initiate discussions in a direct but sensitive way that allows engagement of patients in further obesity-related discussions. One way to open the door is the following21: “I am concerned about your weight. It puts you at risk for a number of conditions such as diabetes. Is this something that concerns you as well? Is this something you would like to discuss and work on together?”
临床医生需要采用有效且敏感的方式来发起有关体重的讨论。作为 2017 年圆桌研讨会的一部分， 21 Rao 描述了发起讨论的“开门”方法，该方法寻求许可以直接但敏感的方式发起讨论，从而允许患者进一步参与与肥胖相关的活动讨论。开门的一种方法是 21 ：“我担心你的体重。它会使您面临患糖尿病等多种疾病的风险。这也是您所关心的事情吗？这是你们愿意共同讨论和共同努力的事情吗？”
临床医生需要采用有效且敏感的方式来发起有关体重的讨论。作为 2017 年圆桌研讨会的一部分， 21 Rao 描述了发起讨论的“开门”方法，该方法寻求许可以直接但敏感的方式发起讨论，从而允许患者进一步参与与肥胖相关的活动讨论。开门的一种方法是 21 ：“我担心你的体重。它会使您面临患糖尿病等多种疾病的风险。这也是您所关心的事情吗？这是你们愿意共同讨论和共同努力的事情吗？”
Alternatively, patients can be empowered to ask their clinicians about weight. Patient empowerment is an important, emerging concept in engagement and delivery of health care.28 Patients can be encouraged to ask questions about a wide range of issues of importance to them related to their care.29 Prompts (sent, for example, by an electronic patient portal) such as “Don’t forget to ask your doctor about your weight” or encouraging the question “I’m concerned about my weight and would like your help in achieving and maintaining a healthy weight” are easy ways for patients and clinicians to begin discussions. Many of the barriers to receiving obesity care are exacerbated by socioeconomic and racial or ethnic inequities. Despite a greater interest in weight management conversations and opportunities,27 underrepresented racial and ethnic groups and those with public insurance are less likely to be referred to weight management programs or have them covered by insurance.30 Furthermore, there is a significant contribution of psychiatric/psychological factors in terms of both contributing to obesity and creating barriers to engaging in appropriate therapies that are not adequately addressed in current care models.
或者，患者可以向临床医生询问体重。患者赋权是参与和提供医疗保健的一个重要的新兴概念。 28 可以鼓励患者就与他们的护理相关的对他们来说很重要的各种问题提出问题。 29 提示（例如，通过电子患者门户发送），例如“不要忘记向您的医生询问您的体重”或鼓励提出问题“我担心自己的体重并且想要您对实现和保持健康体重的帮助”是患者和临床医生开始讨论的简单方法。社会经济和种族或民族不平等加剧了接受肥胖症护理的许多障碍。尽管人们对体重管理对话和机会更感兴趣， 27 代表性不足的种族和族裔群体以及拥有公共保险的人不太可能被推荐参加体重管理计划或获得保险。 30 此外，精神/心理因素在导致肥胖和阻碍采取适当治疗方面发挥着重要作用，而当前的护理模式尚未充分解决这些障碍。
或者，患者可以向临床医生询问体重。患者赋权是参与和提供医疗保健的一个重要的新兴概念。 28 可以鼓励患者就与他们的护理相关的对他们来说很重要的各种问题提出问题。 29 提示（例如，通过电子患者门户发送），例如“不要忘记向您的医生询问您的体重”或鼓励提出问题“我担心自己的体重并且想要您对实现和保持健康体重的帮助”是患者和临床医生开始讨论的简单方法。社会经济和种族或民族不平等加剧了接受肥胖症护理的许多障碍。尽管人们对体重管理对话和机会更感兴趣， 27 代表性不足的种族和族裔群体以及拥有公共保险的人不太可能被推荐参加体重管理计划或获得保险。 30 此外，精神/心理因素在导致肥胖和阻碍采取适当治疗方面发挥着重要作用，而当前的护理模式尚未充分解决这些障碍。
Implementation Gaps in Pharmacotherapies for Treating Obesity
治疗肥胖的药物疗法的实施差距
Newer pharmacotherapies for obesity treatment demonstrate impressive effectiveness in real-world settings that approximates their efficacy in clinical trials. The 2 pharmacotherapies approved most recently by the US Food and Drug Administration (FDA) for long-term weight management are high-dose semaglutide and tirzepatide, which are both associated with an average weight loss of >10% at 6 months in clinical environments, greater than weight loss achieved from other FDA-approved antiobesity medications (AOMs).31,31a However, obesity pharmacotherapies continue to be dramatically underprescribed. Although >50% of adults meet the eligibility criteria for obesity pharmacotherapies, a striking minority of adults trying to lose weight are receiving these agents.32,33 These prescribing patterns for obesity pharmacotherapies stand in stark contrast to those for diabetes and hypertension, conditions that are common consequences of obesity.
较新的肥胖治疗药物疗法在现实环境中表现出令人印象深刻的有效性，与其在临床试验中的疗效相近。美国食品和药物管理局 (FDA) 最近批准的用于长期体重管理的 2 种药物疗法是大剂量索马鲁肽和替泽帕肽，这两种药物在临床环境中均与 6 个月时平均体重减轻 >10% 相关。比 FDA 批准的其他抗肥胖药物 (AOM) 所实现的减肥效果更大。 31,31a 然而，肥胖药物治疗的处方仍然严重不足。尽管超过 50% 的成年人符合肥胖药物治疗的资格标准，但尝试减肥的成年人中却有极少数正在接受这些药物治疗。 32,33 这些肥胖药物治疗的处方模式与糖尿病和高血压的处方模式形成鲜明对比，而糖尿病和高血压是肥胖的常见后果。
较新的肥胖治疗药物疗法在现实环境中表现出令人印象深刻的有效性，与其在临床试验中的疗效相近。美国食品和药物管理局 (FDA) 最近批准的用于长期体重管理的 2 种药物疗法是大剂量索马鲁肽和替泽帕肽，这两种药物在临床环境中均与 6 个月时平均体重减轻 >10% 相关。比 FDA 批准的其他抗肥胖药物 (AOM) 所实现的减肥效果更大。 31,31a 然而，肥胖药物治疗的处方仍然严重不足。尽管超过 50% 的成年人符合肥胖药物治疗的资格标准，但尝试减肥的成年人中却有极少数正在接受这些药物治疗。 32,33 这些肥胖药物治疗的处方模式与糖尿病和高血压的处方模式形成鲜明对比，而糖尿病和高血压是肥胖的常见后果。
The reasons for the low use rates of obesity pharmacotherapies are likely related principally to (1) knowledge gaps among clinicians, (2) concerns about the safety of obesity pharmacotherapies, and (3) perhaps most important, coverage limitations. A survey of health professionals demonstrated that only 15% of clinicians were familiar with the guideline-directed indications for prescribing obesity pharmacotherapies.26 A report of the Government Accountability Office identified limited clinician education and experience related to the provision of obesity pharmacotherapies as a critical barrier to the appropriate use of these medications.33 Low use of obesity pharmacotherapies is also linked to widespread concerns about their potential harms. These concerns likely reflect a legacy effect of the relatively high side effects of older sympathomimetic and combination obesity medications relative to those seen with newer glucagon-like peptide-1 receptor agonists and dual glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide receptor agonist agents. A 2018 statement from the US Preventive Services Task Force describing the potential harm of obesity pharmacotherapies compared with lifestyle modification may have a powerful influence on clinician perceptions about the safety of obesity pharmacotherapies.34
肥胖药物治疗使用率低的原因可能主要与（1）临床医生之间的知识差距，（2）对肥胖药物治疗安全性的担忧，以及（3）也许最重要的是覆盖范围限制有关。一项针对健康专业人员的调查表明，只有 15% 的临床医生熟悉指导肥胖药物治疗的指南指示的适应症。 26 政府问责办公室的一份报告指出，与提供肥胖药物治疗相关的临床医生教育和经验有限是适当使用这些药物的关键障碍。 33 肥胖药物疗法的低使用也与对其潜在危害的广泛担忧有关。这些担忧可能反映了旧的拟交感神经药和联合肥胖药物相对于较新的胰高血糖素样肽-1受体激动剂和双胰高血糖素样肽-1和葡萄糖依赖性促胰岛素多肽受体激动剂的副作用相对较高的遗留影响代理。美国预防服务工作组 2018 年的一份声明描述了肥胖药物疗法与生活方式改变相比的潜在危害，可能会对临床医生对肥胖药物疗法安全性的看法产生重大影响。 34
肥胖药物治疗使用率低的原因可能主要与（1）临床医生之间的知识差距，（2）对肥胖药物治疗安全性的担忧，以及（3）也许最重要的是覆盖范围限制有关。一项针对健康专业人员的调查表明，只有 15% 的临床医生熟悉指导肥胖药物治疗的指南指示的适应症。 26 政府问责办公室的一份报告指出，与提供肥胖药物治疗相关的临床医生教育和经验有限是适当使用这些药物的关键障碍。 33 肥胖药物疗法的低使用也与对其潜在危害的广泛担忧有关。这些担忧可能反映了旧的拟交感神经药和联合肥胖药物相对于较新的胰高血糖素样肽-1受体激动剂和双胰高血糖素样肽-1和葡萄糖依赖性促胰岛素多肽受体激动剂的副作用相对较高的遗留影响代理。美国预防服务工作组 2018 年的一份声明描述了肥胖药物疗法与生活方式改变相比的潜在危害，可能会对临床医生对肥胖药物疗法安全性的看法产生重大影响。 34
Perhaps the most significant barrier to greater use of obesity pharmacotherapies is limited coverage and high out-of-pocket costs for these medications. A 2016 analysis of health insurance plans within the marketplace exchanges demonstrated that only 11% of the plans had some coverage for obesity pharmacotherapies.35 Additionally, although only 7 state Medicaid plans provided coverage for obesity pharmacotherapies, historically, Medicare Part D has explicitly excluded them. Given the high cost of these agents, these coverage limitations have contributed significantly to the undertreatment of excess weight, particularly in high-risk, underrepresented, and historically excluded populations with the highest burden of obesity and its associated comorbidities.
也许更多地使用肥胖药物疗法的最大障碍是这些药物的覆盖范围有限和自付费用较高。 2016 年对市场交易所内健康保险计划的分析表明，只有 11% 的计划对肥胖药物疗法有一定的承保范围。 35 此外，虽然只有 7 个州的医疗补助计划提供肥胖药物治疗的承保，但从历史上看，医疗保险 D 部分已明确将其排除在外。鉴于这些药物的成本高昂，这些覆盖范围的限制在很大程度上导致了超重的治疗不足，特别是在肥胖及其相关合并症负担最高的高风险、代表性不足和历史上被排除的人群中。
也许更多地使用肥胖药物疗法的最大障碍是这些药物的覆盖范围有限和自付费用较高。 2016 年对市场交易所内健康保险计划的分析表明，只有 11% 的计划对肥胖药物疗法有一定的承保范围。 35 此外，虽然只有 7 个州的医疗补助计划提供肥胖药物治疗的承保，但从历史上看，医疗保险 D 部分已明确将其排除在外。鉴于这些药物的成本高昂，这些覆盖范围的限制在很大程度上导致了超重的治疗不足，特别是在肥胖及其相关合并症负担最高的高风险、代表性不足和历史上被排除的人群中。
The recent approval by the FDA to expand the indication of the AOM semaglutide to reduce the risk of cardiovascular death, heart attack, and stroke in adults with CVD and either obesity or overweight based on the results of the SELECT (Semaglutide Effects on Heart Disease and Stroke in Patients With Overweight or Obesity) trial35a is the first step in a potentially major transformation shifting the coverage conversation away from obesity treatment for the goal of weight management to obesity treatment to reduce the risk of resulting adverse clinical consequences. Building on this shift, the Centers for Medicare & Medicaid Services recently issued guidance to Medicare Part D plans stating that AOMs that receive FDA approval for an additional medically accepted indication (eg, CVD) can be considered a Part D drug for that specific use. State Medicaid programs for low-income populations, who are disproportionately affected by obesity and CVD, will also be required to cover FDA-approved AOMs for this same population. However, states may still require step therapy with other medications or treatments before authorization, posing potential delays in access. This news marks transformational progress in policy toward expanding access to AOMs for high-risk, high-need patients for the prevention of adverse cardiovascular events. Nevertheless, ongoing challenges remain, as supplies of glucagon-like peptide-1 agonists in particular have been scarce, further limiting their use.
根据 SELECT（索马鲁肽对心脏病和超重的影响）的结果，FDA 最近批准扩大 AOM 索马鲁肽的适应症，以降低患有 CVD 且肥胖或超重的成年人的心血管死亡、心脏病和中风的风险超重或肥胖患者中风）试验 35a 是潜在重大转变的第一步，将覆盖范围从以体重管理为目标的肥胖治疗转向肥胖治疗，以降低由此产生的不良临床风险结果。基于这一转变，医疗保险和医疗补助服务中心最近发布了医疗保险 D 部分计划指南，指出获得 FDA 批准用于其他医学上可接受的适应症（例如 CVD）的 AOM 可被视为用于该特定用途的 D 部分药物。针对受肥胖和心血管疾病影响尤为严重的低收入人群的州医疗补助计划也将被要求涵盖 FDA 批准的针对同一人群的 AOM。然而，各州可能仍要求在授权之前使用其他药物或治疗进行分步治疗，这可能会导致准入延迟。这一消息标志着政策上的变革性进展，旨在扩大高风险、高需求患者获得 AOM 的机会，以预防不良心血管事件。然而，持续的挑战仍然存在，特别是胰高血糖素样肽-1激动剂的供应一直很稀缺，进一步限制了它们的使用。
根据 SELECT（索马鲁肽对心脏病和超重的影响）的结果，FDA 最近批准扩大 AOM 索马鲁肽的适应症，以降低患有 CVD 且肥胖或超重的成年人的心血管死亡、心脏病和中风的风险超重或肥胖患者中风）试验 35a 是潜在重大转变的第一步，将覆盖范围从以体重管理为目标的肥胖治疗转向肥胖治疗，以降低由此产生的不良临床风险结果。基于这一转变，医疗保险和医疗补助服务中心最近发布了医疗保险 D 部分计划指南，指出获得 FDA 批准用于其他医学上可接受的适应症（例如 CVD）的 AOM 可被视为用于该特定用途的 D 部分药物。针对受肥胖和心血管疾病影响尤为严重的低收入人群的州医疗补助计划也将被要求涵盖 FDA 批准的针对同一人群的 AOM。然而，各州可能仍要求在授权之前使用其他药物或治疗进行分步治疗，这可能会导致准入延迟。这一消息标志着政策上的变革性进展，旨在扩大高风险、高需求患者获得 AOM 的机会，以预防不良心血管事件。然而，持续的挑战仍然存在，特别是胰高血糖素样肽-1激动剂的供应一直很稀缺，进一步限制了它们的使用。
Implementation Gaps in Metabolic and Bariatric Surgery
代谢和减肥手术的实施差距
Bariatric surgery has long been considered the last-line therapy for severe obesity that cannot be managed through lifestyle changes or pharmacotherapies alone. Since bariatric surgery was introduced in the 1950s, the procedures have become safer and more effective.36 In an umbrella review of meta-analyses, patients who underwent bariatric surgery had lower risks for incident CVD, multiple other obesity-associated conditions (eg, type 2 diabetes, hypertension), and adverse pregnancy outcomes, including gestational hypertension and diabetes.37 Among patients with preexisting type 2 diabetes or CVD who underwent bariatric surgery, glycemic parameters and measures of cardiac structure and function improved.38,39 As surgical expertise has grown, eligibility has expanded to include adults with type 2 diabetes and a BMI between 30 and 35 kg/m2,40 as well as adolescents with severe obesity and at least 1 major comorbidity.41 These safety advances and health benefits offer clinicians and patients another option to treat severe obesity.
减肥手术长期以来一直被认为是严重肥胖症的最后一线治疗方法，无法仅通过改变生活方式或药物疗法来控制。自 20 世纪 50 年代引入减肥手术以来，手术变得更加安全和有效。 36 在一项综合荟萃分析中，接受减肥手术的患者发生 CVD、多种其他肥胖相关疾病（例如 2 型糖尿病、高血压）和不良妊娠结局的风险较低，包括妊娠高血压和糖尿病。 37 在接受减肥手术的既往患有 2 型糖尿病或 CVD 的患者中，血糖参数以及心脏结构和功能的测量得到改善。 38,39 随着外科专业知识的增长，资格已扩大到包括 2 型糖尿病且 BMI 在 30 至 35 kg/m 之间的成人 2,40 以及患有严重肥胖且至少1 主要合并症。 41 这些安全性进步和健康益处为临床医生和患者提供了治疗严重肥胖的另一种选择。
减肥手术长期以来一直被认为是严重肥胖症的最后一线治疗方法，无法仅通过改变生活方式或药物疗法来控制。自 20 世纪 50 年代引入减肥手术以来，手术变得更加安全和有效。 36 在一项综合荟萃分析中，接受减肥手术的患者发生 CVD、多种其他肥胖相关疾病（例如 2 型糖尿病、高血压）和不良妊娠结局的风险较低，包括妊娠高血压和糖尿病。 37 在接受减肥手术的既往患有 2 型糖尿病或 CVD 的患者中，血糖参数以及心脏结构和功能的测量得到改善。 38,39 随着外科专业知识的增长，资格已扩大到包括 2 型糖尿病且 BMI 在 30 至 35 kg/m 之间的成人 2,40 以及患有严重肥胖且至少1 主要合并症。 41 这些安全性进步和健康益处为临床医生和患者提供了治疗严重肥胖的另一种选择。
The critical challenge facing the field is ensuring that the populations with the greatest needs can access bariatric surgery. A significant barrier to the implementation of bariatric surgery, despite established disparities in the prevalence of severe obesity, is that adolescents and adults who identify as Black or Hispanic/Latino and those who have fewer social and economic resources are far less likely to undergo surgery.40,42,43 Although structural factors that unfairly limit access to surgery account for some of the inequities, additional reasons include the perception and reality that the social supports needed for surgery to be successful are absent in underresourced populations with the greatest needs. Another gap in implementation may relate to the complexity of bariatric surgery that requires patients to have high levels of health literacy to enact the behavioral modifications necessary for favorable long-term (ie, 2-4 years) weight loss and maintenance.44 Furthermore, widespread availability of high-volume centers is lacking, and as with any procedure, higher bariatric surgical volumes are associated with better outcomes.45 High-volume bariatric surgery centers are more likely to be in major metropolitan areas and academic medical centers, which are the places that are less likely to treat patients with severe obesity and have fewer socioeconomic resources. In addition, although most private and public insurance companies cover the cost of the procedure and there are no differences in the effectiveness of therapy based on insurance status,46 patients with public insurance may face additional socioeconomic barriers to follow-up care, including the time and expense required to travel to and from those visits and resulting lost wages while attending appointments. Last, legacy effects related to the social stigma of surgery, safety concerns due to historically higher complication rates, and the multiple requirements to even qualify for bariatric surgery (eg, visits with psychologists, cardiologists, dieticians, and others to meet criteria) contribute to the implementation gap between science and practice.
该领域面临的关键挑战是确保最需要的人群能够接受减肥手术。尽管严重肥胖症的患病率存在差异，但实施减肥手术的一个重大障碍是，黑人或西班牙裔/拉丁裔的青少年和成年人以及社会和经济资源较少的人接受手术的可能性要小得多。 40,42,43 虽然不公平地限制手术机会的结构性因素造成了一些不平等，但其他原因包括人们认为和现实情况，即最需要的资源贫乏人群缺乏手术成功所需的社会支持。实施中的另一个差距可能与减肥手术的复杂性有关，减肥手术要求患者具有高水平的健康素养，以制定有利的长期（即2-4年）体重减轻和维持所需的行为改变。 44 此外，缺乏大容量中心的广泛可用性，并且与任何手术一样，较高的减肥手术量与更好的结果相关。 45 高容量减肥手术中心更有可能位于主要大都市地区和学术医疗中心，这些地方不太可能治疗严重肥胖患者且社会经济资源较少。 此外，尽管大多数私人和公共保险公司承担手术费用，并且根据保险状况，治疗效果没有差异，但 46 拥有公共保险的患者可能会面临额外的社会经济障碍。护理费用，包括往返这些就诊所需的时间和费用以及因赴约而造成的工资损失。最后，与手术的社会耻辱相关的遗留影响、历史上较高的并发症发生率导致的安全问题，以及减肥手术资格的多重要求（例如，拜访心理学家、心脏病专家、营养师和其他人以满足标准）有助于科学与实践之间的实施差距。
该领域面临的关键挑战是确保最需要的人群能够接受减肥手术。尽管严重肥胖症的患病率存在差异，但实施减肥手术的一个重大障碍是，黑人或西班牙裔/拉丁裔的青少年和成年人以及社会和经济资源较少的人接受手术的可能性要小得多。 40,42,43 虽然不公平地限制手术机会的结构性因素造成了一些不平等，但其他原因包括人们认为和现实情况，即最需要的资源贫乏人群缺乏手术成功所需的社会支持。实施中的另一个差距可能与减肥手术的复杂性有关，减肥手术要求患者具有高水平的健康素养，以制定有利的长期（即2-4年）体重减轻和维持所需的行为改变。 44 此外，缺乏大容量中心的广泛可用性，并且与任何手术一样，较高的减肥手术量与更好的结果相关。 45 高容量减肥手术中心更有可能位于主要大都市地区和学术医疗中心，这些地方不太可能治疗严重肥胖患者且社会经济资源较少。 此外，尽管大多数私人和公共保险公司承担手术费用，并且根据保险状况，治疗效果没有差异，但 46 拥有公共保险的患者可能会面临额外的社会经济障碍。护理费用，包括往返这些就诊所需的时间和费用以及因赴约而造成的工资损失。最后，与手术的社会耻辱相关的遗留影响、历史上较高的并发症发生率导致的安全问题，以及减肥手术资格的多重要求（例如，拜访心理学家、心脏病专家、营养师和其他人以满足标准）有助于科学与实践之间的实施差距。
Cost-Effectiveness of Obesity Therapies and Its Impact on Implementation
肥胖治疗的成本效益及其对实施的影响
Studies demonstrate that despite significant public health efforts to address obesity, rates of obesity are not declining, and the poorer outcomes among individuals with obesity during the COVID-19 pandemic further highlight the need for successful methods for implementing obesity science into clinical practice.30 An important consideration that can stimulate or stall the implementation of scientific advancements in new treatments for obesity is cost-effectiveness. Among obesity treatments, bariatric surgery procedures consistently demonstrate cost savings, for example, reduced medical costs and expenditures.47 The cost-effectiveness of nonsurgical obesity treatment (behavioral and pharmacotherapy) has been demonstrated, although findings are less consistent. This is due in part to lower degrees of weight loss and the challenges in quantifying the multifactorial and likely long-term or lagged benefits from these therapies.48,49 Studying the cost-effectiveness of obesity prevention is even more challenging.50 Still, this lack of definitive cost-effectiveness data likely contributes to the low uptake of obesity science implementation in clinical settings. Engagement of stakeholders, community partners, and health economists to help prospective design measurement of program costs and benefits in obesity science research is one strategy that could address this gap.51
研究表明，尽管公共卫生部门为解决肥胖问题做出了巨大努力，但肥胖率并没有下降，而且 COVID-19 大流行期间肥胖症患者的预后较差，进一步凸显了将肥胖科学应用于临床实践的成功方法的必要性。 30 可以刺激或阻碍肥胖新疗法中科学进步的实施的一个重要考虑因素是成本效益。在肥胖治疗中，减肥手术始终证明可以节省成本，例如减少医疗成本和支出。 47 非手术肥胖治疗（行为疗法和药物疗法）的成本效益已得到证实，尽管研究结果不太一致。部分原因是体重减轻程度较低，以及量化这些疗法的多因素和可能的长期或滞后益处面临挑战。 48,49 研究肥胖预防的成本效益更具挑战性。 50 尽管如此，缺乏明确的成本效益数据可能导致临床环境中肥胖科学实施的利用率较低。利益相关者、社区合作伙伴和健康经济学家的参与，帮助对肥胖科学研究中的项目成本和效益进行前瞻性设计衡量，是解决这一差距的一项策略。 51
研究表明，尽管公共卫生部门为解决肥胖问题做出了巨大努力，但肥胖率并没有下降，而且 COVID-19 大流行期间肥胖症患者的预后较差，进一步凸显了将肥胖科学应用于临床实践的成功方法的必要性。 30 可以刺激或阻碍肥胖新疗法中科学进步的实施的一个重要考虑因素是成本效益。在肥胖治疗中，减肥手术始终证明可以节省成本，例如减少医疗成本和支出。 47 非手术肥胖治疗（行为疗法和药物疗法）的成本效益已得到证实，尽管研究结果不太一致。部分原因是体重减轻程度较低，以及量化这些疗法的多因素和可能的长期或滞后益处面临挑战。 48,49 研究肥胖预防的成本效益更具挑战性。 50 尽管如此，缺乏明确的成本效益数据可能导致临床环境中肥胖科学实施的利用率较低。利益相关者、社区合作伙伴和健康经济学家的参与，帮助对肥胖科学研究中的项目成本和效益进行前瞻性设计衡量，是解决这一差距的一项策略。 51
The limited availability of cost-effectiveness and health outcomes data for obesity treatment relates to additional challenges in clinician reimbursement and patient costs for obesity treatment, which are significant obesity science implementation barriers. A recent qualitative study concluded that primary care clinicians believed that addressing obesity is an essential part of their job and furthermore that many find it feasible and rewarding. Yet, a lack of adequate reimbursement emerged as a primary barrier to these clinicians implementing obesity counseling in their practice.52 For example, policies in which patients must have a BMI ≥30 kg/m2 or clinical prediabetes before obesity services are reimbursable can impede and frustrate clinicians and patients who seek to prevent obesity or maintain obesity treatment successes. Furthermore, the limited availability of hard outcomes data (eg, cardiovascular outcomes, mortality) is an impediment to convincing payers to reimburse treatments for obesity. On the other hand, outcomes trials cannot be reasonably conducted in lower-risk populations with obesity (ie, younger people, those with no/minimal prevalent comorbidities) because of low event rates, high costs, and prolonged follow-up. Moreover, the lack of consensus on appropriate clinical parameters or quality benchmarks to define obesity-related outcomes (given its heterogeneity)24 that qualify for reimbursement further adds to clinician frustrations and thwarts implementation of obesity management programs.23,53 For example, although cardiovascular outcomes and mortality are obviously important, weight loss by itself may lead to more immediate improvements in quality of life and well-being that are not captured in outcomes used by payers to decide coverage. In addition, inadequate reimbursement for evidence-based behavioral treatments by nonphysicians (eg, dieticians and psychologists) further limits the application of evidence-based behavioral treatments for obesity.20 Bariatric surgery is covered by Medicaid, but reimbursement has declined dramatically over the past decade, disincentivizing the provision of this effective treatment.54 Although questions about the cost-effectiveness and long-term outcomes of many obesity-related treatments remain, evidence for benefit is gradually emerging, and there is a gap between this body of evidence and the willingness of payers to cover treatments.50,53 This leads to a situation in which clinicians are not incentivized to provide obesity management services, resulting in further widening of the implementation gap.
肥胖治疗的成本效益和健康结果数据有限，这与肥胖治疗的临床医生报销和患者费用方面的额外挑战有关，这是肥胖科学实施的重大障碍。最近的一项定性研究得出结论，初级保健临床医生认为解决肥胖问题是他们工作的重要组成部分，而且许多人认为这是可行且有益的。然而，缺乏足够的报销成为这些临床医生在实践中实施肥胖咨询的主要障碍。 52 例如，在肥胖服务可报销之前，患者必须达到 BMI ≥ 30 kg/m 2 或临床前驱糖尿病的政策可能会阻碍和挫败寻求预防肥胖的临床医生和患者或保持肥胖治疗的成功。此外，硬结果数据（例如，心血管结果、死亡率）的有限性阻碍了说服付款人报销肥胖治疗费用。另一方面，由于事件发生率低、成本高且随访时间长，结果试验无法合理地在肥胖的低风险人群（即年轻人、没有/很少有普遍合并症的人群）中进行。此外，缺乏对适当的临床参数或质量基准的共识来定义符合报销资格的肥胖相关结果（鉴于其异质性） 24 ，这进一步增加了临床医生的挫败感并阻碍了肥胖管理计划的实施。 23,53 例如，尽管心血管结局和死亡率显然很重要，但体重减轻本身可能会导致生活质量和福祉的更直接改善，而付款人用来决定承保范围的结果并未体现这一点。此外，非医生（例如营养师和心理学家）对循证行为治疗的报销不足进一步限制了肥胖循证行为治疗的应用。 20 减肥手术由医疗补助覆盖，但报销在过去十年中急剧下降，抑制了提供这种有效治疗的动力。 54 尽管许多肥胖相关治疗的成本效益和长期结果仍然存在疑问，但有益的证据正在逐渐出现，而且这些证据与支付者的意愿之间存在差距。覆盖治疗。 50,53 这导致临床医生没有动力提供肥胖管理服务，导致实施差距进一步扩大。
肥胖治疗的成本效益和健康结果数据有限，这与肥胖治疗的临床医生报销和患者费用方面的额外挑战有关，这是肥胖科学实施的重大障碍。最近的一项定性研究得出结论，初级保健临床医生认为解决肥胖问题是他们工作的重要组成部分，而且许多人认为这是可行且有益的。然而，缺乏足够的报销成为这些临床医生在实践中实施肥胖咨询的主要障碍。 52 例如，在肥胖服务可报销之前，患者必须达到 BMI ≥ 30 kg/m 2 或临床前驱糖尿病的政策可能会阻碍和挫败寻求预防肥胖的临床医生和患者或保持肥胖治疗的成功。此外，硬结果数据（例如，心血管结果、死亡率）的有限性阻碍了说服付款人报销肥胖治疗费用。另一方面，由于事件发生率低、成本高且随访时间长，结果试验无法合理地在肥胖的低风险人群（即年轻人、没有/很少有普遍合并症的人群）中进行。此外，缺乏对适当的临床参数或质量基准的共识来定义符合报销资格的肥胖相关结果（鉴于其异质性） 24 ，这进一步增加了临床医生的挫败感并阻碍了肥胖管理计划的实施。 23,53 例如，尽管心血管结局和死亡率显然很重要，但体重减轻本身可能会导致生活质量和福祉的更直接改善，而付款人用来决定承保范围的结果并未体现这一点。此外，非医生（例如营养师和心理学家）对循证行为治疗的报销不足进一步限制了肥胖循证行为治疗的应用。 20 减肥手术由医疗补助覆盖，但报销在过去十年中急剧下降，抑制了提供这种有效治疗的动力。 54 尽管许多肥胖相关治疗的成本效益和长期结果仍然存在疑问，但有益的证据正在逐渐出现，而且这些证据与支付者的意愿之间存在差距。覆盖治疗。 50,53 这导致临床医生没有动力提供肥胖管理服务，导致实施差距进一步扩大。
FOCUS ON RESOURCES TO FACILITATE IMPROVED POPULATION-LEVEL OBESITY MANAGEMENT
专注于资源以促进改善人群肥胖管理
Despite advancements in understanding the causes and mechanisms that contribute to obesity, ongoing gaps in implementing evidence-based obesity science have impeded efforts to improve the quality, effectiveness, scalability, and equitability of successful obesity strategies into clinical practice. The following sections summarize existing and promising opportunities to address key implementation gaps and enable progress in the translation of obesity science into clinical practice for greater prevention, treatment, and control of this epidemic (Table).
尽管在了解导致肥胖的原因和机制方面取得了进展，但在实施基于证据的肥胖科学方面持续存在的差距阻碍了将成功的肥胖策略提高到临床实践的质量、有效性、可扩展性和公平性的努力。以下各节总结了现有的和有希望的机会，以解决关键的实施差距，并在将肥胖科学转化为临床实践方面取得进展，以更好地预防、治疗和控制这种流行病（表）。
尽管在了解导致肥胖的原因和机制方面取得了进展，但在实施基于证据的肥胖科学方面持续存在的差距阻碍了将成功的肥胖策略提高到临床实践的质量、有效性、可扩展性和公平性的努力。以下各节总结了现有的和有希望的机会，以解决关键的实施差距，并在将肥胖科学转化为临床实践方面取得进展，以更好地预防、治疗和控制这种流行病（表）。
桌子。将肥胖科学转化为临床实践的实施差距和新机遇
| Implementation gap 实施差距 | Existing and emerging opportunities 现有和新兴机会 |
|---|---|
| Clinician knowledge about diet and nutrition, physical activity recommendations, intensive behavioral therapy, pharmacological therapies, and bariatric surgeries 临床医生有关饮食和营养、体力活动建议、强化行为疗法、药物疗法和减肥手术的知识 | Increase clinician training; facilitate referral to obesity medicine specialists 加强临床医生培训；方便转介给肥胖医学专家 |
| Clinician comfort to discuss weight management and sensitivity to weight stigma/bias 临床医生舒适地讨论体重管理和对体重耻辱/偏见的敏感性 | Increase clinician training and diversity; facilitate referral to obesity medicine specialists; engage community health workers for underrepresented racial and ethnic groups 加强临床医生培训和多样性；方便转诊至肥胖医学专家；让社区卫生工作者参与代表性不足的种族和族裔群体 |
| Cost/insurance coverage/lack of access for pharmacological, bariatric, and behavioral therapies 费用/保险范围/缺乏药物、减肥和行为疗法 | The Centers for Medicare & Medicaid Services now recognize obesity as a target for treatment to improve cardiovascular health outcomes 医疗保险和医疗补助服务中心现已将肥胖视为改善心血管健康结果的治疗目标 Increase reimbursement for all obesity management options across all payer types, and increase support for community resources 增加对所有付款人类型的所有肥胖管理选项的报销，并增加对社区资源的支持 |
| Patient avoidance and stigma | Make available clinician sensitivity training to reduce weight bias; use telemedicine to enhance adherence to visits; make clinical spaces safe and comfortable for all patients |
| Perceptions of safety and rates of adverse effects | Offer clinician training and education in obesity medicine; facilitate referral to obesity medicine specialists |
| Connection to resources | Pair clinical recommendations directly with tangible community resources; enhance use of technology such as digital tools and mobile health solutions |
| Uncertain cost-effectiveness | Enhance cost-effectiveness and implementation research; engage stakeholders, community partners, and health economists to help design cost-effectiveness programs |
| Lack of social and community support | Provide treatment approaches focused on couples, families, or households; offer connection to patient and community groups that provides resources and support |
Will Technology Help Address Gaps in Care?
技术能否帮助解决护理方面的差距？
Technology solutions to bridge the know-do gap in obesity prevention and treatment are promising, with emerging evidence to support multiple implementation strategies,55,56 including in many low- and middle-income countries that have seen rapid adoption of digital technologies.57 Mobile health solutions, including popular weight loss applications (apps), are implementing various evidence-based behavior change techniques.58 However, the literature needs to be improved by better reporting of implementation strategies.59 Challenges with awareness, access, and engagement persist, especially in historically excluded groups who experience a high prevalence of obesity and disparities in care. One modeling study, for example, suggested that 75% awareness, 75% downloading, and 75% engagement with notifications may be required to achieve significant changes in physical activity and obesity prevalence among African American women in Washington, DC.60 Leveraging the increased access to telemedicine is another future opportunity to improve access to obesity specialists and treatments,56 especially in rural areas where the distance to the clinic is a major barrier.61 Increasing the use of inexpensive obesity-related health indicators such as routine measurement of the waist circumference as part of the standard vital signs or measurement of the supine sagittal abdominal diameter using sliding-beam caliper to estimate visceral adipose tissue burden62,63 clinically may shift the focus of obesity treatment from weight/BMI to risk-based markers. An even simpler tool for weight loss is regular (ie, weekly) self-weighing. Self-weighing as part of weight management programs has been shown to improve weight loss.64 Wireless scales allow remote monitoring of weight and transmission of weight data to clinicians, peers involved in group programs, and others to provide feedback, accountability, and support.65
缩小肥胖预防和治疗方面的知识差距的技术解决方案前景广阔，新的证据支持多种实施策略， 55,56 包括在许多已快速采用数字技术的低收入和中等收入国家技术。 57 移动健康解决方案，包括流行的减肥应用程序 (app)，正在实施各种基于证据的行为改变技术。 58 然而，文献需要通过更好地报告实施策略来改进。 59 认识、获取和参与方面的挑战仍然存在，特别是在历史上被排除在外的群体中，这些群体肥胖率很高，而且护理方面存在差异。例如，一项模型研究表明，华盛顿特区的非裔美国女性的体力活动和肥胖流行率可能需要 75% 的知晓率、75% 的下载率和 75% 的通知参与率才能实现显着变化。 60 利用远程医疗的增加是未来改善获得肥胖专家和治疗的另一个机会， 56 特别是在距离诊所的距离是主要障碍的农村地区。 61 增加使用廉价的肥胖相关健康指标，例如常规测量腰围作为标准生命体征的一部分，或使用滑梁卡尺测量仰卧矢状腹部直径来估计内脏脂肪组织临床上的负担 62,63 可能会将肥胖治疗的重点从体重/BMI转移到基于风险的标志物。一个更简单的减肥工具是定期（即每周）自我称重。作为体重管理计划的一部分，自我称重已被证明可以改善体重减轻。 64 无线秤允许远程监测体重并将体重数据传输给临床医生、参与团体项目的同行和其他人，以提供反馈、问责和支持。 65
缩小肥胖预防和治疗方面的知识差距的技术解决方案前景广阔，新的证据支持多种实施策略， 55,56 包括在许多已快速采用数字技术的低收入和中等收入国家技术。 57 移动健康解决方案，包括流行的减肥应用程序 (app)，正在实施各种基于证据的行为改变技术。 58 然而，文献需要通过更好地报告实施策略来改进。 59 认识、获取和参与方面的挑战仍然存在，特别是在历史上被排除在外的群体中，这些群体肥胖率很高，而且护理方面存在差异。例如，一项模型研究表明，华盛顿特区的非裔美国女性的体力活动和肥胖流行率可能需要 75% 的知晓率、75% 的下载率和 75% 的通知参与率才能实现显着变化。 60 利用远程医疗的增加是未来改善获得肥胖专家和治疗的另一个机会， 56 特别是在距离诊所的距离是主要障碍的农村地区。 61 增加使用廉价的肥胖相关健康指标，例如常规测量腰围作为标准生命体征的一部分，或使用滑梁卡尺测量仰卧矢状腹部直径来估计内脏脂肪组织临床上的负担 62,63 可能会将肥胖治疗的重点从体重/BMI转移到基于风险的标志物。一个更简单的减肥工具是定期（即每周）自我称重。作为体重管理计划的一部分，自我称重已被证明可以改善体重减轻。 64 无线秤允许远程监测体重并将体重数据传输给临床医生、参与团体项目的同行和其他人，以提供反馈、问责和支持。 65
Barriers to Commercial and Community Resources Must Be Addressed
必须解决商业和社区资源的障碍
In addition to a multilevel need to improve referrals and equitable access to clinical weight management programs and other treatment options, it is important for future implementation work to emphasize connections to programs outside clinical settings. Some commercial weight loss programs can be effective, but access is often limited by cost, distance, and patient perceptions of safety and belonging. Nonprofit community programs like the YMCA or Take Off Pounds Sensibly66 may be more acceptable and affordable than medical or commercial options. These programs offer tangible and structured support for weight loss or maintenance and often serve as a link to social support as well. Strategies to inform patients and clinicians about which programs are available in their area and which might be appropriate according to different patient factors may enhance equitable reach and quality of health services delivery but need to be developed and tested at scale.
除了改善转诊和公平获得临床体重管理计划和其他治疗选择的多层次需求之外，未来的实施工作还必须强调与临床环境之外的计划的联系。一些商业减肥计划可能是有效的，但获得途径往往受到成本、距离以及患者对安全和归属感的看法的限制。像 YMCA 或 Take Off Pounds Sensously 66 这样的非营利社区计划可能比医疗或商业选择更容易被接受和负担得起。这些计划为减肥或维持体重提供切实和结构化的支持，并且通常也充当与社会支持的联系。告知患者和临床医生哪些项目在他们的地区可用以及哪些项目可能适合不同患者因素的策略可能会提高卫生服务提供的公平覆盖范围和质量，但需要大规模开发和测试。
除了改善转诊和公平获得临床体重管理计划和其他治疗选择的多层次需求之外，未来的实施工作还必须强调与临床环境之外的计划的联系。一些商业减肥计划可能是有效的，但获得途径往往受到成本、距离以及患者对安全和归属感的看法的限制。像 YMCA 或 Take Off Pounds Sensously 66 这样的非营利社区计划可能比医疗或商业选择更容易被接受和负担得起。这些计划为减肥或维持体重提供切实和结构化的支持，并且通常也充当与社会支持的联系。告知患者和临床医生哪些项目在他们的地区可用以及哪些项目可能适合不同患者因素的策略可能会提高卫生服务提供的公平覆盖范围和质量，但需要大规模开发和测试。
Targeting the Patient’s Broader Social Support Network to Promote Broader, More Comprehensive Implementation of Obesity-Focused Strategies
针对患者更广泛的社会支持网络，促进更广泛、更全面地实施以肥胖为重点的战略
Although much of the evidence available for successful weight loss and maintenance programs comes from individual-level clinical trials, there is increasing acknowledgment that lifestyle changes may be more likely to succeed if implemented at the couple, family, or household level.67–69 The importance of social support for success is well recognized, even for pharmacological and surgical treatments that are inherently implemented at the individual level. Behaviors and environments that contribute to obesity are often shared among those with close social connections, and unsurprisingly, attempts to modify behavior without influencing other sociological factors that contribute to obesity in the first place are often unsuccessful. Despite this growing understanding, widespread implementation of successful programs is rare, and accessibility and acceptability in underrepresented racial and ethnic populations that commonly impede implementation of weight-modifying programs are often overlooked.70 Although clinicians care for individual patients with obesity, patients are part of families and communities. A patient’s social environment has a great deal of influence on their weight, and it is important for clinicians to recognize and assess this broader context, as well as for programs to take sociological factors into consideration. Here is an example: A community-based program must take into consideration what food sources are available at a reasonable cost to participants in the vicinity in order to be practical and effective.
尽管成功的减肥和维持计划的大部分证据都来自个人层面的临床试验，但越来越多的人认识到，如果在夫妻、家庭或家庭层面实施生活方式的改变可能更有可能成功。 67–69 社会支持对成功的重要性已得到广泛认可，即使对于本质上在个人层面实施的药物和手术治疗也是如此。导致肥胖的行为和环境通常是那些具有密切社会联系的人共有的，毫不奇怪，在不影响其他导致肥胖的社会学因素的情况下改变行为的尝试往往会失败。尽管人们的认识不断加深，但成功项目的广泛实施却很少，而且通常阻碍体重调节项目实施的少数族裔和族裔人群的可及性和可接受性常常被忽视。 70 虽然临床医生照顾个体肥胖患者，但患者也是家庭和社区的一部分。患者的社会环境对其体重有很大影响，临床医生认识和评估这一更广泛的背景以及将社会学因素考虑在内的计划非常重要。这里有一个例子：以社区为基础的计划必须考虑到附近的参与者可以以合理的成本获得哪些食物来源，以便切实有效。
尽管成功的减肥和维持计划的大部分证据都来自个人层面的临床试验，但越来越多的人认识到，如果在夫妻、家庭或家庭层面实施生活方式的改变可能更有可能成功。 67–69 社会支持对成功的重要性已得到广泛认可，即使对于本质上在个人层面实施的药物和手术治疗也是如此。导致肥胖的行为和环境通常是那些具有密切社会联系的人共有的，毫不奇怪，在不影响其他导致肥胖的社会学因素的情况下改变行为的尝试往往会失败。尽管人们的认识不断加深，但成功项目的广泛实施却很少，而且通常阻碍体重调节项目实施的少数族裔和族裔人群的可及性和可接受性常常被忽视。 70 虽然临床医生照顾个体肥胖患者，但患者也是家庭和社区的一部分。患者的社会环境对其体重有很大影响，临床医生认识和评估这一更广泛的背景以及将社会学因素考虑在内的计划非常重要。这里有一个例子：以社区为基础的计划必须考虑到附近的参与者可以以合理的成本获得哪些食物来源，以便切实有效。
More Evaluation Is Needed to Support Health Policy Change, Implementation, and Scalability
需要更多的评估来支持卫生政策的改变、实施和可扩展性
Health policy changes are essential to increase the provision of available evidence-based strategies such as behavioral therapy, pharmacotherapy, and bariatric surgery to the large population of individuals with or at risk for obesity who critically need these services.30 Efforts to provide evidence-based coverage for the treatment of obesity are often inhibited by current legislation in the US Congress. Despite recent important advancements in obesity pharmacotherapy coverage by Medicare Part D for individuals with existing CVD to reduce adverse cardiovascular events, further action is needed. Efforts led by the Treat and Reduce Obesity Act to expand Medicare coverage, including screening and treatment of obesity for a broader range of health care clinicians, as well as providing coverage for FDA-approved medications for long-term weight management, has stalled at the federal level over the past decade.71 This underscores the persistent challenges in achieving universal coverage for AOMs, despite notable progress in addressing specific patient populations, such as those with existing CVD who are at highest risk for adverse cardiovascular outcomes. Several professional societies and stakeholders are currently engaged in efforts to lobby for health policy changes to make obesity treatment more accessible and affordable for patients with obesity at high risk for developing CVD.
卫生政策的改变对于向大量迫切需要这些服务的肥胖人群或有肥胖风险的人群提供更多可用的循证策略至关重要，例如行为疗法、药物疗法和减肥手术。 30 为肥胖治疗提供基于证据的覆盖范围的努力常常受到美国国会现行立法的抑制。尽管医疗保险 D 部分最近在针对患有 CVD 的个体的肥胖药物治疗覆盖范围上取得了重要进展，以减少不良心血管事件，但仍需要采取进一步行动。由《治疗和减少肥胖法案》主导的扩大医疗保险覆盖范围的努力，包括为更广泛的医疗保健临床医生筛查和治疗肥胖，以及为 FDA 批准的长期体重管理药物提供覆盖范围，目前已陷入停滞。过去十年的联邦层面。 71 这凸显了实现 AOM 全民覆盖方面持续存在的挑战，尽管在解决特定患者群体（例如患有心血管疾病且心血管不良结局风险最高的患者）方面取得了显着进展。一些专业协会和利益相关者目前正在努力游说卫生政策的改变，以使患有心血管疾病高风险的肥胖患者更容易获得和负担得起肥胖治疗。
卫生政策的改变对于向大量迫切需要这些服务的肥胖人群或有肥胖风险的人群提供更多可用的循证策略至关重要，例如行为疗法、药物疗法和减肥手术。 30 为肥胖治疗提供基于证据的覆盖范围的努力常常受到美国国会现行立法的抑制。尽管医疗保险 D 部分最近在针对患有 CVD 的个体的肥胖药物治疗覆盖范围上取得了重要进展，以减少不良心血管事件，但仍需要采取进一步行动。由《治疗和减少肥胖法案》主导的扩大医疗保险覆盖范围的努力，包括为更广泛的医疗保健临床医生筛查和治疗肥胖，以及为 FDA 批准的长期体重管理药物提供覆盖范围，目前已陷入停滞。过去十年的联邦层面。 71 这凸显了实现 AOM 全民覆盖方面持续存在的挑战，尽管在解决特定患者群体（例如患有心血管疾病且心血管不良结局风险最高的患者）方面取得了显着进展。一些专业协会和利益相关者目前正在努力游说卫生政策的改变，以使患有心血管疾病高风险的肥胖患者更容易获得和负担得起肥胖治疗。
Further evaluation is needed to support policy implementation and scalability. Evidence on implementation costs and cost-effectiveness will be integral to policy implementation efforts and systemic change. Because they can be more rapidly scaled with fewer human resources, digital interventions may prove particularly cost-effective, as shown in a recent analysis of adolescent obesity interventions.72 This is particularly true for resource-constrained health systems worldwide, where health departments will continue to focus on “best buys” to address an epidemic of noncommunicable diseases.73,74 Last, forming a shared resource library accessible to all clinicians engaged in obesity care might help clinicians connect patients to resources and offer connections that might be the best fit for each patient. Establishing such resources and evaluating their effectiveness is only one example of a future goal for implementing obesity science into clinical practice. Given the widespread increase in obesity prevalence worldwide, attention to global implementation strategies, each with its unique geographic challenges, will be important to address the implementation gap of obesity science into practice worldwide in the future.
需要进一步评估以支持政策实施和可扩展性。关于实施成本和成本效益的证据将成为政策实施工作和系统变革的组成部分。正如最近对青少年肥胖干预措施的分析所示，由于数字干预措施可以用更少的人力资源更快地扩大规模，因此可能证明特别具有成本效益。 72 对于全世界资源有限的卫生系统来说尤其如此，卫生部门将继续关注“最划算”的措施来应对非传染性疾病的流行。 73,74 最后，建立一个可供所有从事肥胖护理的临床医生访问的共享资源库可能会帮助临床医生将患者与资源联系起来，并提供最适合每位患者的连接。建立此类资源并评估其有效性只是将肥胖科学应用于临床实践的未来目标的一个例子。鉴于全球肥胖患病率普遍上升，关注全球实施战略（每项战略都有其独特的地理挑战）对于解决未来全球肥胖科学在实践中的实施差距非常重要。
需要进一步评估以支持政策实施和可扩展性。关于实施成本和成本效益的证据将成为政策实施工作和系统变革的组成部分。正如最近对青少年肥胖干预措施的分析所示，由于数字干预措施可以用更少的人力资源更快地扩大规模，因此可能证明特别具有成本效益。 72 对于全世界资源有限的卫生系统来说尤其如此，卫生部门将继续关注“最划算”的措施来应对非传染性疾病的流行。 73,74 最后，建立一个可供所有从事肥胖护理的临床医生访问的共享资源库可能会帮助临床医生将患者与资源联系起来，并提供最适合每位患者的连接。建立此类资源并评估其有效性只是将肥胖科学应用于临床实践的未来目标的一个例子。鉴于全球肥胖患病率普遍上升，关注全球实施战略（每项战略都有其独特的地理挑战）对于解决未来全球肥胖科学在实践中的实施差距非常重要。
CONCLUSIONS 结论
The science of obesity is a relatively young field, gaining traction in the 1970s when the prevalence of obesity among men and women of all ethnic groups, ages, and educational and socioeconomic levels started to increase.75 Despite decades of advancement in our scientific understanding of the pathophysiology underlying obesity and its potential treatment, a substantial gap between that knowledge and the successful implementation of obesity science to treat obesity within clinical practice remains. It is equally important to recognize that the lack of sufficient implementation of evidence-informed science into practice, albeit largely evidenced in adults, is magnified in the pediatric and adolescent populations, wherein identifying and managing overweight or obesity is vital to preventing the development of long-term obesity and its sequalae.76 Determining when and how to implement obesity-targeted therapies for maximum effectiveness remains challenging. Identification of barriers to implementing guideline-driven care and prompt discussions about solutions are needed to ensure that patients in greatest need have access to appropriate therapies. To reach and successfully affect these populations in need, clinicians may consider how the social determinants of health, including insurance type, health literacy, access to health-promoting resources, and social support, influence the likelihood of successful treatment. Addressing the barriers to the successful implementation of obesity science into practice requires investment in methodologies proven to narrow the know-do gap that includes education about the complex origins and clinical consequences of obesity, a framework for the delivery of obesity care, and health policy interventions that are essential to the success of applying obesity science to the individual patient. Health care systems can contribute to the success of implementation by coordinating care teams into fewer visits to reduce the burden on patients who would find themselves coming for multiple visits and scheduling with numerous specialists. Comprehensive care teams that include various health care professionals, in addition to social workers and social services personnel, are essential to addressing nonmedical barriers to successful implementation. Public policy should align with implementation efforts to further support the research and evaluation needed to drive policy implementation and scalability. Evidence for implementation costs and cost-effectiveness will be integral to prioritizing policy implementation efforts and systemic change. Funding to promote and sustain such research is vital to the success and reach of these endeavors. Last, there is an urgent need for better education and training in implementing science in obesity medicine. Building obesity care around these principles requires substantial financial input and engagement from multiple stakeholders. Still, the rewards of lower mortality, long-term health care cost savings, and improved quality of life warrant the investment.
肥胖科学是一个相对年轻的领域，在 20 世纪 70 年代受到关注，当时所有种族、年龄、教育和社会经济水平的男性和女性的肥胖患病率开始增加。 75 尽管我们对肥胖的病理生理学及其潜在治疗方法的科学理解取得了数十年的进步，但这些知识与在临床实践中成功实施肥胖科学来治疗肥胖之间仍然存在巨大差距。同样重要的是要认识到，尽管在成人中得到充分证明，但在实践中缺乏充分的证据科学落实，在儿童和青少年群体中更为严重，其中识别和管理超重或肥胖对于预防长期肥胖的发展至关重要。足月肥胖及其后遗症。 76 确定何时以及如何实施针对肥胖的治疗以获得最大效果仍然具有挑战性。需要确定实施指南驱动的护理的障碍并及时讨论解决方案，以确保最需要的患者能够获得适当的治疗。为了接触并成功影响这些有需要的人群，临床医生可以考虑健康的社会决定因素，包括保险类型、健康素养、获得健康促进资源和社会支持，如何影响成功治疗的可能性。 要解决肥胖科学成功实施到实践中的障碍，需要对已证明可以缩小知识差距的方法进行投资，其中包括有关肥胖的复杂起源和临床后果的教育、提供肥胖护理的框架以及卫生政策干预措施这对于将肥胖科学成功应用于个体患者至关重要。医疗保健系统可以通过协调护理团队减少就诊次数来帮助实施的成功，从而减轻患者的负担，因为患者会发现自己需要多次就诊并安排众多专家的时间。除社会工作者和社会服务人员外，还包括各种医疗保健专业人员的综合护理团队对于解决成功实施的非医疗障碍至关重要。公共政策应与实施工作保持一致，以进一步支持推动政策实施和可扩展性所需的研究和评估。实施成本和成本效益的证据对于确定政策实施工作和系统性变革的优先顺序至关重要。促进和维持此类研究的资金对于这些努力的成功和影响至关重要。最后，迫切需要更好的教育和培训来实施肥胖医学的科学。围绕这些原则建立肥胖护理需要大量资金投入和多个利益相关者的参与。尽管如此，较低的死亡率、长期的医疗保健成本节省和生活质量的提高等回报值得投资。
肥胖科学是一个相对年轻的领域，在 20 世纪 70 年代受到关注，当时所有种族、年龄、教育和社会经济水平的男性和女性的肥胖患病率开始增加。 75 尽管我们对肥胖的病理生理学及其潜在治疗方法的科学理解取得了数十年的进步，但这些知识与在临床实践中成功实施肥胖科学来治疗肥胖之间仍然存在巨大差距。同样重要的是要认识到，尽管在成人中得到充分证明，但在实践中缺乏充分的证据科学落实，在儿童和青少年群体中更为严重，其中识别和管理超重或肥胖对于预防长期肥胖的发展至关重要。足月肥胖及其后遗症。 76 确定何时以及如何实施针对肥胖的治疗以获得最大效果仍然具有挑战性。需要确定实施指南驱动的护理的障碍并及时讨论解决方案，以确保最需要的患者能够获得适当的治疗。为了接触并成功影响这些有需要的人群，临床医生可以考虑健康的社会决定因素，包括保险类型、健康素养、获得健康促进资源和社会支持，如何影响成功治疗的可能性。 要解决肥胖科学成功实施到实践中的障碍，需要对已证明可以缩小知识差距的方法进行投资，其中包括有关肥胖的复杂起源和临床后果的教育、提供肥胖护理的框架以及卫生政策干预措施这对于将肥胖科学成功应用于个体患者至关重要。医疗保健系统可以通过协调护理团队减少就诊次数来帮助实施的成功，从而减轻患者的负担，因为患者会发现自己需要多次就诊并安排众多专家的时间。除社会工作者和社会服务人员外，还包括各种医疗保健专业人员的综合护理团队对于解决成功实施的非医疗障碍至关重要。公共政策应与实施工作保持一致，以进一步支持推动政策实施和可扩展性所需的研究和评估。实施成本和成本效益的证据对于确定政策实施工作和系统性变革的优先顺序至关重要。促进和维持此类研究的资金对于这些努力的成功和影响至关重要。最后，迫切需要更好的教育和培训来实施肥胖医学的科学。围绕这些原则建立肥胖护理需要大量资金投入和多个利益相关者的参与。尽管如此，较低的死亡率、长期的医疗保健成本节省和生活质量的提高等回报值得投资。
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Published online: 20 May 2024
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| Writing group member | Employment | Research grant | Other research support | Speakers’ bureau/honoraria | Expert witness | Ownership interest | Consultant/advisory board | Other |
|---|---|---|---|---|---|---|---|---|
| Deepika Laddu | Arbor Research Collaborative for Health | NIH/NHLBI (K01 career development grant award: 1K01HL148503-01)† | None | None | None | None | None | None |
| Ian J. Neeland | UH Cleveland Medical Center–Case Western Reserve University | Industry (PI of PORTRAIT DM trial)*; NIH (PI of R01 research grant [ADIPOSA study])† | None | Boehringer Ingelheim/Lilly Alliance†; Bayer† | None | None | Boehringer Ingelheim†; Lilly*; AMRA Medical*; Novo Nordisk* | None |
| Bethany Barone Gibbs | University of West Virginia | None | None | None | None | None | None | None |
| Mercedes Carnethon | Northwestern University Feinberg School of Medicine | None | None | None | None | None | Centers for Disease Control and Prevention† | None |
| Misook L. Chung | University of Kentucky College of Nursing | NIH (co-I on R01NR019456)*; PCORI (co-I on AD-2019C3-17982)*; NIH (co-I on R01NR02478)* | None | None | None | None | None | None |
| Chris T. Longenecker | University of Washington | None | None | None | None | None | None | None |
| Morgana Mongraw-Chaffin | Wake Forest School of Medicine | None | None | None | None | None | None | None |
| Chiadi E. Ndumele | Johns Hopkins University | None | None | None | None | None | None | None |
| Goutham Rao | Case Western Reserve University and University Hospitals of Cleveland | None | None | None | None | None | None | None |
| Fatima C. Stanford | Massachusetts General Hospital/Harvard Medical School | None | None | None | None | None | Novo Nordisk†; Eli Lilly†; Pfizer*; Boehringer Ingelheim*; Calibrate*; Currax*; Sweetch†; Vida Health*; GoodRx†; Rhythm* | None |
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*
Modest.
†
Significant.
| Reviewer | Employment | Research grant | Other research support | Speakers’ bureau/honoraria | Expert witness | Ownership interest | Consultant/advisory board | Other |
|---|---|---|---|---|---|---|---|---|
| Jens Jordan | German Aerospace Center (DLR) (Germany) | None | None | None | None | None | None | None |
| Henry S. Kahn | Emory University School of Medicine | None | None | None | None | None | None | None |
| Peter T. Katzmarzyk | Pennington Biomedical Research Center | NIH (principal investigator on an active NIH grant studying the implementation of a multicomponent behavioral intervention within a digital medicine program)* | None | None | None | None | None | None |
| Arnold Ng | Princess Alexandra Hospital, The University of Queensland (Australia) | None | None | None | None | None | None | None |
| Al Rocchini | University of Michigan | None | None | None | None | None | None | None |
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $5000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $5000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*
Significant.
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