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Tipping the Scales

The obesity crisis is one of the nation’s biggest health concerns. Pharmacists are on the front lines when it comes to helping patients shed and keep off extra pounds.

By Jane E. Rooney

As obesity becomes more prevalent among the U.S. population—more than a third of adults and one in five children are now considered to be obese—the effects on society are harder to ignore. Health conditions that can be tied to obesity include heart disease, stroke, type 2 diabetes, respiratory problems and certain cancers, according to the Centers for Disease Control and Prevention.

Children who are obese are more likely to become obese adults, and obesity and disease risk factors in adulthood are likely to be more severe. The estimated annual medical cost of obesity in this country is more than $200 billion. Medical costs for people who have obesity are approximately $1,429 higher than those of normal weight.

In 2013, the American Medical Association began recognizing obesity—defined as a body mass index (BMI) of 30 or above—as a disease. The Office of Disease Prevention and Health Promotion, part of the U.S. Department of Health and Human Services, establishes national health objectives with 10-year targets. One of its Healthy People 2010 goals was to reduce the proportion of adults who were obese to 15 percent. No state met that objective; in fact, the proportion of adults age 20 and over who were obese rose from 23 percent to 34 percent, according to data from 2012. To put the dangers of obesity in perspective, consider the numbers in relation to the opioid epidemic. The New York Times reported that overdoses from opioids were the leading cause of death last year for Americans under 50 years old, killing approximately 64,000 people. The CDC estimates 112,000 deaths per year that are associated with obesity.

The Obesity Society, which refers to obesity as one of the greatest public health challenges of our time, notes that it is a condition “that has often been stigmatized because of the perception that it is caused mostly by the modifiable behavioral factors of diet and physical inactivity. Nevertheless, a rich body of research demonstrates that obesity is a complex disease condition mediated through the interplay of multiple genetic, biologic, metabolic, behavioral, social, economic and cultural determinants.” The organization suggests that reducing the burden of this disease requires a team of multidisciplinary healthcare providers. Healthcare professionals play a key role in working with patients battling obesity, and pharmacists and pharmacy schools are uniquely positioned to prompt change through prevention and treatment efforts.

When talking to patients about other conditions, pharmacists are really in a position to listen to patients about the role that obesity plays in their overall health, and particularly the management of whatever condition they might be discussing, whether it be diabetes, hypertension, etc. …Some community pharmacies and pharmacy-based clinics across the country are engaging in advanced care services that incorporate weight loss for purposes of health and chronic disease management.

Dr. Jan Kavookjian

Communication Is Key

Dr. Jan Kavookjian, associate professor, Auburn University Harrison School of Pharmacy, said pharmacists can play a significant role in providing continuity of care for patients, particularly those that they see regularly for chronic conditions for monitoring in between physician visits. “When talking to patients about other conditions, pharmacists are really in a position to listen to patients about the role that obesity plays in their overall health, and particularly the management of whatever condition they might be discussing, whether it be diabetes, hypertension, etc. Weight loss is an important part of controlling those conditions,” she said. “Some community pharmacies and pharmacy-based clinics across the country are engaging in advanced care services that incorporate weight loss for purposes of health and chronic disease management.”

With recent changes to accreditation standards for pharmacy education, engaging in patient-centered communication skills is one area that is getting attention and is especially relevant in discussions about obesity. “Pharmacists working in teams with other healthcare providers is something we’re seeing really becoming an important focus area,” Kavookjian added. “The topic of health management and weight loss is well suited across health professions.” She represented AACP and pharmacy education on an interdisciplinary panel at a National Academy of Medicine/Institute of Medicine initiative in 2017, which brought together 20 leading health organizations in an attempt to come to consensus on a core set of competencies for preventing and managing obesity that are applicable across health professions. She said she is pleased with the report, “Provider Competencies for the Prevention and Management of Obesity,” which resulted after several brainstorming sessions that involved a diverse group of providers and support professions. The report highlighted the fact that fewer than 25 percent of physicians feel they received adequate training to be able to counsel patients in making lifestyle changes.

Measuring tape spiraling around vegetables and hand weights.

“The competencies that emerged for behavior change interventions and patient-centered communication really are applicable across health professions and are very relevant even for people who are not clinically trained,” she noted. “A big part of my specific role was bringing in the experiences I have with communication best practices that demonstrate an evidence base in applications with patients. It’s part of the language used and knowing how to have these conversations with patients in a way that is not perpetuating the stigma of being overweight, and in a way that is being supportive and encouraging. Providers need to help the patient find his or her own internal motivation to make changes.”

Dr. Jacqueise Unonu, assistant professor at the Howard University College of Pharmacy, agrees that getting patients to open up and be honest about their struggles with weight is crucial. “Oftentimes patients do not receive education in neither the appropriate language with regards to reading level nor the appropriate delivery method. Due to time constraints they are handed a booklet of information addressing their condition, especially in the environment of the emergency department. That information may touch on obesity as it relates to the main conditions being attended to and merely provided instructions on what to do.”

Motivational interviewing is an important part of what pharmacists do, Unonu added. “We want patients to know that it’s a team effort and they can do it,” she said. “We never want to seem like a parent telling them what to do. We want them to feel like part of a team and let them make decisions about what they’re going to do.” Pharmacists are in a great position to offer education and make sure that patients understand information that they have received” she noted. “We utilize guidelines and best practices from organizations such as the American Heart Association and American Diabetes Association to see what the recommendation needs to be for the patient. Pharmacists can assess the risk factor and look at what percent weight loss the patient needs to have, and then let them know that even the smallest amount can increase life expectancy. From there we go to medication and talking about any kinds of changes the patient needs to make in terms of behavior.”

An Interprofessional Look at “Inflammaging”

By Doug Bennett

Complications from obesity can compound with age. But a group of University of Florida Health researchers has found a new role for protein in significantly reducing the chronic, low-grade inflammation that may contribute to aging and aging-related diseases.

Using human cell and fruit fly models, the researchers showed the liver-produced protein, known as human alpha-1 antitrypsin, has anti-inflammatory and cell-protecting properties. That makes it particularly effective at stopping so-called “inflammaging,” chronic inflammation that has been implicated in a host of aging-related disorders such as cardiovascular disease, Type 2 diabetes and osteoporosis. The findings by 13 scientists in the UF department of molecular genetics, the College of Pharmacy, the UF Genetics Institute and the UF Health Cancer Center were published in the journal, Aging Cell.

While much research remains to be done, understanding how the protein works to suppress the genes that promote inflammation is a crucial step, said Dr. Sihong Song, an associate professor of pharmaceutics in the UF College of Pharmacy, part of UF Health.

“Although this protein may contribute to extending the lifespan of humans, we’re more interested in improving quality of life for the elderly,” Song said.

Lei Zhou and Sihong Song at the University of Florida. — Lei Zhou, Ph.D., (left) is an associate professor in the UF College of Medicine’s department of molecular genetics and microbiology. Sihong Song, Ph.D., is an associate professor of pharmaceutics in the UF College of Pharmacy.

A Tough Target

Inflammation is an obvious but challenging target for preventing aging-related diseases, Song said. In both fruit flies and human cells, the protein was shown to significantly inhibit inflammation-related genes and molecular pathways, the researchers found.

The protein is appealing as a potential treatment because it is naturally produced and can be harvested from blood plasma, Song said. It already has federal approval to treat a genetic disorder known as alpha-1 antitrypsin deficiency, which can cause lung disorders such as emphysema and chronic obstructive pulmonary disease.

Fruit flies that had the human protein-producing gene inserted lived significantly longer and survived in greater numbers than those that were untreated, the researchers found. More than 50 percent of the transgenic flies that were given the medication RU486 to induce expression of the human protein-producing gene survived at least 100 days. The fly’s normal lifespan is 40 to 60 days, Song noted.

During testing on human connective tissue cells, the researchers studied the protein’s effectiveness at inhibiting gene activity in cells that are no longer capable of dividing — essentially a laboratory model of what happens during inflammaging. They found that the activity of 42 genes was significantly affected by the introduction of the protein when compared with a control group.

While the researchers say they don’t fully understand the molecular mechanisms of anti-inflammaging, some of the data suggest the human protein has an effect on the NF-kappaB protein, which controls certain DNA activity.

One limitation for any potential human therapy involves a supply issue: For the protein to be effective against inflammaging, the proper dose has to be delivered at the right time and place. However, the supply of protein is potentially limited because it is harvested from blood plasma. To address that, Song said he sees potential in a gene therapy technique known as AAV, which uses a small, harmless virus to deliver new genes to a patient’s cells. That targeted technique would require less of the protein and provide longer-lasting treatment, he said.

Considering its status as a Food and Drug Administration-approved therapy and its newly discovered anti-inflammaging properties, researchers said the protein is a promising candidate to fight aging and aging-related diseases.

Adapted and edited with permission from UF Health.

Doug Bennett is a
science writer and editor with UF Health.

An Ounce of Prevention

Auburn launched a new integrated curriculum last fall, which includes obesity as a specific condition to be addressed. “There is significant coverage of how to communicate with patients who are at risk or who are obese and talking about treatment and prevention,” Kavookjian explained. “Auburn has a pharmaceutical care clinic that engages in services including healthy lifestyles—things that are important to maintaining a healthy weight,” she continued. “The program is run in the pharmacy-based clinic at the school and addresses goal setting and monitoring of lifestyle factors that impact weight and obesity. Fourth-year students rotate through this setting and have an opportunity to get engaged with employee patients and also people in the community. This is about rounding out opportunities to provide direct patient care experiences that will spill over in this realm of working with people whose health is affected by obesity.”

At Howard University College of Pharmacy, discussions about obesity are part of the curriculum and the institution offers a Healthy Rewards program that provides a health coach and incentives as employees meet healthy diet and exercise goals. “Institutions are being proactive in making sure faculty and staff are knowledgeable about obesity and focusing on preventive measures,” said Unonu, who has a background in exercise and nutrition. She echoed Kavookjian’s sentiment that pharmacists are on the front lines for offering prevention and treatment assistance to patients struggling with obesity.

“The initial step is the non-pharmacological aspect of therapy,” she said. “Our role is not only to be knowledgeable about medication interventions but what to initially recommend to providers and educate patients on regarding lifestyle modifications including diet and exercise before we move to medication. The educational part should come first with the patient weighing in on what they feel they can gradually do. That being said, it should be recognized that medication is an option as obesity is not only a risk factor for other conditions but is a disease in and of itself. Once that concept is accepted patients will feel more comfortable seeking help and healthcare professionals will be on the same page so that the disease can be addressed properly.”

Unonu further explained that pharmacists are an integral part in patients’ access to medication, particularly those for obesity. Pharmacists know how to navigate around the red tape to help providers obtain medications that seem inaccessible due to insurance processes or out of pocket costs. Unonu recently represented AACP this past November at The Obesity Society (TOS) Roundtable titled “Obesity is a Disease—Progress and Gaps” where multidisciplinary stakeholders worked together with the goal of updating the official TOS position statement. Unonu stated that she was able to contribute the perspective of a pharmacist and how pharmacists can assist in closing the gap and addressing treatment. “Again, helping patients is a joint effort. The patient is at the center and is a part of the decision-making process. The ultimate goal is to improve their health and improve quality of life at the end of the day. As pharmacists that’s what we’re here to do.

Kavookjian said that early intervention at the community level is a good place for pharmacists to start. Focusing efforts at the family level on youth and trying to break unhealthy patterns is a promising strategy being addressed by outcomes researchers across professions. Within academia, Unonu emphasized that schools need to be integrating discussions about obesity into the curriculum. “We see it in different disease states as a risk factor, but we really need to be looking at it as a disease on its own,” she said. “We try to have a comprehensive approach to the patient and the weight loss journey.”

Competencies for Obesity Prevention and Management

These are the top-line competencies designed for health professionals that emerged from the NAM/IOM summit. They are intended to set the bar for what schools and training programs should be teaching future healthcare providers.

Demonstrate a working knowledge of obesity as a disease.
Demonstrate a working knowledge of the epidemiology of the obesity epidemic.
Describe the disparate burden of obesity and approaches to mitigate it.
Describe the benefits of working interprofessionally to address obesity to achieve results that cannot be achieved by a single health professional.
Apply the skills necessary for effective interprofessional collaboration and integration of clinical and community care for obesity.
Use patient-centered communication when working with individuals with obesity and others.
Employ strategies to minimize bias towards and discrimination against people with obesity, including weight, body habitus, and the causes of obesity.
Implement a range of accommodations and safety measures specific to people with obesity.
Utilize evidence-based care/services for persons with obesity or at risk for obesity.
Provide evidence-based care/services for persons with obesity co-morbidities.

Removing the Stigma

Kavookjian said that getting providers adequately trained in communicating with patients can have a positive impact in building a relationship as well as the trust that is required to help patients feel supported. “They’ve got to feel that support to find their own internal motivation,” she emphasized. “To be really impactful, behavior changes need to be sustained through continued positive reinforcement for what patients are thinking and doing for healthy behaviors. We’re going to see this emphasized more and more as we have these future healthcare providers trained in the evidence-based motivational interviewing skills set and way of being. When we’re talking about treatment decisions, we’re really engaging patients in goal setting and change decisions. Pharmacists will be better equipped with these tools in hand to have these conversations specifically about these difficult topics related to being obese. Being able to have a caring, nonjudgemental conversation with someone is very important.”

Our society has stigmatized persons with obesity in negative ways, she continued, to the point that there’s a weight bias and patients won’t even reach out to their provider to talk about weight loss. Issues such as access to care, literacy, economic barriers, transportation and other inequalities also come into play that make the burden of obesity harder on some populations. Providers need to think about obese patients in the same way they would think about someone with depression or cancer.

“Pharmacists who are willing to educate themselves and become aware of their own biases is one of the first steps in having that empathic encounter with someone who is overweight,” Kavookjian explained. “We need to think about even the language we use. The word obese is negative. We need to be direct and assertive, but there’s a way to do that in a caring way. Using ‘people-first’ language (people with obesity vs. obese people, or talking about healthier weight vs. morbid obesity). Such a sensitive topic is often brought up in a shaming or blaming way. The first step is being aware and then educating oneself about constructive strategies and skills.”

Said Unonu: “The next step is really addressing obesity as a disease and recognizing it as such. Many don’t think about obesity as being something you have to address. There’s this idea that the person got there because they aren’t exercising or they are just watching TV and eating. The fact is that there are so many things compounding it—depression, genetics….Instead of an ‘I told you’ attitude, clinicians need to help address obesity just as much as the other issues.”

Jane E. Rooney is a freelance writer
based in Oakton, Virginia.

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