2024+AHA科学声明：肥胖症科学在临床实践中的应用(英文版）.pdf

CirculationCirculation.2024;149:e00e00.DOI:10.1161/CIR.0000000000001221 TBD TBD,2024e1Circulation is available at www.ahajournals.org/journal/circ 2024 American Heart Association,Inc.AHA SCIENTIFIC STATEMENTImplementation of Obesity Science Into Clinical Practice:A Scientific Statement From the American Heart AssociationDeepika Laddu,PhD,FAHA,Chair;Ian J.Neeland,MD,FAHA,Vice Chair;Mercedes Carnethon,PhD,FAHA;Fatima C.Stanford,MD,MPH,MPA,MBA,FAHA;Morgana Mongraw-Chaffin,PhD,FAHA;Bethany Barone Gibbs,PhD,FAHA;Chiadi E.Ndumele,MD,PhD,FAHA;Chris T.Longenecker,MD,FAHA;Misook L.Chung,PhD,RN,FAHA;Goutham Rao,MD,FAHA;on behalf of the American Heart Association Obesity Committee of the Council on Lifestyle and Cardiometabolic Health;Council on Epidemiology and Prevention;Council on Clinical Cardiology;Council on Hypertension;Council on the Kidney in Cardiovascular Disease;and Council on Cardiovascular and Stroke NursingABSTRACT: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.Key Words:AHA Scientific Statements evidence-based practice implementation science obesity risk factorsThe 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 inevita-bly slowed the decline in rates of cardiovascular disease(CVD)despite improvements in other population risk fac-tors.3 Moreover,forecasted trends in global obesity prev-alence underscore the significant impact that obesity will continue to have on CVD incidence,especially among people of underrepresented races and ethnicities.46 Over the past decade,significant progress made in obe-sity science has contributed to the discovery of knowl-edge 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 effi-cacy of lifestyle modification programs,new pharmaco-therapies,and robust outcomes data for bariatric surgery.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 CLINICAL STATEMENTS AND GUIDELINESTBD TBD,2024 Circulation.2024;149:e00e00.DOI:10.1161/CIR.0000000000001221e2Laddu et alImplementing Obesity Science Into Clinical Practiceof the science of obesity and the clinical implementa-tion of that science for ideal patient care.The lack of sufficient implementation exemplifies important gaps that exist between our biological and sociological under-standing of obesity,interventions that target obesity(eg,lifestyle,pharmacological,and surgical),and the appli-cation of evidence-based research into clinical practice for improved management of obesity.79 These gaps are sustained by structural,societal,and cultural barri-ers 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 appro-priate care to diverse,underrepresented populations with obesity.10,11 Bridging the gap in obesity implemen-tation 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 integra-tion of novel,empirically supported obesity science into routine clinical care(Figure 1).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 stakehold-ers to facilitate improved population-level management of obesity.This scientific statement also discusses addi-tional implications for policy,as well as future research Figure 1.The implementation pipeline for obesity science.Scientific advancement in knowledge and treatment of obesity begins at the bench,where ideas and hypotheses are tested with basic research tools such as preclinical biological and genetic models of obesity.In this phase,lack of appropriate models and heterogeneity of populations limit the success and application of basic research and prevent advancement to human research.In the human research phase,observational studies,randomized trials,and health services research inform and confirm how knowledge from basic research can be applied to the human clinical setting.In this phase,new diagnostic tools and treatment strategies for obesity are tested for efficacy and safety.Barriers to implementation in this phase include lack of proven effectiveness for therapies,heterogeneity of populations studied/lack of generalizability,and a breakdown in the biological-sociological link to obesity.In the next phase of implementation,health care policy and practice become essential to deliver care to the right patient at the right time,provide equitable access to new therapeutics,and implement validated strategies and guideline recommendations to broad populations.Implementation science is used in this phase to assess,measure,and modify clinical approaches to increase the uptake and effectiveness of validated interventions.This implementation is furthered by patient and community outcomes,demonstrating that patients are positively affected by the change in care,with potential for additional public health impact through dissemination of the research to reach those in need.In this phase,there are often gaps between policy and implementation into practice,highlighted by limitations in systems of care,reimbursement for care,timely and equitable access to resources,and lack of demonstration of cost-effectiveness.Overcoming and narrowing these gaps between knowledge/science and clinical implementation can lead to better health for all patients living with obesity and better health outcomes.CLINICAL STATEMENTS AND GUIDELINESCirculation.2024;149:e00e00.DOI:10.1161/CIR.0000000000001221 TBD TBD,2024e3Laddu et alImplementing Obesity Science Into Clinical Practiceto improve patient care models and optimize the delivery and sustainability of equitable obesity-related care.METHODS FOR SUCCESSFUL IMPLEMENTATION OF OBESITY SCIENCE INTO CLINICAL PRACTICESuccessful implementation of obesity science into clini-cal 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 therapeu-tic options for obesity based on scientific discoveries have become increasingly prevalent in the past several years.Education on the complex origins and clinical con-sequences 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 suc-cess of obesity science.To address the growing obesity epidemic and success-fully implement obesity science,health care profession-als must first be equipped with the proper knowledge and implementation skills.Yet,numerous studies have dem-onstrated that obesity education is lacking.For example,although the American Board of Medical Specialties cer-tification 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 train-ing,Mastrocola and colleagues14 determined that there is a paucity of obesity education programs for medical students,residents,and fellow physicians in training pro-grams throughout the world despite high obesity preva-lence.Still,they note that these programs often improve outcomes when administered.One increasingly successful method for improving health care professional education and subsequent imple-mentation is the certification program in obesity medi-cine 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,pharma-cotherapy,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 profession-als.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 preva-lence,leading to widened health care disparities.This is even more pronounced in the pediatric population,with fewer ABOM-certified physicians.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 imple-mentation of obesity treatments in clinical practice set-tings(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 clini-cal 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 effec-tiveness of health care professionaldelivered behavior counseling interventions on the maintenance of behav-ioral outcomes,promoting a healthy lifestyle and assist-ing patients in achieving health behavior goals presents a feasible strategy that health care professionals in clini-cal 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 link-ages is necessary to facilitate the implementation of obe-sity/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 obe-sity science into clinical practice.20For example,beginning in 2014,the National Academy of Medicine established the Roundtable on Obesity Solutions and has convened workshops and related activi-ties to address key issues related to obesity prevention,evaluation,and treatment.These have included assessing CLINICAL STATEMENTS AND GUIDELINESTBD TBD,2024 Circulation.2024;149:e00e00.DOI:10.1161/CIR.0000000000001221e4Laddu et alImplementing Obesity Science Into Clinical Practicetraining needs and defining competencies.21 The round-tables work is a valuable resource in filling important gaps in knowledge and skills among health care professionals.Health policy interventions that can enhance the provi-sion of obesity care are emerging globally.One example is Lifes Essential 8,the key measures for improving and main-taining cardiovascular health as defined by the American Heart Association.22 The goal of Lifes Essential 8 is to link science to implementation.Many of the Lifes Essential 8 health behaviors and habits affect body weight,and the Lifes Essential 8 advisory contains important methods for implementing cardi