Clarifying the second and third levels of recourse, gradual reduction of energy, appropriate physical activity, place of follow-up care and rehabilitation, the new recommendations of the High Authority of Health in obesity aim to improve the management of severe cases or complex cases.
“ Nearly 8.5 million French people are obese, with an increase in the prevalence of this chronic disease by 13% since 2012, and up to 66% for severe forms. ‘, refers to HAS.
The association announces that these recommendations will be followed by publication in the fall of the Care Track for the management of overweight and obesity in adults, and early next year with an update to the recommendation for bariatric surgery.
How to assess the level of asylum
In order to improve the appropriate level of referral – a level 1 general practitioner, a level 2 specialist, obesity specialist centers and level 3 university hospitals – HAS clarified the classification by taking into account not only body mass index (BMI) and waist circumference, but also other factors such as medical comorbidities and functional impact Quality of life, mental, cognitive and/or behavioral disorders, etiology, eating behavior and weight trajectory. The table with 3 colors (green, orange, red by level) and 7 entries per column for phenotyping summarizes things.
Comorbidities were identified and screened for, particularly for type 2 diabetes (at least every three years or even every year in the case of prediabetes), sleep disturbances, metabolic lipopathy or renal damage. For osteoarthritis, HAS recalls the increased risk of postoperative complications after fitting a knee or hip prosthesis, especially infection, and poor functional prognosis. For cancer, screening is the same as in the general population. Dental examinations are recommended once a year.
For patients over 70 years of age, HAS insists that there is a need to be particularly vigilant about the risks of significant reductions in muscle mass, weakness and malnutrition that can lead to or exacerbate weight loss.
Moderate and increased nutritional support
Regarding nutritional support, From the perspective of permanent weight loss, limiting energy intake should be moderate and subjective “The change in eating behavior should be regulated by internal cues of hunger, satiety, or satiety, as well as the emotional component of eating. If unbalanced or highly restrictive diets (ketogenic diet, Atkins) are not recommended,” recommends HAS. The Mediterranean diet can be interesting, because of its health benefits ‘, shown.
The HAS also sets goals for physical activity,” To adapt and gradually achieve the capabilities of the patient ”, we read, whether it is about rest and leisure activities (games, matches, sports), travel (cycling, walking), work or household chores. So the World Health Assembly recommends exercising every week as desired: 2.5 to 3 hours of activity Moderate physical activity 1.15 to 2.30 hours of intense physical activity or an equivalent combination of moderate to intense activities A combination of muscle strengthening sessions, at least 2 days a week, periods of inactivity should be limited and regularly intermittent.
Place SSR and drugs
As for Follow-up Care and Rehabilitation (SSR) specializing in gastroenterology, endocrinology, diabetes and nutrition, the indications retained are severe, disabling or involving multiple comorbidities; acute care ward for patients who require adequate equipment; stay a long “break”; motor rehabilitation in case of loss of independence associated with obesity; Patients who failed treatment and were referred by various Level 3 representatives.
As for the prescription of the drug, it can be considered if nutritional management (loss of less than 5% of weight at 6 months) has failed well. ” A possible drug treatment decision falls under Appeal Levels 2 and 3 “We read. HAS specifies that it can be described from the start.” In patients in whom obesity impairs their independence or causes severe impairment of organ function, and for whom changes in lifestyle are limited “.
In the particular case of liraglutide (Saxenda), this GLP-1 analogue given by daily subcutaneous injection, patients should be re-evaluated after 12 weeks at a dose of 3 mg daily. If they do not lose at least 5% of their body weight, liraglutide should be discontinued. The ATU group was assigned in June 2021 to semaglutide (Wegovy), another analog of GLP-1 in weekly injections. Early access permission was granted at the beginning of the year (mid-January 2022) to setmelanotide (Imcivree) in a rare form of hereditary obesity (loss of biallelic function of pro-opiomelanocortin).
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