MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”
“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.
“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”
The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.
Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
More treatment choices
Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.
Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.
“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”
Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.
But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.
And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.
They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.
As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
Precision medicine will amp up treatments
Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.
“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.
Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”
At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.
“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
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