Sept. 13, 2016
Nearly 40 percent of adults in the United States are obese, with a body mass index (BMI) greater than 30, and more than 70 percent are overweight, according to recent data from the Centers for Disease Control and Prevention. It is clear that obesity is a chronic, relapsing, multifactorial disease for which no easy solutions exist; for the majority of people, the traditional approach of diet and exercise has not led to significant and sustained weight loss.
Many of these people may present with weight-related gastrointestinal (GI) disorders, including gastroesophageal reflux disease (GERD), Barrett's esophagus, cancer or nonalcoholic fatty liver disease (NAFLD), before they develop symptoms of type 2 diabetes or cardiovascular disease. Gastroenterologists therefore have the opportunity to play a major role in the multidisciplinary management of obesity and its complications and comorbidities.
Barham K. Abu Dayyeh, M.D., a gastroenterologist specializing in bariatric and metabolic endoscopy at Mayo Clinic's campus in Rochester, Minnesota, stresses that multidisciplinary obesity management is not simply a cliche.
"Similar to other chronic diseases, obesity can't be cured, but it can be managed. And that is best accomplished when physicians partner with other specialists who have expertise in the nutritional, behavioral and physical activity aspects of treatment," he says. "Using multiple interventions allows us to tailor treatments to patients with varying degrees of obesity severity. We have created a team that includes physicians with training in obesity medicine, gastroenterologists, bariatric surgeons, endoscopists, exercise physiologists, registered dietitians, and psychologists."
The weight management program
Patients in the weight management program at Mayo Clinic's Rochester campus are triaged by BMI; where they fall on the spectrum of care depends on the degree of obesity. Although the spectrum is fluid, the general trend is toward increasingly invasive therapies, all of which are grounded in an intensive program of nutritional, physical and behavioral changes.
All patients begin with and maintain lifestyle interventions, including regular physical activity (a minimum of 150 minutes a week) and a normo-caloric diet — 1,200 to 1,500 calories a day for women and 1,500 to 1,800 for men, adjusted for body weight and physical activity. The diet, which is tailored to meet each patient's needs and circumstances, includes a variety of healthy foods; avoids sugar, sodium, soda and alcohol; and is designed so that patients are likely to follow it.
For patients with 10 pounds or less to lose, lifestyle changes and therapies that explore eating triggers and patterns are usually sufficient for successful weight loss. These patients may still require frequent monitoring to ensure ongoing motivation and accountability, however.
Medications may be added to an intensive lifestyle program for patients unable to lose or maintain weight loss with diet and exercise alone. Medications can improve adherence to a low-calorie diet by decreasing appetite and increasing satiety and generally produce a 3 to 10 percent weight loss compared with 3 to 5 percent for lifestyle interventions. They are usually considered for patients with a BMI of 30 or 27 with comorbidities, such as type 2 diabetes, dyslipidemia or obstructive sleep apnea.
"Medications provide good benefit, but they're expensive and once stopped, patients tend to regain the weight," Dr. Abu Dayyeh says. "If you are treating obesity as a chronic disease, then medications need to be taken continuously."
The FDA has approved two intragastric balloons, a gastric aspiration device and an endoscopic suturing device for use in sleeve gastroplasty procedures for patients with a BMI of 30 to 40. Gastric balloons are implanted for six months whereas sleeve gastroplasty is an endoscopic volume reduction technique that is similar but not identical to sleeve gastrectomy.
"Most patients will need something more effective than medications but not as invasive as surgery, and endoscopy is well-positioned to assume that role," Dr. Abu Dayyeh says. "We know that altering various segments of the intestinal tract in gastric bypass can induce changes in the neurohormonal signals between the gut and brain and other organs, leading to improved satiety, increased metabolism and reduction, if not resolution, of diabetes. In endoscopy, we now have the tools to replicate some of those benefits."
This is the most efficacious and durable treatment for severe obesity (a BMI of 40 or 35 with one weight-related comorbidity). Long-term studies assessing outcomes of bariatric surgery have demonstrated improvement in all-cause survival compared with obese patients who have related comorbidities and did not undergo surgery.
In addition to weight loss, many obesity-related diseases including diabetes, hypertension, hypertriglyceridemia, obstructive sleep apnea, NAFLD, GERD, degenerative joint disease and cardiovascular disease may improve or resolve in patients who have undergone bariatric surgery.
Yet weight regain after bariatric surgery and other therapies is common; about one-third of patients regain significant weight after Roux-en-Y gastric bypass. In such cases, re-establishing patient goals and determining if new strategies are needed to aid weight loss are essential.
Andres J. Acosta Cardenas, M.D., Ph.D., a specialist in obesity medicine and pharmacology at Mayo Clinic's campus in Rochester, Minnesota, says about 40 patients enter the weight-loss program at Mayo's Rochester campus every month. Approximately 20 percent of them have an endoscopic procedure; the rest are prescribed medications, undergo bariatric surgery, or reach and maintain weight-loss goals with lifestyle changes only.
"Ours is a multidisciplinary program with many tools that can be combined with diet and exercise to achieve and sustain weight loss. The success of this comprehensive team approach is yielding better results than expected in clinical trials, and we will be presenting our data at Obesity Week this fall," he says.
Weight loss at Mayo Clinic's campus in Arizona
Mayo Clinic's campus in Arizona has recently launched the Ken and Linda Morris Weight & Wellness Solutions Program — a patient-centered, multidisciplinary approach to weight management with monitored outcomes. Amy E. Foxx-Orenstein, D.O., a gastroenterologist at Mayo Clinic's campus in Arizona and the program's medical director, says the program brings together experts in the medical, physiological, nutritional and psychological areas of wellness with the goal of supporting patients in making enduring lifestyle behavior changes.
"Patients are evaluated by an experienced, multidisciplinary care team to identify the unique health, behavioral and environmental factors that influence their wellness," she explains. "After the initial assessment, physical activity, nutrition management and behavioral treatment strategies are developed and tailored to the patient, with optional pharmacological and interventional treatments. Patients have follow-up appointments at intervals of three, six and 12 weeks."
Dr. Foxx-Orenstein says the Weight & Wellness Solutions Program is the first outcomes-based program of its kind. "The objective is to link patients to healthy weight strategies that can be effective across time," she says, noting that the longitudinal research design will afford Mayo Clinic the opportunity not only to gauge individual success in the program but also to identify the combinations of weight loss and weight management strategies that seem to have the most significant long-term results.
The program is currently enrolling employee patients, with nonemployee patient enrollment expected later this year.
Weight loss at Mayo Clinic’s campus in Florida
At Mayo Clinic's campus in Jacksonville, patients referred for weight-loss therapy undergo a comprehensive evaluation by all members of the bariatric team, including a medical bariatrician, dietician, psychologist and, in the case, of patients requiring endoscopy bariatric therapy, gastroenterologists who perform intragastric balloon procedures. All patients are carefully pre-screened and informed about out-of-pocket costs before meeting with team members.
"The planning process for incorporating endoscopic bariatric therapies into the bariatric program has taken over a year, with many discussions on how best to manage patients, explains Victoria Gomez, M.D., a gastroenterologist specializing in weight-loss therapy with the intragastric balloon at Mayo Clinic's campus in Florida."At the end of the day, we want to provide the safest and most effective weight-loss options while also taking into account patient preferences."