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‘Clinical paradox’? Bariatric surgery may protect from GI cancers
In fact, an analysis of close to 1 million French adults suggests that the weight-loss surgery may offer some protection against these cancers.
The study results present a “clinical paradox,” according to authors of a commentary published this week along with the study in JAMA Surgery. A procedure known to increase the risk of gastroesophageal reflux disease (GERD), and potentially adenocarcinoma of the distal esophagus and gastroesophageal junction, may help shield patients from esophagogastric cancer.
The study marks “an important step toward improving the understanding of potential lifetime risks of bariatric surgery and overall major health benefits of surgically induced weight loss,” commentary authors Piotr Gorecki, MD, and Michael Zenilman, MD, with Weill Cornell Medicine in New York, write.
Recent data indicate that excess body weight is associated with nearly 8% of cancer cases and 6.5% of cancer deaths. Studies also show that bariatric surgery can reduce the risk of some cancers, but whether this extends to esophageal and gastric cancer remains unclear.
To investigate, the researchers used French national data to compare the incidence of esophageal and gastric cancer in 303,709 mostly female patients with obesity who underwent bariatric surgery and a matched group of 605,140 patients with obesity who did not undergo the surgery.
The mean age of the cohort was about 40 years. The mean period of follow-up was 6 years for the surgery group and 5.6 years for the control arm. A total of 337 patients underwent esophagogastric cancer – 83 in the surgical group and 254 in the control group. Gastric cancer was about two times more common than esophageal cancer (225 vs. 112 patients).
The incidence rate of esophagogastric cancer was higher in the control group than in the surgery group – 6.9 vs. 4.9 cases per 100,000 population per year, for an incidence rate ratio of 1.42 (P = .005).
Bariatric surgery was associated with a significant 24% lower risk of esophagogastric cancer (hazard ratio, 0.76; P = .03) and a 40% lower risk of overall in-hospital mortality, defined as “any death occurring during a hospital stay regardless of the cause” (HR, 0.60; P < .001).
The authors also found no significant difference in cancer outcomes and type of bariatric procedure, which included sleeve gastrectomy, gastric bypass, and adjustable gastric banding.
They note that key study limitations include the retrospective design, limited follow-up period, and lack of histologic data on the specific cancers. In addition, the study population was relatively young, whereas esophageal cancer is more common in older people.
But overall, the findings suggest that bariatric surgery can be performed to treat severe obesity without increasing the risk of esophageal and gastric cancer, the authors conclude.
“It seems that the balance between protective factors (weight loss, metabolic effects, and eradication of H. pylori infection) and risk factors (GERD and bile reflux) for cancer after bariatric surgery is in favor of protective factors,” the authors, led by Andrea Lazzati, MD, PhD, of Centre Hospitalier Intercommunal de Créteil, France, explain.
Although the potential protective mechanisms remain unclear, in their commentary, Dr. Gorecki and Dr. Zenilman suggest that a reduction in chronic inflammation and immunosuppression following bariatric surgery could help explain the results.
Although the study provides “reassurance of the protective clinical benefits of weight loss surgery,” more large-scale studies are needed to “better identify, elucidate, and address the pathophysiological processes of bariatric procedure,” Dr. Gorecki and Dr. Zenilman conclude.
No specific funding for the study was reported. Dr. Lazzati has received personal fees from Johnson & Johnson, Medtronic, and Gore. Dr. Zenilman has received personal fees from Academic Medical Professionals Insurance and Mohamed & Obaid Almulla Group.
A version of this article first appeared on Medscape.com.
In fact, an analysis of close to 1 million French adults suggests that the weight-loss surgery may offer some protection against these cancers.
The study results present a “clinical paradox,” according to authors of a commentary published this week along with the study in JAMA Surgery. A procedure known to increase the risk of gastroesophageal reflux disease (GERD), and potentially adenocarcinoma of the distal esophagus and gastroesophageal junction, may help shield patients from esophagogastric cancer.
The study marks “an important step toward improving the understanding of potential lifetime risks of bariatric surgery and overall major health benefits of surgically induced weight loss,” commentary authors Piotr Gorecki, MD, and Michael Zenilman, MD, with Weill Cornell Medicine in New York, write.
Recent data indicate that excess body weight is associated with nearly 8% of cancer cases and 6.5% of cancer deaths. Studies also show that bariatric surgery can reduce the risk of some cancers, but whether this extends to esophageal and gastric cancer remains unclear.
To investigate, the researchers used French national data to compare the incidence of esophageal and gastric cancer in 303,709 mostly female patients with obesity who underwent bariatric surgery and a matched group of 605,140 patients with obesity who did not undergo the surgery.
The mean age of the cohort was about 40 years. The mean period of follow-up was 6 years for the surgery group and 5.6 years for the control arm. A total of 337 patients underwent esophagogastric cancer – 83 in the surgical group and 254 in the control group. Gastric cancer was about two times more common than esophageal cancer (225 vs. 112 patients).
The incidence rate of esophagogastric cancer was higher in the control group than in the surgery group – 6.9 vs. 4.9 cases per 100,000 population per year, for an incidence rate ratio of 1.42 (P = .005).
Bariatric surgery was associated with a significant 24% lower risk of esophagogastric cancer (hazard ratio, 0.76; P = .03) and a 40% lower risk of overall in-hospital mortality, defined as “any death occurring during a hospital stay regardless of the cause” (HR, 0.60; P < .001).
The authors also found no significant difference in cancer outcomes and type of bariatric procedure, which included sleeve gastrectomy, gastric bypass, and adjustable gastric banding.
They note that key study limitations include the retrospective design, limited follow-up period, and lack of histologic data on the specific cancers. In addition, the study population was relatively young, whereas esophageal cancer is more common in older people.
But overall, the findings suggest that bariatric surgery can be performed to treat severe obesity without increasing the risk of esophageal and gastric cancer, the authors conclude.
“It seems that the balance between protective factors (weight loss, metabolic effects, and eradication of H. pylori infection) and risk factors (GERD and bile reflux) for cancer after bariatric surgery is in favor of protective factors,” the authors, led by Andrea Lazzati, MD, PhD, of Centre Hospitalier Intercommunal de Créteil, France, explain.
Although the potential protective mechanisms remain unclear, in their commentary, Dr. Gorecki and Dr. Zenilman suggest that a reduction in chronic inflammation and immunosuppression following bariatric surgery could help explain the results.
Although the study provides “reassurance of the protective clinical benefits of weight loss surgery,” more large-scale studies are needed to “better identify, elucidate, and address the pathophysiological processes of bariatric procedure,” Dr. Gorecki and Dr. Zenilman conclude.
No specific funding for the study was reported. Dr. Lazzati has received personal fees from Johnson & Johnson, Medtronic, and Gore. Dr. Zenilman has received personal fees from Academic Medical Professionals Insurance and Mohamed & Obaid Almulla Group.
A version of this article first appeared on Medscape.com.
In fact, an analysis of close to 1 million French adults suggests that the weight-loss surgery may offer some protection against these cancers.
The study results present a “clinical paradox,” according to authors of a commentary published this week along with the study in JAMA Surgery. A procedure known to increase the risk of gastroesophageal reflux disease (GERD), and potentially adenocarcinoma of the distal esophagus and gastroesophageal junction, may help shield patients from esophagogastric cancer.
The study marks “an important step toward improving the understanding of potential lifetime risks of bariatric surgery and overall major health benefits of surgically induced weight loss,” commentary authors Piotr Gorecki, MD, and Michael Zenilman, MD, with Weill Cornell Medicine in New York, write.
Recent data indicate that excess body weight is associated with nearly 8% of cancer cases and 6.5% of cancer deaths. Studies also show that bariatric surgery can reduce the risk of some cancers, but whether this extends to esophageal and gastric cancer remains unclear.
To investigate, the researchers used French national data to compare the incidence of esophageal and gastric cancer in 303,709 mostly female patients with obesity who underwent bariatric surgery and a matched group of 605,140 patients with obesity who did not undergo the surgery.
The mean age of the cohort was about 40 years. The mean period of follow-up was 6 years for the surgery group and 5.6 years for the control arm. A total of 337 patients underwent esophagogastric cancer – 83 in the surgical group and 254 in the control group. Gastric cancer was about two times more common than esophageal cancer (225 vs. 112 patients).
The incidence rate of esophagogastric cancer was higher in the control group than in the surgery group – 6.9 vs. 4.9 cases per 100,000 population per year, for an incidence rate ratio of 1.42 (P = .005).
Bariatric surgery was associated with a significant 24% lower risk of esophagogastric cancer (hazard ratio, 0.76; P = .03) and a 40% lower risk of overall in-hospital mortality, defined as “any death occurring during a hospital stay regardless of the cause” (HR, 0.60; P < .001).
The authors also found no significant difference in cancer outcomes and type of bariatric procedure, which included sleeve gastrectomy, gastric bypass, and adjustable gastric banding.
They note that key study limitations include the retrospective design, limited follow-up period, and lack of histologic data on the specific cancers. In addition, the study population was relatively young, whereas esophageal cancer is more common in older people.
But overall, the findings suggest that bariatric surgery can be performed to treat severe obesity without increasing the risk of esophageal and gastric cancer, the authors conclude.
“It seems that the balance between protective factors (weight loss, metabolic effects, and eradication of H. pylori infection) and risk factors (GERD and bile reflux) for cancer after bariatric surgery is in favor of protective factors,” the authors, led by Andrea Lazzati, MD, PhD, of Centre Hospitalier Intercommunal de Créteil, France, explain.
Although the potential protective mechanisms remain unclear, in their commentary, Dr. Gorecki and Dr. Zenilman suggest that a reduction in chronic inflammation and immunosuppression following bariatric surgery could help explain the results.
Although the study provides “reassurance of the protective clinical benefits of weight loss surgery,” more large-scale studies are needed to “better identify, elucidate, and address the pathophysiological processes of bariatric procedure,” Dr. Gorecki and Dr. Zenilman conclude.
No specific funding for the study was reported. Dr. Lazzati has received personal fees from Johnson & Johnson, Medtronic, and Gore. Dr. Zenilman has received personal fees from Academic Medical Professionals Insurance and Mohamed & Obaid Almulla Group.
A version of this article first appeared on Medscape.com.
FROM JAMA SURGERY
Obesity impacts peripheral airway reactivity, asthma
Peripheral airway response to methacholine was similar among obese adults with and without asthma, although forced expiratory volume was lower for those with asthma, based on data from 53 individuals.
Obesity remains a risk factor for asthma, and obese individuals with asthma tend to have worse control and more severe disease, compared with nonobese asthma patients, wrote Anne E. Dixon, BM, BCh, of the University of Vermont, Burlington, and colleagues.
Previous studies have shown that airway reactivity can occur in obese individuals without airway inflammation, but studies characterizing obese asthma based on lung function are lacking, they said. “Combining spirometry and oscillometry might reveal abnormalities in lung mechanics particularly pertinent to people with obesity and asthma,” the researchers noted.
In a cross-sectional study published in the journal CHEST, the researchers reviewed data from 31 obese adults with asthma and 22 obese adults without asthma. The participants were aged 18 years and older, with forced expiratory volume (FEV1) of at least 60% of predicted. All had class III obesity, with an average BMI of 47.2 kg/m2 for those with asthma and 46.7 kg/m2 for nonasthma controls. Demographic characteristics were similar between the groups.
Airway reactivity was defined as a 20% decrease in FEV1 and/or a 50% change in resistance or reactance at 5 Hz (R5 and X5), at a concentration of 16 mg/mL or less of methacholine. Patients were assessed using spirometry and oscillometry.
For those with asthma, the resistance at 5 Hz, measured by oscillometry, increased by 52% in response to the PC20 methacholine challenge, with an area under the reactance curve (AX) of 361%. For controls without asthma, the resistance at 5 Hz increased by 45%, with an AX of 268% in response to 16 mg/mL of methacholine.
This finding suggests that obesity predisposes individuals to peripheral airway reactivity regardless of asthma status, the researchers wrote in their discussion.
The researchers also identified two distinct groups of asthma patients categorized by respiratory system impedance based on more concordant vs. discordant bronchoconstriction in the central and peripheral airways. The baseline AX for these two groups was 11.8 and 46.7, respectively, with interquartile ranges of 9.9-23.4 and 23.2-53.7, respectively.
The discordant group included only women, and these patients reported significantly more gastroesophageal reflux, increased chest tightness, and more wheezing and asthma exacerbations than the concordant group, which may be related to air trapping, shown on previous studies of obese individuals with asthma, the researchers wrote.
The findings were limited by several factors, including the measurement of airway impedance only at the peak methacholine dose and the measurement of oscillometry after spirometry, the researchers noted. Other limitations included the relatively small study population at a single center, and the focus on obese individuals only.
More research is needed in larger and more diverse patient populations, but the results support the characterization of a subgroup of obese asthma patients with significant peripheral airway dysfunction, the researchers wrote.
“Oscillometry testing can reveal a physiologic phenotype of asthma in obesity that may be related to worse symptoms and more severe disease, and also reveal subclinical abnormalities in people with obesity, but without clinically diagnosed lung disease,” they concluded.
The study was supported in part by the National Institutes of Health. The researchers declared no financial conflicts.
A version of this article first appeared on Medscape.com.
Peripheral airway response to methacholine was similar among obese adults with and without asthma, although forced expiratory volume was lower for those with asthma, based on data from 53 individuals.
Obesity remains a risk factor for asthma, and obese individuals with asthma tend to have worse control and more severe disease, compared with nonobese asthma patients, wrote Anne E. Dixon, BM, BCh, of the University of Vermont, Burlington, and colleagues.
Previous studies have shown that airway reactivity can occur in obese individuals without airway inflammation, but studies characterizing obese asthma based on lung function are lacking, they said. “Combining spirometry and oscillometry might reveal abnormalities in lung mechanics particularly pertinent to people with obesity and asthma,” the researchers noted.
In a cross-sectional study published in the journal CHEST, the researchers reviewed data from 31 obese adults with asthma and 22 obese adults without asthma. The participants were aged 18 years and older, with forced expiratory volume (FEV1) of at least 60% of predicted. All had class III obesity, with an average BMI of 47.2 kg/m2 for those with asthma and 46.7 kg/m2 for nonasthma controls. Demographic characteristics were similar between the groups.
Airway reactivity was defined as a 20% decrease in FEV1 and/or a 50% change in resistance or reactance at 5 Hz (R5 and X5), at a concentration of 16 mg/mL or less of methacholine. Patients were assessed using spirometry and oscillometry.
For those with asthma, the resistance at 5 Hz, measured by oscillometry, increased by 52% in response to the PC20 methacholine challenge, with an area under the reactance curve (AX) of 361%. For controls without asthma, the resistance at 5 Hz increased by 45%, with an AX of 268% in response to 16 mg/mL of methacholine.
This finding suggests that obesity predisposes individuals to peripheral airway reactivity regardless of asthma status, the researchers wrote in their discussion.
The researchers also identified two distinct groups of asthma patients categorized by respiratory system impedance based on more concordant vs. discordant bronchoconstriction in the central and peripheral airways. The baseline AX for these two groups was 11.8 and 46.7, respectively, with interquartile ranges of 9.9-23.4 and 23.2-53.7, respectively.
The discordant group included only women, and these patients reported significantly more gastroesophageal reflux, increased chest tightness, and more wheezing and asthma exacerbations than the concordant group, which may be related to air trapping, shown on previous studies of obese individuals with asthma, the researchers wrote.
The findings were limited by several factors, including the measurement of airway impedance only at the peak methacholine dose and the measurement of oscillometry after spirometry, the researchers noted. Other limitations included the relatively small study population at a single center, and the focus on obese individuals only.
More research is needed in larger and more diverse patient populations, but the results support the characterization of a subgroup of obese asthma patients with significant peripheral airway dysfunction, the researchers wrote.
“Oscillometry testing can reveal a physiologic phenotype of asthma in obesity that may be related to worse symptoms and more severe disease, and also reveal subclinical abnormalities in people with obesity, but without clinically diagnosed lung disease,” they concluded.
The study was supported in part by the National Institutes of Health. The researchers declared no financial conflicts.
A version of this article first appeared on Medscape.com.
Peripheral airway response to methacholine was similar among obese adults with and without asthma, although forced expiratory volume was lower for those with asthma, based on data from 53 individuals.
Obesity remains a risk factor for asthma, and obese individuals with asthma tend to have worse control and more severe disease, compared with nonobese asthma patients, wrote Anne E. Dixon, BM, BCh, of the University of Vermont, Burlington, and colleagues.
Previous studies have shown that airway reactivity can occur in obese individuals without airway inflammation, but studies characterizing obese asthma based on lung function are lacking, they said. “Combining spirometry and oscillometry might reveal abnormalities in lung mechanics particularly pertinent to people with obesity and asthma,” the researchers noted.
In a cross-sectional study published in the journal CHEST, the researchers reviewed data from 31 obese adults with asthma and 22 obese adults without asthma. The participants were aged 18 years and older, with forced expiratory volume (FEV1) of at least 60% of predicted. All had class III obesity, with an average BMI of 47.2 kg/m2 for those with asthma and 46.7 kg/m2 for nonasthma controls. Demographic characteristics were similar between the groups.
Airway reactivity was defined as a 20% decrease in FEV1 and/or a 50% change in resistance or reactance at 5 Hz (R5 and X5), at a concentration of 16 mg/mL or less of methacholine. Patients were assessed using spirometry and oscillometry.
For those with asthma, the resistance at 5 Hz, measured by oscillometry, increased by 52% in response to the PC20 methacholine challenge, with an area under the reactance curve (AX) of 361%. For controls without asthma, the resistance at 5 Hz increased by 45%, with an AX of 268% in response to 16 mg/mL of methacholine.
This finding suggests that obesity predisposes individuals to peripheral airway reactivity regardless of asthma status, the researchers wrote in their discussion.
The researchers also identified two distinct groups of asthma patients categorized by respiratory system impedance based on more concordant vs. discordant bronchoconstriction in the central and peripheral airways. The baseline AX for these two groups was 11.8 and 46.7, respectively, with interquartile ranges of 9.9-23.4 and 23.2-53.7, respectively.
The discordant group included only women, and these patients reported significantly more gastroesophageal reflux, increased chest tightness, and more wheezing and asthma exacerbations than the concordant group, which may be related to air trapping, shown on previous studies of obese individuals with asthma, the researchers wrote.
The findings were limited by several factors, including the measurement of airway impedance only at the peak methacholine dose and the measurement of oscillometry after spirometry, the researchers noted. Other limitations included the relatively small study population at a single center, and the focus on obese individuals only.
More research is needed in larger and more diverse patient populations, but the results support the characterization of a subgroup of obese asthma patients with significant peripheral airway dysfunction, the researchers wrote.
“Oscillometry testing can reveal a physiologic phenotype of asthma in obesity that may be related to worse symptoms and more severe disease, and also reveal subclinical abnormalities in people with obesity, but without clinically diagnosed lung disease,” they concluded.
The study was supported in part by the National Institutes of Health. The researchers declared no financial conflicts.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL CHEST
New guidelines on peds obesity call for aggressive treatment
and hope the problem solves itself. That’s the upshot of new guidelines from the American Academy of Pediatrics.
The authors of the guidelines also encourage primary care doctors to collaborate with other medical professionals to treat the comorbidities often linked to obesity, rather than take on the entire challenge themselves.
“It’s impossible to treat obesity within the four walls of the clinic. That’s one thing I have learned,” Ihuoma Eneli, MD, associate director of the AAP Institute for Healthy Childhood Weight, told this news organization. For example, a primary care doctor could partner with a gastroenterologist when treating a child who has nonalcoholic fatty liver disease, added Dr. Eneli, a professor of pediatrics at the Ohio State University, Columbus, who helped write the recommendations.
The new document updates 2007 recommendations from AAP about treating children and adolescents who are overweight or obese. The earlier statement focused on behavioral modification and healthy eating behaviors and paid less attention to weight-lowering medications or bariatric surgery for young people. That document did not offer specific advice to health care providers about how to address childhood overweight or obesity.
The 2023 guidelines recommend that pediatricians offer anyone aged 12 years and older with obesity – defined as a body mass index (BMI) at the 95th percentile or higher – the option of receiving weight-loss medications in addition to ongoing support for lifestyle modifications, such as exercising more and eating healthier foods.
The same approach holds for bariatric surgery once children reach age 13, and AAP stressed that no physician should ever stigmatize children or imply that they are to blame for their weight.
AAP did not receive any industry funding to develop the guidelines.
As children reach the threshold BMI levels, physicians should conduct complete physicals and order blood tests to get a fuller picture of the patients’ health.
These are the first guidelines from AAP aimed at giving pediatricians and other primary care providers concrete guidance for managing overweight and obesity in younger patients.
“Obesity is a complex, chronic disease, and that’s a frame shift here,” said Sandra S. Hassink, MD, leader of the guideline group and director of the AAP Institute for Healthy Childhood Weight.
Dr. Hassink compared obesity to asthma, another chronic disease that merits prompt attention and ongoing treatment. A physician would never let a child with asthma go untreated until their breathing problems are so severe that they turn blue, Dr. Hassink said; similarly, physicians should treat obesity in young people promptly and over time.
While some aspects of treating overweight and obesity are the same for children and adults, Dr. Hassink noted distinct differences. “Every child is embedded in a family and extended support structure,” Dr. Hassink said, which means that any obesity management technique needs the buy-in and support of the child’s family too.
AAP’s new advice reflects current understanding that excess weight or obesity in children is a result of biological and social factors, such as living in a food desert or experiencing the effects of structural racism.
The guidelines synthesize the results of hundreds of studies about the best way to treat excess weight in young people. If multiple studies were of high quality and all reached similar conclusions, they received an “A.” Less robust but still informative studies rated a “B.” In aggregate, the guideline about weight-lowering medication is based on “B” evidence that could shift with further research.
The authors recommend that clinicians calculate a child’s BMI beginning at age 2 years, with particular attention to those at the 85th percentile or higher for their age and sex (which would be defined as overweight), at the 95th percentile or higher (obesity), or at the 120th percentile and higher (severe obesity). Clinicians also should monitor blood pressure and cholesterol in their patients with overweight or obesity, particularly once they reach age 10.
Starting at age 6, providers should interview patients and their families about what would motivate them to lose weight, then tailor interventions to those factors rather than just make a blanket declaration that weight loss is necessary. This step should be coupled with intensive support – ideally, at least 26 hours of face-to-face support over the course of a year, although more is better – about effective exercise and dietary habits that result in weight loss.
The intensive support model should remain in place throughout childhood and adolescence and should be coupled with referrals for weight-loss medications or bariatric surgeries as needed once children reach age 12 or 13. Those age cutoffs are based on current evidence as to when weight-loss medications or surgery becomes effective, Dr. Hassink said, and could be shifted to lower ages if that’s what new evidence shows.
“Intensive health behavioral and lifestyle treatment is the base of all other treatment extensions,” Dr. Eneli said.
Young patients who needed weight-lowering medication used to have fewer options, according to Aaron S. Kelly, PhD, the Minnesota American Legion and Auxiliary Chair in Children’s Health at the University of Minnesota, Minneapolis.
.No longer.
Dr. Kelly was not involved in drafting the guidelines but was the lead investigator for trials of liraglutide (Saxenda), which in 2020 received U.S. Food and Drug Administration approval for treating obesity in adolescents. In 2022, the agency approved phentermine and topiramate extended-release capsules (Qsymia) for long-term weight management for patients aged 12 years and older, along with a once-weekly injection of semaglutide (Wegovy) patients in this age group. There are no weight-lowering medications for children younger than 12, Dr. Kelly said.
“Obesity is not a lifestyle problem. A lot of it is driven by the underlying biology,” Dr. Kelly said. “Really, what these medicines do is make it easier for people to make the right lifestyle choices by pushing back against the biology.”
For example, a drug can make people feel full for longer or disrupt chemical pathways that result in craving certain foods. Dr. Kelly emphasized that these drugs do not give license for people to eat as much as they want.
As for bariatric surgery, the new guidelines adhere closely to those in a 2019 AAP statement that bariatric surgery is safe and effective in pediatric settings. This is gratifying to Kirk W. Reichard, MD, MBA, a lead author of the 2019 article and director of the bariatric surgery program at Nemours Children’s Health.
Even if the information isn’t new as of 2023, Dr. Reichard said, AAP’s imprimatur could cause some eligible families to consider bariatric surgery when they may not have done so before.
Dr. Eneli, Dr. Hassink, and Dr. Reichard reported no relevant financial conflicts of interest. Dr. Kelly has relationships with Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Vivus.
A version of this article first appeared on Medscape.com.
and hope the problem solves itself. That’s the upshot of new guidelines from the American Academy of Pediatrics.
The authors of the guidelines also encourage primary care doctors to collaborate with other medical professionals to treat the comorbidities often linked to obesity, rather than take on the entire challenge themselves.
“It’s impossible to treat obesity within the four walls of the clinic. That’s one thing I have learned,” Ihuoma Eneli, MD, associate director of the AAP Institute for Healthy Childhood Weight, told this news organization. For example, a primary care doctor could partner with a gastroenterologist when treating a child who has nonalcoholic fatty liver disease, added Dr. Eneli, a professor of pediatrics at the Ohio State University, Columbus, who helped write the recommendations.
The new document updates 2007 recommendations from AAP about treating children and adolescents who are overweight or obese. The earlier statement focused on behavioral modification and healthy eating behaviors and paid less attention to weight-lowering medications or bariatric surgery for young people. That document did not offer specific advice to health care providers about how to address childhood overweight or obesity.
The 2023 guidelines recommend that pediatricians offer anyone aged 12 years and older with obesity – defined as a body mass index (BMI) at the 95th percentile or higher – the option of receiving weight-loss medications in addition to ongoing support for lifestyle modifications, such as exercising more and eating healthier foods.
The same approach holds for bariatric surgery once children reach age 13, and AAP stressed that no physician should ever stigmatize children or imply that they are to blame for their weight.
AAP did not receive any industry funding to develop the guidelines.
As children reach the threshold BMI levels, physicians should conduct complete physicals and order blood tests to get a fuller picture of the patients’ health.
These are the first guidelines from AAP aimed at giving pediatricians and other primary care providers concrete guidance for managing overweight and obesity in younger patients.
“Obesity is a complex, chronic disease, and that’s a frame shift here,” said Sandra S. Hassink, MD, leader of the guideline group and director of the AAP Institute for Healthy Childhood Weight.
Dr. Hassink compared obesity to asthma, another chronic disease that merits prompt attention and ongoing treatment. A physician would never let a child with asthma go untreated until their breathing problems are so severe that they turn blue, Dr. Hassink said; similarly, physicians should treat obesity in young people promptly and over time.
While some aspects of treating overweight and obesity are the same for children and adults, Dr. Hassink noted distinct differences. “Every child is embedded in a family and extended support structure,” Dr. Hassink said, which means that any obesity management technique needs the buy-in and support of the child’s family too.
AAP’s new advice reflects current understanding that excess weight or obesity in children is a result of biological and social factors, such as living in a food desert or experiencing the effects of structural racism.
The guidelines synthesize the results of hundreds of studies about the best way to treat excess weight in young people. If multiple studies were of high quality and all reached similar conclusions, they received an “A.” Less robust but still informative studies rated a “B.” In aggregate, the guideline about weight-lowering medication is based on “B” evidence that could shift with further research.
The authors recommend that clinicians calculate a child’s BMI beginning at age 2 years, with particular attention to those at the 85th percentile or higher for their age and sex (which would be defined as overweight), at the 95th percentile or higher (obesity), or at the 120th percentile and higher (severe obesity). Clinicians also should monitor blood pressure and cholesterol in their patients with overweight or obesity, particularly once they reach age 10.
Starting at age 6, providers should interview patients and their families about what would motivate them to lose weight, then tailor interventions to those factors rather than just make a blanket declaration that weight loss is necessary. This step should be coupled with intensive support – ideally, at least 26 hours of face-to-face support over the course of a year, although more is better – about effective exercise and dietary habits that result in weight loss.
The intensive support model should remain in place throughout childhood and adolescence and should be coupled with referrals for weight-loss medications or bariatric surgeries as needed once children reach age 12 or 13. Those age cutoffs are based on current evidence as to when weight-loss medications or surgery becomes effective, Dr. Hassink said, and could be shifted to lower ages if that’s what new evidence shows.
“Intensive health behavioral and lifestyle treatment is the base of all other treatment extensions,” Dr. Eneli said.
Young patients who needed weight-lowering medication used to have fewer options, according to Aaron S. Kelly, PhD, the Minnesota American Legion and Auxiliary Chair in Children’s Health at the University of Minnesota, Minneapolis.
.No longer.
Dr. Kelly was not involved in drafting the guidelines but was the lead investigator for trials of liraglutide (Saxenda), which in 2020 received U.S. Food and Drug Administration approval for treating obesity in adolescents. In 2022, the agency approved phentermine and topiramate extended-release capsules (Qsymia) for long-term weight management for patients aged 12 years and older, along with a once-weekly injection of semaglutide (Wegovy) patients in this age group. There are no weight-lowering medications for children younger than 12, Dr. Kelly said.
“Obesity is not a lifestyle problem. A lot of it is driven by the underlying biology,” Dr. Kelly said. “Really, what these medicines do is make it easier for people to make the right lifestyle choices by pushing back against the biology.”
For example, a drug can make people feel full for longer or disrupt chemical pathways that result in craving certain foods. Dr. Kelly emphasized that these drugs do not give license for people to eat as much as they want.
As for bariatric surgery, the new guidelines adhere closely to those in a 2019 AAP statement that bariatric surgery is safe and effective in pediatric settings. This is gratifying to Kirk W. Reichard, MD, MBA, a lead author of the 2019 article and director of the bariatric surgery program at Nemours Children’s Health.
Even if the information isn’t new as of 2023, Dr. Reichard said, AAP’s imprimatur could cause some eligible families to consider bariatric surgery when they may not have done so before.
Dr. Eneli, Dr. Hassink, and Dr. Reichard reported no relevant financial conflicts of interest. Dr. Kelly has relationships with Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Vivus.
A version of this article first appeared on Medscape.com.
and hope the problem solves itself. That’s the upshot of new guidelines from the American Academy of Pediatrics.
The authors of the guidelines also encourage primary care doctors to collaborate with other medical professionals to treat the comorbidities often linked to obesity, rather than take on the entire challenge themselves.
“It’s impossible to treat obesity within the four walls of the clinic. That’s one thing I have learned,” Ihuoma Eneli, MD, associate director of the AAP Institute for Healthy Childhood Weight, told this news organization. For example, a primary care doctor could partner with a gastroenterologist when treating a child who has nonalcoholic fatty liver disease, added Dr. Eneli, a professor of pediatrics at the Ohio State University, Columbus, who helped write the recommendations.
The new document updates 2007 recommendations from AAP about treating children and adolescents who are overweight or obese. The earlier statement focused on behavioral modification and healthy eating behaviors and paid less attention to weight-lowering medications or bariatric surgery for young people. That document did not offer specific advice to health care providers about how to address childhood overweight or obesity.
The 2023 guidelines recommend that pediatricians offer anyone aged 12 years and older with obesity – defined as a body mass index (BMI) at the 95th percentile or higher – the option of receiving weight-loss medications in addition to ongoing support for lifestyle modifications, such as exercising more and eating healthier foods.
The same approach holds for bariatric surgery once children reach age 13, and AAP stressed that no physician should ever stigmatize children or imply that they are to blame for their weight.
AAP did not receive any industry funding to develop the guidelines.
As children reach the threshold BMI levels, physicians should conduct complete physicals and order blood tests to get a fuller picture of the patients’ health.
These are the first guidelines from AAP aimed at giving pediatricians and other primary care providers concrete guidance for managing overweight and obesity in younger patients.
“Obesity is a complex, chronic disease, and that’s a frame shift here,” said Sandra S. Hassink, MD, leader of the guideline group and director of the AAP Institute for Healthy Childhood Weight.
Dr. Hassink compared obesity to asthma, another chronic disease that merits prompt attention and ongoing treatment. A physician would never let a child with asthma go untreated until their breathing problems are so severe that they turn blue, Dr. Hassink said; similarly, physicians should treat obesity in young people promptly and over time.
While some aspects of treating overweight and obesity are the same for children and adults, Dr. Hassink noted distinct differences. “Every child is embedded in a family and extended support structure,” Dr. Hassink said, which means that any obesity management technique needs the buy-in and support of the child’s family too.
AAP’s new advice reflects current understanding that excess weight or obesity in children is a result of biological and social factors, such as living in a food desert or experiencing the effects of structural racism.
The guidelines synthesize the results of hundreds of studies about the best way to treat excess weight in young people. If multiple studies were of high quality and all reached similar conclusions, they received an “A.” Less robust but still informative studies rated a “B.” In aggregate, the guideline about weight-lowering medication is based on “B” evidence that could shift with further research.
The authors recommend that clinicians calculate a child’s BMI beginning at age 2 years, with particular attention to those at the 85th percentile or higher for their age and sex (which would be defined as overweight), at the 95th percentile or higher (obesity), or at the 120th percentile and higher (severe obesity). Clinicians also should monitor blood pressure and cholesterol in their patients with overweight or obesity, particularly once they reach age 10.
Starting at age 6, providers should interview patients and their families about what would motivate them to lose weight, then tailor interventions to those factors rather than just make a blanket declaration that weight loss is necessary. This step should be coupled with intensive support – ideally, at least 26 hours of face-to-face support over the course of a year, although more is better – about effective exercise and dietary habits that result in weight loss.
The intensive support model should remain in place throughout childhood and adolescence and should be coupled with referrals for weight-loss medications or bariatric surgeries as needed once children reach age 12 or 13. Those age cutoffs are based on current evidence as to when weight-loss medications or surgery becomes effective, Dr. Hassink said, and could be shifted to lower ages if that’s what new evidence shows.
“Intensive health behavioral and lifestyle treatment is the base of all other treatment extensions,” Dr. Eneli said.
Young patients who needed weight-lowering medication used to have fewer options, according to Aaron S. Kelly, PhD, the Minnesota American Legion and Auxiliary Chair in Children’s Health at the University of Minnesota, Minneapolis.
.No longer.
Dr. Kelly was not involved in drafting the guidelines but was the lead investigator for trials of liraglutide (Saxenda), which in 2020 received U.S. Food and Drug Administration approval for treating obesity in adolescents. In 2022, the agency approved phentermine and topiramate extended-release capsules (Qsymia) for long-term weight management for patients aged 12 years and older, along with a once-weekly injection of semaglutide (Wegovy) patients in this age group. There are no weight-lowering medications for children younger than 12, Dr. Kelly said.
“Obesity is not a lifestyle problem. A lot of it is driven by the underlying biology,” Dr. Kelly said. “Really, what these medicines do is make it easier for people to make the right lifestyle choices by pushing back against the biology.”
For example, a drug can make people feel full for longer or disrupt chemical pathways that result in craving certain foods. Dr. Kelly emphasized that these drugs do not give license for people to eat as much as they want.
As for bariatric surgery, the new guidelines adhere closely to those in a 2019 AAP statement that bariatric surgery is safe and effective in pediatric settings. This is gratifying to Kirk W. Reichard, MD, MBA, a lead author of the 2019 article and director of the bariatric surgery program at Nemours Children’s Health.
Even if the information isn’t new as of 2023, Dr. Reichard said, AAP’s imprimatur could cause some eligible families to consider bariatric surgery when they may not have done so before.
Dr. Eneli, Dr. Hassink, and Dr. Reichard reported no relevant financial conflicts of interest. Dr. Kelly has relationships with Boehringer Ingelheim, Eli Lilly, Novo Nordisk, and Vivus.
A version of this article first appeared on Medscape.com.
FROM PEDIATRICS
Earlier colorectal cancer screening appears cost-effective in overweight, obese patients
Starting colorectal cancer screening earlier than age 50 appears to be cost-effective for both men and women across all body mass index (BMI) measures, according to a study published in Clinical Gastroenterology and Hepatology.
In particular, colonoscopy is cost-effective at age 45 for all BMI strata and at age 40 in obese men. In addition, fecal immunochemical testing (FIT) is highly cost-effective at ages 40 or 45 for all BMI values, wrote Aaron Yeoh, MD, a gastroenterologist at the Stanford (Calif.) University, and colleagues.
Increased body fatness, defined as a high BMI, has increased sharply in recent decades and has been associated with a higher risk of colorectal cancer (CRC). Given the rising incidence of CRC in younger people, the American Cancer Society and U.S. Preventive Services Task Force now endorse screening at age 45. In previous analyses, Dr. Yeoh and colleagues suggested that the policy is likely to be cost-effective, but they didn’t explore the potential differences by BMI.
“Our results suggest that 45 years of age is a reasonable screening initiation age for women and men with BMI ranging from normal through all classes of obesity,” the authors wrote. “Before changing screening policy, supportive data from clinical studies would be needed. Our approach can be applied to future efforts aiming to risk-stratify CRC screening based on multiple clinical factors or biomarkers.”
The research team examined the potential effectiveness and cost-effectiveness of screening tailored to BMI starting as early as age 40 and ending at age 75 in 10 separate cohorts of men and women of normal weight (18.5 to <25 kg/m2), overweight (25 to <30 kg/m2), and three strata of obesity – obese I (30 to <35 kg/m2), obese II (35 to <40 kg/m2), and obese III (>40 kg/m2).
For each cohort, the researchers estimated incremental costs per quality-adjusted life year (QALY) gained by initiating screening at age 40 versus age 45 versus age 50, or by shortening colonoscopy intervals. They modeled screening colonoscopy every 10 years (Colo10) or every 5 years (Colo5), or annual FIT, offered from ages 40, 45, or 50 through age 75 with 100% adherence, with postpolypectomy surveillance through age 80.
For model inputs, the research team favored high-quality data from meta-analyses or large prospective trials. Screening, treatment, and complication costs were set at 2018 Centers for Medicare & Medicaid Services rates for ages 65 and older and modified to reflect commercial costs at ages 65 and younger. The authors assumed use of moderate sedation, and sensitivity analyses addressed possible increased costs and complications of colonoscopy under propofol.
Overall, without screening, sex-specific total CRC deaths were similar for people with overweight or obesity I-III and slightly higher than for people with normal BMI. For both men and women across all BMI strata, Colo10 or FIT starting at age 50 substantially decreased CRC incidence and mortality versus no screening, and the magnitude of the clinical impact was comparable across BMI.
For both sexes across BMI, Colo10 or FIT starting at age 50 was highly cost-effective. The cost per QALY gained for Colo10 compared with no screening became more favorable as BMI increased from normal to obesity III. FIT was cost-saving compared with no screening for all cohorts and was cost-saving or highly cost-effective compared with Colo10 within each cohort.
Initiating Colo10 at age 45 showed incremental decreases in CRC incidence and mortality, which were modest compared with the gains of Colo10 at age 50 versus no screening. However, the incremental gains were achieved at acceptable incremental costs ranging from $64,500 to $85,900 per QALY gained in women and from $33,400 to $64,200 per QALY gained in men.
Initiating Colo10 at age 40 in women and men in the lowest three BMI strata was associated with high incremental costs per QALY gained. In contrast, Colo10 initiation at age 40 cost $80,400 per QALY gained in men with obesity III and $93,300 per QALY gained in men with obesity II.
FIT starting at ages 40 or 45 yielded progressively greater decreases in CRC incidence and mortality for both men and women across BMI strata, and it was highly cost-effective versus starting at later ages. Compared with Colo10, at every screening initiation age, FIT was cost-saving or preferred based on very high incremental costs per QALY, and FIT required substantially fewer colonoscopies per person.
Intensifying screening by shortening the colonoscopy interval to Colo5 was never preferred over shifting Colo10 to earlier screening initiation ages. In all cohorts, Colo5 was either less effective and more costly than Colo10 at a younger age, or when it was more effective, the cost per QALY gained was substantially higher than $100,000 per QALY gained.
Additional studies are needed to understand obesity-specific colonoscopy risks and costs, the authors wrote. In addition, obesity is only one of several factors that should be considered when tailoring CRC screening to the level of CRC risk, they wrote.
“As the search for a multifactor prediction tool that is ready for clinical application continues, we face the question of how to approach single CRC risk factors such as obesity,” they wrote. “While screening guidelines based on BMI can be envisioned if supportive clinical data accumulate, clinical implementation must overcome operational challenges.”
The study funding was not disclosed. One author reported advisory and consultant roles for several medical companies, and the remaining authors disclosed no conflicts.
Obesity is associated with an increased risk of colorectal cancer, along with cancers of the breast, endometrium, and esophagus. Even maternal obesity is associated with higher offspring colorectal cancer rates. Key mechanisms that underlie these associations include high insulin levels in obesity that propel tumor growth, adipose tissue that secretes inflammatory cytokines, and high glucose levels that act as fuel for cancer proliferation.
For men with BMI over 35, moving the colonoscopy screening age earlier to age 40 was cost-effective. However, it’s not clear that in practice the juice is worth the squeeze. Changing screening initiation times further based on personalized factors such as BMI could make screening more confusing for patients and physicians and may hurt uptake, a critical factor for the success of any screening program.
The study supports the current paradigm that screening starting at age 45 is cost-effective among men and women at all BMI ranges, a reassuring conclusion. It also serves as a sobering reminder that promoting metabolic health in our patients, our schools, and our communities is a valuable endeavor.
Sarah McGill, MD, MSc, FACG, FASGE, is associate professor medicine, gastroenterology, and hepatology at the University of North Carolina at Chapel Hill. She receives research funding from Olympus America, Finch Therapeutics, Genentech, Guardant Health, and Exact Sciences.
Obesity is associated with an increased risk of colorectal cancer, along with cancers of the breast, endometrium, and esophagus. Even maternal obesity is associated with higher offspring colorectal cancer rates. Key mechanisms that underlie these associations include high insulin levels in obesity that propel tumor growth, adipose tissue that secretes inflammatory cytokines, and high glucose levels that act as fuel for cancer proliferation.
For men with BMI over 35, moving the colonoscopy screening age earlier to age 40 was cost-effective. However, it’s not clear that in practice the juice is worth the squeeze. Changing screening initiation times further based on personalized factors such as BMI could make screening more confusing for patients and physicians and may hurt uptake, a critical factor for the success of any screening program.
The study supports the current paradigm that screening starting at age 45 is cost-effective among men and women at all BMI ranges, a reassuring conclusion. It also serves as a sobering reminder that promoting metabolic health in our patients, our schools, and our communities is a valuable endeavor.
Sarah McGill, MD, MSc, FACG, FASGE, is associate professor medicine, gastroenterology, and hepatology at the University of North Carolina at Chapel Hill. She receives research funding from Olympus America, Finch Therapeutics, Genentech, Guardant Health, and Exact Sciences.
Obesity is associated with an increased risk of colorectal cancer, along with cancers of the breast, endometrium, and esophagus. Even maternal obesity is associated with higher offspring colorectal cancer rates. Key mechanisms that underlie these associations include high insulin levels in obesity that propel tumor growth, adipose tissue that secretes inflammatory cytokines, and high glucose levels that act as fuel for cancer proliferation.
For men with BMI over 35, moving the colonoscopy screening age earlier to age 40 was cost-effective. However, it’s not clear that in practice the juice is worth the squeeze. Changing screening initiation times further based on personalized factors such as BMI could make screening more confusing for patients and physicians and may hurt uptake, a critical factor for the success of any screening program.
The study supports the current paradigm that screening starting at age 45 is cost-effective among men and women at all BMI ranges, a reassuring conclusion. It also serves as a sobering reminder that promoting metabolic health in our patients, our schools, and our communities is a valuable endeavor.
Sarah McGill, MD, MSc, FACG, FASGE, is associate professor medicine, gastroenterology, and hepatology at the University of North Carolina at Chapel Hill. She receives research funding from Olympus America, Finch Therapeutics, Genentech, Guardant Health, and Exact Sciences.
Starting colorectal cancer screening earlier than age 50 appears to be cost-effective for both men and women across all body mass index (BMI) measures, according to a study published in Clinical Gastroenterology and Hepatology.
In particular, colonoscopy is cost-effective at age 45 for all BMI strata and at age 40 in obese men. In addition, fecal immunochemical testing (FIT) is highly cost-effective at ages 40 or 45 for all BMI values, wrote Aaron Yeoh, MD, a gastroenterologist at the Stanford (Calif.) University, and colleagues.
Increased body fatness, defined as a high BMI, has increased sharply in recent decades and has been associated with a higher risk of colorectal cancer (CRC). Given the rising incidence of CRC in younger people, the American Cancer Society and U.S. Preventive Services Task Force now endorse screening at age 45. In previous analyses, Dr. Yeoh and colleagues suggested that the policy is likely to be cost-effective, but they didn’t explore the potential differences by BMI.
“Our results suggest that 45 years of age is a reasonable screening initiation age for women and men with BMI ranging from normal through all classes of obesity,” the authors wrote. “Before changing screening policy, supportive data from clinical studies would be needed. Our approach can be applied to future efforts aiming to risk-stratify CRC screening based on multiple clinical factors or biomarkers.”
The research team examined the potential effectiveness and cost-effectiveness of screening tailored to BMI starting as early as age 40 and ending at age 75 in 10 separate cohorts of men and women of normal weight (18.5 to <25 kg/m2), overweight (25 to <30 kg/m2), and three strata of obesity – obese I (30 to <35 kg/m2), obese II (35 to <40 kg/m2), and obese III (>40 kg/m2).
For each cohort, the researchers estimated incremental costs per quality-adjusted life year (QALY) gained by initiating screening at age 40 versus age 45 versus age 50, or by shortening colonoscopy intervals. They modeled screening colonoscopy every 10 years (Colo10) or every 5 years (Colo5), or annual FIT, offered from ages 40, 45, or 50 through age 75 with 100% adherence, with postpolypectomy surveillance through age 80.
For model inputs, the research team favored high-quality data from meta-analyses or large prospective trials. Screening, treatment, and complication costs were set at 2018 Centers for Medicare & Medicaid Services rates for ages 65 and older and modified to reflect commercial costs at ages 65 and younger. The authors assumed use of moderate sedation, and sensitivity analyses addressed possible increased costs and complications of colonoscopy under propofol.
Overall, without screening, sex-specific total CRC deaths were similar for people with overweight or obesity I-III and slightly higher than for people with normal BMI. For both men and women across all BMI strata, Colo10 or FIT starting at age 50 substantially decreased CRC incidence and mortality versus no screening, and the magnitude of the clinical impact was comparable across BMI.
For both sexes across BMI, Colo10 or FIT starting at age 50 was highly cost-effective. The cost per QALY gained for Colo10 compared with no screening became more favorable as BMI increased from normal to obesity III. FIT was cost-saving compared with no screening for all cohorts and was cost-saving or highly cost-effective compared with Colo10 within each cohort.
Initiating Colo10 at age 45 showed incremental decreases in CRC incidence and mortality, which were modest compared with the gains of Colo10 at age 50 versus no screening. However, the incremental gains were achieved at acceptable incremental costs ranging from $64,500 to $85,900 per QALY gained in women and from $33,400 to $64,200 per QALY gained in men.
Initiating Colo10 at age 40 in women and men in the lowest three BMI strata was associated with high incremental costs per QALY gained. In contrast, Colo10 initiation at age 40 cost $80,400 per QALY gained in men with obesity III and $93,300 per QALY gained in men with obesity II.
FIT starting at ages 40 or 45 yielded progressively greater decreases in CRC incidence and mortality for both men and women across BMI strata, and it was highly cost-effective versus starting at later ages. Compared with Colo10, at every screening initiation age, FIT was cost-saving or preferred based on very high incremental costs per QALY, and FIT required substantially fewer colonoscopies per person.
Intensifying screening by shortening the colonoscopy interval to Colo5 was never preferred over shifting Colo10 to earlier screening initiation ages. In all cohorts, Colo5 was either less effective and more costly than Colo10 at a younger age, or when it was more effective, the cost per QALY gained was substantially higher than $100,000 per QALY gained.
Additional studies are needed to understand obesity-specific colonoscopy risks and costs, the authors wrote. In addition, obesity is only one of several factors that should be considered when tailoring CRC screening to the level of CRC risk, they wrote.
“As the search for a multifactor prediction tool that is ready for clinical application continues, we face the question of how to approach single CRC risk factors such as obesity,” they wrote. “While screening guidelines based on BMI can be envisioned if supportive clinical data accumulate, clinical implementation must overcome operational challenges.”
The study funding was not disclosed. One author reported advisory and consultant roles for several medical companies, and the remaining authors disclosed no conflicts.
Starting colorectal cancer screening earlier than age 50 appears to be cost-effective for both men and women across all body mass index (BMI) measures, according to a study published in Clinical Gastroenterology and Hepatology.
In particular, colonoscopy is cost-effective at age 45 for all BMI strata and at age 40 in obese men. In addition, fecal immunochemical testing (FIT) is highly cost-effective at ages 40 or 45 for all BMI values, wrote Aaron Yeoh, MD, a gastroenterologist at the Stanford (Calif.) University, and colleagues.
Increased body fatness, defined as a high BMI, has increased sharply in recent decades and has been associated with a higher risk of colorectal cancer (CRC). Given the rising incidence of CRC in younger people, the American Cancer Society and U.S. Preventive Services Task Force now endorse screening at age 45. In previous analyses, Dr. Yeoh and colleagues suggested that the policy is likely to be cost-effective, but they didn’t explore the potential differences by BMI.
“Our results suggest that 45 years of age is a reasonable screening initiation age for women and men with BMI ranging from normal through all classes of obesity,” the authors wrote. “Before changing screening policy, supportive data from clinical studies would be needed. Our approach can be applied to future efforts aiming to risk-stratify CRC screening based on multiple clinical factors or biomarkers.”
The research team examined the potential effectiveness and cost-effectiveness of screening tailored to BMI starting as early as age 40 and ending at age 75 in 10 separate cohorts of men and women of normal weight (18.5 to <25 kg/m2), overweight (25 to <30 kg/m2), and three strata of obesity – obese I (30 to <35 kg/m2), obese II (35 to <40 kg/m2), and obese III (>40 kg/m2).
For each cohort, the researchers estimated incremental costs per quality-adjusted life year (QALY) gained by initiating screening at age 40 versus age 45 versus age 50, or by shortening colonoscopy intervals. They modeled screening colonoscopy every 10 years (Colo10) or every 5 years (Colo5), or annual FIT, offered from ages 40, 45, or 50 through age 75 with 100% adherence, with postpolypectomy surveillance through age 80.
For model inputs, the research team favored high-quality data from meta-analyses or large prospective trials. Screening, treatment, and complication costs were set at 2018 Centers for Medicare & Medicaid Services rates for ages 65 and older and modified to reflect commercial costs at ages 65 and younger. The authors assumed use of moderate sedation, and sensitivity analyses addressed possible increased costs and complications of colonoscopy under propofol.
Overall, without screening, sex-specific total CRC deaths were similar for people with overweight or obesity I-III and slightly higher than for people with normal BMI. For both men and women across all BMI strata, Colo10 or FIT starting at age 50 substantially decreased CRC incidence and mortality versus no screening, and the magnitude of the clinical impact was comparable across BMI.
For both sexes across BMI, Colo10 or FIT starting at age 50 was highly cost-effective. The cost per QALY gained for Colo10 compared with no screening became more favorable as BMI increased from normal to obesity III. FIT was cost-saving compared with no screening for all cohorts and was cost-saving or highly cost-effective compared with Colo10 within each cohort.
Initiating Colo10 at age 45 showed incremental decreases in CRC incidence and mortality, which were modest compared with the gains of Colo10 at age 50 versus no screening. However, the incremental gains were achieved at acceptable incremental costs ranging from $64,500 to $85,900 per QALY gained in women and from $33,400 to $64,200 per QALY gained in men.
Initiating Colo10 at age 40 in women and men in the lowest three BMI strata was associated with high incremental costs per QALY gained. In contrast, Colo10 initiation at age 40 cost $80,400 per QALY gained in men with obesity III and $93,300 per QALY gained in men with obesity II.
FIT starting at ages 40 or 45 yielded progressively greater decreases in CRC incidence and mortality for both men and women across BMI strata, and it was highly cost-effective versus starting at later ages. Compared with Colo10, at every screening initiation age, FIT was cost-saving or preferred based on very high incremental costs per QALY, and FIT required substantially fewer colonoscopies per person.
Intensifying screening by shortening the colonoscopy interval to Colo5 was never preferred over shifting Colo10 to earlier screening initiation ages. In all cohorts, Colo5 was either less effective and more costly than Colo10 at a younger age, or when it was more effective, the cost per QALY gained was substantially higher than $100,000 per QALY gained.
Additional studies are needed to understand obesity-specific colonoscopy risks and costs, the authors wrote. In addition, obesity is only one of several factors that should be considered when tailoring CRC screening to the level of CRC risk, they wrote.
“As the search for a multifactor prediction tool that is ready for clinical application continues, we face the question of how to approach single CRC risk factors such as obesity,” they wrote. “While screening guidelines based on BMI can be envisioned if supportive clinical data accumulate, clinical implementation must overcome operational challenges.”
The study funding was not disclosed. One author reported advisory and consultant roles for several medical companies, and the remaining authors disclosed no conflicts.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Best diets in 2023: Mediterranean diet wins again
After all, weight loss usually lands one of the top spots on New Year’s resolution surveys.
And just in time, there’s guidance to pick the best plan, as U.S. News & World Report’s annual rankings of the best diet plans were released on Jan. 3.
Once again, the Mediterranean diet, which emphasizes fruits, vegetables, olive oil, and fish, got the top spot, as best diet overall. It’s the sixth consecutive year for that win. But many other diets got top marks as well.
In 2023, U.S. News, with the help of more than 30 nutritionists, doctors, and epidemiologists, ranked 24 diets in several categories to help people find a plan that meets their goals, whether it’s finding the best weight loss diet, easiest one to follow, or plans for other goals, such as managing diabetes or heart disease. Two new categories were added: Best Diets for Bone & Joint Health and Best Family-Friendly Diets.
In previous years, the publication ranked 40 diets. Even if a diet is no longer ranked, its profile with detailed information remains on the site.
“Each year we ask ourselves what we can do better or differently next time,” said Gretel Schueller, managing editor of health for U.S. News. When the publication got feedback from their experts this year, they had requests to consider sustainability of diets and whether they meet a busy family’s needs, in addition to considering many other factors.
This year’s report ranks plans in 11 categories.
The winners and the categories:
Best diets overall
After the Mediterranean diet, two others tied for second place:
- DASH (Dietary Approaches to Stop Hypertension) diet, which fights high blood pressure and emphasizes fruits, vegetables, whole grains, lean protein, and low-fat dairy.
- Flexitarian diet, which focuses on fruits, vegetables, and other healthy foods but also allows occasional meat.
Best weight-loss diets
WW, formerly known as Weight Watchers, got first place. The plan emphasizes not only weight loss but healthier eating and regular activity. The Points program, which assigns specific points to foods, with a daily Points budget, is more personalized than in the past.
- DASH got second place.
- Mayo Clinic Diet and TLC diet tied for third place. The Mayo Clinic Diet focuses on fruits, vegetables, and whole grains. It helps people improve their eating habits. The TLC diet (Therapeutic Lifestyle Changes) focuses on vegetables, fruit, lean protein, and reducing cholesterol levels.
Best fast weight-loss diets
The keto diet got first place. It’s a high-fat, low-carb diet that aims to achieve weight loss through fat burning. Four others tied for second place:
- Atkins, a diet created by the cardiologist Robert Atkins, which begins with very few carbs and then recommends progressively eating more until the weight loss goal is achieved
- Nutrisystem, a commercial program that includes prepackaged meals and focuses on high-protein, lower-glycemic foods to stabilize blood sugar levels
- Optavia, a plan focused on low-carb, low-calorie foods and including fortified meal replacements
- SlimFast Diet, a plan of shakes, smoothies, and meal bars to replace two of three meals a day
Best diets for healthy eating
- Mediterranean
- DASH
- Flexitarian
Best heart-healthy diets
- DASH
- Mediterranean
- Flexitarian and Ornish tied for third. The Ornish Diet focuses on plant-based and whole foods and limiting animal products. It recommends daily exercise and stress reduction.
Best diets for diabetes
- DASH
- Mediterranean
- Flexitarian
Best diets for bone and joint health
DASH and Mediterranean are in a first-place tie, followed by the flexitarian diet.
Best family-friendly diets
This category has a three-way tie: the flexitarian, Mediterranean, and TLC diets.
Best plant-based diets
Mediterranean was first, then flexitarian and the MIND diet. The MIND diet combines the DASH and Mediterranean diets and focuses on “brain-healthy” foods.
Easiest diets to follow
Flexitarian and TLC tied for first, followed by a tie between DASH and Mediterranean.
Best diet programs (formerly called commercial plans)
- WW
- There was a tie for second place between Jenny Craig and Noom, the latter of which focuses on low-calorie foods, with personalized calorie ranges and coaching to help meet goals.
Methodology
A variety of factors were considered, such as whether a diet includes all food groups, how easy it is to follow, whether it can be customized to meet cultural and personal preferences, and if it has a realistic timeline for weight loss.
Response from diet plans
Representatives from two plans that received mixed reviews in the rankings responded.
Jenny Craig was ranked second for best diet program but much lower for family friendly, landing at 22nd place of 24.
“Our program is designed to address the needs of the individual through personalized experiences,” Jenny Craig CEO Mandy Dowson said. “We have many families that participate in our program together but are still evaluated separately to determine appropriate individual goals.”
Its high ranking for best diet program reflects feedback from satisfied members, she said. Among advances will be the new Jenny Fresh program, a line of entrées prepared fresh and delivered to customers’ doors.
Atkins got second place for best fast weight loss but ranked near the bottom for best overall, best weight loss, diabetes, healthy eating, and heart health. In response, Colette Heimowitz, vice president of nutrition and education for Simply Good Foods, which makes Atkins’s food products, said that low-carb eating approaches are a viable option for anyone today.
“There are more than 130 independent, peer-reviewed published studies that show the efficacy and safety of low-carb eating,” she said. “The studies have been conducted for several decades and counting.”
Expert perspective
Samantha Cassetty, a registered dietitian, nutritionist, and wellness expert in New York and author of Sugar Shock, reviewed the report for this news organization. She was not involved in the rankings.
“I think what this shows you is, the best diet overall is also the best for various conditions,” she said. For instance, the Mediterranean, the No. 1 overall, also got high ranking for diabetes, heart health, and bone and joint health.
For consumers trying to lose weight: “If you see fast weight loss, that should be a red flag. A healthy diet for weight loss is one you can sustain,” she said.
She’s not a fan of the programs with prepackaged foods. “It takes the guesswork out, but the portion sizes tend to be unsatisfying. They don’t teach you how to deal with some of the challenges [such as realizing an ‘ideal’ portion size].”
How to use the report
Ms. Schueller’s advice: “Recognize that no diet fits everyone.” When considering which plan to choose, she suggests thinking long-term.
“Whatever we choose has to work in the long run,” she said.
Consumers should consider expenses, meal prep time, and whether the diet fits their lifestyle.
Ideally, she said, the best diet “teaches you smart food preparation and how to make healthy choices, allows the flexibility to be social and eat with groups, whether family or friends.”
Before choosing a diet to follow, consult a medical professional for input on the decision, U.S. News cautioned.
A version of this article first appeared on Medscape.com.
After all, weight loss usually lands one of the top spots on New Year’s resolution surveys.
And just in time, there’s guidance to pick the best plan, as U.S. News & World Report’s annual rankings of the best diet plans were released on Jan. 3.
Once again, the Mediterranean diet, which emphasizes fruits, vegetables, olive oil, and fish, got the top spot, as best diet overall. It’s the sixth consecutive year for that win. But many other diets got top marks as well.
In 2023, U.S. News, with the help of more than 30 nutritionists, doctors, and epidemiologists, ranked 24 diets in several categories to help people find a plan that meets their goals, whether it’s finding the best weight loss diet, easiest one to follow, or plans for other goals, such as managing diabetes or heart disease. Two new categories were added: Best Diets for Bone & Joint Health and Best Family-Friendly Diets.
In previous years, the publication ranked 40 diets. Even if a diet is no longer ranked, its profile with detailed information remains on the site.
“Each year we ask ourselves what we can do better or differently next time,” said Gretel Schueller, managing editor of health for U.S. News. When the publication got feedback from their experts this year, they had requests to consider sustainability of diets and whether they meet a busy family’s needs, in addition to considering many other factors.
This year’s report ranks plans in 11 categories.
The winners and the categories:
Best diets overall
After the Mediterranean diet, two others tied for second place:
- DASH (Dietary Approaches to Stop Hypertension) diet, which fights high blood pressure and emphasizes fruits, vegetables, whole grains, lean protein, and low-fat dairy.
- Flexitarian diet, which focuses on fruits, vegetables, and other healthy foods but also allows occasional meat.
Best weight-loss diets
WW, formerly known as Weight Watchers, got first place. The plan emphasizes not only weight loss but healthier eating and regular activity. The Points program, which assigns specific points to foods, with a daily Points budget, is more personalized than in the past.
- DASH got second place.
- Mayo Clinic Diet and TLC diet tied for third place. The Mayo Clinic Diet focuses on fruits, vegetables, and whole grains. It helps people improve their eating habits. The TLC diet (Therapeutic Lifestyle Changes) focuses on vegetables, fruit, lean protein, and reducing cholesterol levels.
Best fast weight-loss diets
The keto diet got first place. It’s a high-fat, low-carb diet that aims to achieve weight loss through fat burning. Four others tied for second place:
- Atkins, a diet created by the cardiologist Robert Atkins, which begins with very few carbs and then recommends progressively eating more until the weight loss goal is achieved
- Nutrisystem, a commercial program that includes prepackaged meals and focuses on high-protein, lower-glycemic foods to stabilize blood sugar levels
- Optavia, a plan focused on low-carb, low-calorie foods and including fortified meal replacements
- SlimFast Diet, a plan of shakes, smoothies, and meal bars to replace two of three meals a day
Best diets for healthy eating
- Mediterranean
- DASH
- Flexitarian
Best heart-healthy diets
- DASH
- Mediterranean
- Flexitarian and Ornish tied for third. The Ornish Diet focuses on plant-based and whole foods and limiting animal products. It recommends daily exercise and stress reduction.
Best diets for diabetes
- DASH
- Mediterranean
- Flexitarian
Best diets for bone and joint health
DASH and Mediterranean are in a first-place tie, followed by the flexitarian diet.
Best family-friendly diets
This category has a three-way tie: the flexitarian, Mediterranean, and TLC diets.
Best plant-based diets
Mediterranean was first, then flexitarian and the MIND diet. The MIND diet combines the DASH and Mediterranean diets and focuses on “brain-healthy” foods.
Easiest diets to follow
Flexitarian and TLC tied for first, followed by a tie between DASH and Mediterranean.
Best diet programs (formerly called commercial plans)
- WW
- There was a tie for second place between Jenny Craig and Noom, the latter of which focuses on low-calorie foods, with personalized calorie ranges and coaching to help meet goals.
Methodology
A variety of factors were considered, such as whether a diet includes all food groups, how easy it is to follow, whether it can be customized to meet cultural and personal preferences, and if it has a realistic timeline for weight loss.
Response from diet plans
Representatives from two plans that received mixed reviews in the rankings responded.
Jenny Craig was ranked second for best diet program but much lower for family friendly, landing at 22nd place of 24.
“Our program is designed to address the needs of the individual through personalized experiences,” Jenny Craig CEO Mandy Dowson said. “We have many families that participate in our program together but are still evaluated separately to determine appropriate individual goals.”
Its high ranking for best diet program reflects feedback from satisfied members, she said. Among advances will be the new Jenny Fresh program, a line of entrées prepared fresh and delivered to customers’ doors.
Atkins got second place for best fast weight loss but ranked near the bottom for best overall, best weight loss, diabetes, healthy eating, and heart health. In response, Colette Heimowitz, vice president of nutrition and education for Simply Good Foods, which makes Atkins’s food products, said that low-carb eating approaches are a viable option for anyone today.
“There are more than 130 independent, peer-reviewed published studies that show the efficacy and safety of low-carb eating,” she said. “The studies have been conducted for several decades and counting.”
Expert perspective
Samantha Cassetty, a registered dietitian, nutritionist, and wellness expert in New York and author of Sugar Shock, reviewed the report for this news organization. She was not involved in the rankings.
“I think what this shows you is, the best diet overall is also the best for various conditions,” she said. For instance, the Mediterranean, the No. 1 overall, also got high ranking for diabetes, heart health, and bone and joint health.
For consumers trying to lose weight: “If you see fast weight loss, that should be a red flag. A healthy diet for weight loss is one you can sustain,” she said.
She’s not a fan of the programs with prepackaged foods. “It takes the guesswork out, but the portion sizes tend to be unsatisfying. They don’t teach you how to deal with some of the challenges [such as realizing an ‘ideal’ portion size].”
How to use the report
Ms. Schueller’s advice: “Recognize that no diet fits everyone.” When considering which plan to choose, she suggests thinking long-term.
“Whatever we choose has to work in the long run,” she said.
Consumers should consider expenses, meal prep time, and whether the diet fits their lifestyle.
Ideally, she said, the best diet “teaches you smart food preparation and how to make healthy choices, allows the flexibility to be social and eat with groups, whether family or friends.”
Before choosing a diet to follow, consult a medical professional for input on the decision, U.S. News cautioned.
A version of this article first appeared on Medscape.com.
After all, weight loss usually lands one of the top spots on New Year’s resolution surveys.
And just in time, there’s guidance to pick the best plan, as U.S. News & World Report’s annual rankings of the best diet plans were released on Jan. 3.
Once again, the Mediterranean diet, which emphasizes fruits, vegetables, olive oil, and fish, got the top spot, as best diet overall. It’s the sixth consecutive year for that win. But many other diets got top marks as well.
In 2023, U.S. News, with the help of more than 30 nutritionists, doctors, and epidemiologists, ranked 24 diets in several categories to help people find a plan that meets their goals, whether it’s finding the best weight loss diet, easiest one to follow, or plans for other goals, such as managing diabetes or heart disease. Two new categories were added: Best Diets for Bone & Joint Health and Best Family-Friendly Diets.
In previous years, the publication ranked 40 diets. Even if a diet is no longer ranked, its profile with detailed information remains on the site.
“Each year we ask ourselves what we can do better or differently next time,” said Gretel Schueller, managing editor of health for U.S. News. When the publication got feedback from their experts this year, they had requests to consider sustainability of diets and whether they meet a busy family’s needs, in addition to considering many other factors.
This year’s report ranks plans in 11 categories.
The winners and the categories:
Best diets overall
After the Mediterranean diet, two others tied for second place:
- DASH (Dietary Approaches to Stop Hypertension) diet, which fights high blood pressure and emphasizes fruits, vegetables, whole grains, lean protein, and low-fat dairy.
- Flexitarian diet, which focuses on fruits, vegetables, and other healthy foods but also allows occasional meat.
Best weight-loss diets
WW, formerly known as Weight Watchers, got first place. The plan emphasizes not only weight loss but healthier eating and regular activity. The Points program, which assigns specific points to foods, with a daily Points budget, is more personalized than in the past.
- DASH got second place.
- Mayo Clinic Diet and TLC diet tied for third place. The Mayo Clinic Diet focuses on fruits, vegetables, and whole grains. It helps people improve their eating habits. The TLC diet (Therapeutic Lifestyle Changes) focuses on vegetables, fruit, lean protein, and reducing cholesterol levels.
Best fast weight-loss diets
The keto diet got first place. It’s a high-fat, low-carb diet that aims to achieve weight loss through fat burning. Four others tied for second place:
- Atkins, a diet created by the cardiologist Robert Atkins, which begins with very few carbs and then recommends progressively eating more until the weight loss goal is achieved
- Nutrisystem, a commercial program that includes prepackaged meals and focuses on high-protein, lower-glycemic foods to stabilize blood sugar levels
- Optavia, a plan focused on low-carb, low-calorie foods and including fortified meal replacements
- SlimFast Diet, a plan of shakes, smoothies, and meal bars to replace two of three meals a day
Best diets for healthy eating
- Mediterranean
- DASH
- Flexitarian
Best heart-healthy diets
- DASH
- Mediterranean
- Flexitarian and Ornish tied for third. The Ornish Diet focuses on plant-based and whole foods and limiting animal products. It recommends daily exercise and stress reduction.
Best diets for diabetes
- DASH
- Mediterranean
- Flexitarian
Best diets for bone and joint health
DASH and Mediterranean are in a first-place tie, followed by the flexitarian diet.
Best family-friendly diets
This category has a three-way tie: the flexitarian, Mediterranean, and TLC diets.
Best plant-based diets
Mediterranean was first, then flexitarian and the MIND diet. The MIND diet combines the DASH and Mediterranean diets and focuses on “brain-healthy” foods.
Easiest diets to follow
Flexitarian and TLC tied for first, followed by a tie between DASH and Mediterranean.
Best diet programs (formerly called commercial plans)
- WW
- There was a tie for second place between Jenny Craig and Noom, the latter of which focuses on low-calorie foods, with personalized calorie ranges and coaching to help meet goals.
Methodology
A variety of factors were considered, such as whether a diet includes all food groups, how easy it is to follow, whether it can be customized to meet cultural and personal preferences, and if it has a realistic timeline for weight loss.
Response from diet plans
Representatives from two plans that received mixed reviews in the rankings responded.
Jenny Craig was ranked second for best diet program but much lower for family friendly, landing at 22nd place of 24.
“Our program is designed to address the needs of the individual through personalized experiences,” Jenny Craig CEO Mandy Dowson said. “We have many families that participate in our program together but are still evaluated separately to determine appropriate individual goals.”
Its high ranking for best diet program reflects feedback from satisfied members, she said. Among advances will be the new Jenny Fresh program, a line of entrées prepared fresh and delivered to customers’ doors.
Atkins got second place for best fast weight loss but ranked near the bottom for best overall, best weight loss, diabetes, healthy eating, and heart health. In response, Colette Heimowitz, vice president of nutrition and education for Simply Good Foods, which makes Atkins’s food products, said that low-carb eating approaches are a viable option for anyone today.
“There are more than 130 independent, peer-reviewed published studies that show the efficacy and safety of low-carb eating,” she said. “The studies have been conducted for several decades and counting.”
Expert perspective
Samantha Cassetty, a registered dietitian, nutritionist, and wellness expert in New York and author of Sugar Shock, reviewed the report for this news organization. She was not involved in the rankings.
“I think what this shows you is, the best diet overall is also the best for various conditions,” she said. For instance, the Mediterranean, the No. 1 overall, also got high ranking for diabetes, heart health, and bone and joint health.
For consumers trying to lose weight: “If you see fast weight loss, that should be a red flag. A healthy diet for weight loss is one you can sustain,” she said.
She’s not a fan of the programs with prepackaged foods. “It takes the guesswork out, but the portion sizes tend to be unsatisfying. They don’t teach you how to deal with some of the challenges [such as realizing an ‘ideal’ portion size].”
How to use the report
Ms. Schueller’s advice: “Recognize that no diet fits everyone.” When considering which plan to choose, she suggests thinking long-term.
“Whatever we choose has to work in the long run,” she said.
Consumers should consider expenses, meal prep time, and whether the diet fits their lifestyle.
Ideally, she said, the best diet “teaches you smart food preparation and how to make healthy choices, allows the flexibility to be social and eat with groups, whether family or friends.”
Before choosing a diet to follow, consult a medical professional for input on the decision, U.S. News cautioned.
A version of this article first appeared on Medscape.com.
FDA approves Wegovy (semaglutide) for obesity in teens 12 and up
The Food and Drug Administration has approved semaglutide 2.4 mg (Wegovy), a once-weekly subcutaneous injection, for the additional indication of treating obesity in adolescents aged 12 years and older.
This is defined as those with an initial body mass index at or above the 95th percentile for age and sex (based on CDC growth charts). Semaglutide must be administered along with lifestyle intervention of a reduced calorie meal plan and increased physical activity.
When Wegovy was approved for use in adults with obesity in June 2021, it was labeled a “game changer.”
The new approval is based on the results of the STEP TEENS phase 3 trial of once-weekly 2.4 mg of semaglutide in adolescents 12- to <18 years old with obesity, the drug’s manufacturer, Novo Nordisk, announced in a press release.
In STEP TEENS, reported at Obesity Week 2022 in November, and simultaneously published in the New England Journal of Medicine, adolescents with obesity treated with semaglutide for 68 weeks had a 16.1% reduction in BMI compared with a 0.6% increase in BMI in those receiving placebo. Both groups also received lifestyle intervention. Mean weight loss was 15.3 kg (33.7 pounds) among teens on semaglutide, while those on placebo gained 2.4 kg (5.3 pounds).
At the time, Claudia K. Fox, MD, MPH, codirector of the Center for Pediatric Obesity Medicine at the University of Minnesota – who was not involved with the research – told this news organization the results were “mind-blowing ... we are getting close to bariatric surgery results” in these adolescent patients with obesity.
Semaglutide is a GLP-1 agonist, as is a related agent, also from Novo Nordisk, liraglutide (Saxenda), a daily subcutaneous injection, which was approved for use in adolescents aged 12 and older in December 2020. Wegovy is the first weekly subcutaneous injection approved for use in adolescents.
Other agents approved for obesity in those older than 12 in the United States include the combination phentermine and topiramate extended-release capsules (Qsymia) in June 2022, and orlistat (Alli). Phentermine is approved for those aged 16 and older.
A version of this article first appeared on Medscape.com.
The Food and Drug Administration has approved semaglutide 2.4 mg (Wegovy), a once-weekly subcutaneous injection, for the additional indication of treating obesity in adolescents aged 12 years and older.
This is defined as those with an initial body mass index at or above the 95th percentile for age and sex (based on CDC growth charts). Semaglutide must be administered along with lifestyle intervention of a reduced calorie meal plan and increased physical activity.
When Wegovy was approved for use in adults with obesity in June 2021, it was labeled a “game changer.”
The new approval is based on the results of the STEP TEENS phase 3 trial of once-weekly 2.4 mg of semaglutide in adolescents 12- to <18 years old with obesity, the drug’s manufacturer, Novo Nordisk, announced in a press release.
In STEP TEENS, reported at Obesity Week 2022 in November, and simultaneously published in the New England Journal of Medicine, adolescents with obesity treated with semaglutide for 68 weeks had a 16.1% reduction in BMI compared with a 0.6% increase in BMI in those receiving placebo. Both groups also received lifestyle intervention. Mean weight loss was 15.3 kg (33.7 pounds) among teens on semaglutide, while those on placebo gained 2.4 kg (5.3 pounds).
At the time, Claudia K. Fox, MD, MPH, codirector of the Center for Pediatric Obesity Medicine at the University of Minnesota – who was not involved with the research – told this news organization the results were “mind-blowing ... we are getting close to bariatric surgery results” in these adolescent patients with obesity.
Semaglutide is a GLP-1 agonist, as is a related agent, also from Novo Nordisk, liraglutide (Saxenda), a daily subcutaneous injection, which was approved for use in adolescents aged 12 and older in December 2020. Wegovy is the first weekly subcutaneous injection approved for use in adolescents.
Other agents approved for obesity in those older than 12 in the United States include the combination phentermine and topiramate extended-release capsules (Qsymia) in June 2022, and orlistat (Alli). Phentermine is approved for those aged 16 and older.
A version of this article first appeared on Medscape.com.
The Food and Drug Administration has approved semaglutide 2.4 mg (Wegovy), a once-weekly subcutaneous injection, for the additional indication of treating obesity in adolescents aged 12 years and older.
This is defined as those with an initial body mass index at or above the 95th percentile for age and sex (based on CDC growth charts). Semaglutide must be administered along with lifestyle intervention of a reduced calorie meal plan and increased physical activity.
When Wegovy was approved for use in adults with obesity in June 2021, it was labeled a “game changer.”
The new approval is based on the results of the STEP TEENS phase 3 trial of once-weekly 2.4 mg of semaglutide in adolescents 12- to <18 years old with obesity, the drug’s manufacturer, Novo Nordisk, announced in a press release.
In STEP TEENS, reported at Obesity Week 2022 in November, and simultaneously published in the New England Journal of Medicine, adolescents with obesity treated with semaglutide for 68 weeks had a 16.1% reduction in BMI compared with a 0.6% increase in BMI in those receiving placebo. Both groups also received lifestyle intervention. Mean weight loss was 15.3 kg (33.7 pounds) among teens on semaglutide, while those on placebo gained 2.4 kg (5.3 pounds).
At the time, Claudia K. Fox, MD, MPH, codirector of the Center for Pediatric Obesity Medicine at the University of Minnesota – who was not involved with the research – told this news organization the results were “mind-blowing ... we are getting close to bariatric surgery results” in these adolescent patients with obesity.
Semaglutide is a GLP-1 agonist, as is a related agent, also from Novo Nordisk, liraglutide (Saxenda), a daily subcutaneous injection, which was approved for use in adolescents aged 12 and older in December 2020. Wegovy is the first weekly subcutaneous injection approved for use in adolescents.
Other agents approved for obesity in those older than 12 in the United States include the combination phentermine and topiramate extended-release capsules (Qsymia) in June 2022, and orlistat (Alli). Phentermine is approved for those aged 16 and older.
A version of this article first appeared on Medscape.com.
Weight loss management ... a new frontier?
Dear colleagues,
Treating obesity easily falls under our purview as gastroenterologists. But like the mouse who would bell the cat, our direct involvement has been limited. However, over the past decade, advances in endobariatrics and medical management have given us many options. But how do we choose from this growing armamentarium of minimally invasive procedures and weight loss medicines? What combination is best? And what about the standard “diet and exercise”?
In this issue of perspectives, Carolyn Newberry, MD, director of GI nutrition at Innovation Center for Health and Nutrition in Gastroenterology, Weill Cornell Medicine, New York, will emphasize the benefits of medical and lifestyle management. Pichamol Jirapinyo, MD, MPH, ABOM, director of bariatric endoscopy fellowship at Brigham and Women’s Hospital/Harvard Medical School, Boston, responds with robust data for endoscopic therapies. We hope that their expert perspectives will help guide you in your own approach to obesity management – certainly no one size fits all. I welcome your thoughts on this growing field in gastroenterology – share with us on Twitter @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Exciting time for endoscopic bariatric and metabolic therapies (EBMTs)
BY PICHAMOL JIRAPINYO, MD, MPH, ABOM
2022 was an exciting year for our field of endoscopic bariatric and metabolic therapy (EBMT). Not only did it mark the 10th year anniversary since the very first-in-human endoscopic sleeve gastroplasty (ESG) performed by Christopher Thompson and Robert Hawes in India, but also the MERIT trial (a randomized-controlled trial on ESG) was published.1 This decade of work led to the OverStitch Endoscopic Suturing System (Apollo Endosurgery, Austin, Tex.) being granted de novo authorization from the Food and Drug Administration for the treatment of obesity and weight regain following bariatric surgery.
Currently, at our institution, we offer four primary EBMTs for patients who are seeking endoscopic weight loss therapy and have not yet undergone prior bariatric surgery. These include the Orbera intragastric balloon (IGB) (Apollo Endosurgery), ESG (Apollo Endosurgery), primary obesity surgery endoluminal (POSE: USGI Medical, San Clemente, Calif.), and a gastric plication procedure using Endomina (Endo Tools Therapeutics, Gosselies, Belgium). While the former two have FDA approval, the latter two devices have FDA clearance for tissue approximation. The indication for primary EBMTs includes having a body mass index of at least 30 kg/m2.
From our experience, patients who present to our bariatric endoscopy clinic consist of three groups. First are those who have tried several anti-obesity medications (AOMs), but are unable to tolerate the side effects or their BMI remains greater than 30 kg/m2. Second are those who have heard about EBMTs and are interested in the procedures. Usually, these patients are either too light to qualify for bariatric surgery (BMI 30-35 kg/m2 or 35-40 kg/m2 without an obesity-related comorbidity) or are not interested in bariatric surgery for a variety of reasons, including its perceived invasiveness. The last group are those whose BMI falls within the “super obese” category, defined as a BMI ≥ 50 kg/m2, who are deemed too high risk to undergo medically necessary procedures, such as an orthopedic, colorectal, or transplant surgery.
During the initial consultation, I always discuss pros and cons of all treatment modalities for obesity with the patients, ranging from lifestyle modification to AOMs, EBMTs, and bariatric surgeries. While the data on AOMs are promising, especially with the most recent FDA-approved semaglutide (Wegovy: Novo Nordisk, Bagsvaerd, Denmark) yielding 14.9% total weight loss (TWL) at 1 year, in reality, the starting doses of this medication have been out of stock for over a year.2 Other AOMs, on the other hand, are associated with 6%-8% TWL and are frequently associated with intolerance due to side effects. In comparison, meta-analyses demonstrate that an IGB is associated with 11.3% TWL and ESG with 16.5% TWL at 1 year. Our recent publication describing a new technique for POSE, also known as a distal POSE procedure with a double-helix technique, demonstrates a 20.3% TWL at 1 year.3 The rate of serious adverse events for EBMTs is low with 0.1% for IGB and 1%-2% for ESG/POSE.
The question regarding a comparison between AOMs and EBMTs comes up quite frequently in clinical practice. In reality, I often encourage my patients to consider combination therapy where I prescribe an AOM at 3-6 months following EBMTs to augment the amount of weight loss. However, since this is a debate, I will highlight a few advantages of EBMTs. First, the amount of weight loss following EBMTs, especially with ESG/POSE (which is currently the most commonly-requested procedure in our practice), tends to be higher than that of most AOMs. Second, while we are eagerly awaiting the long-term safety and efficacy data for semaglutide, ESG has been shown to be durable with the patients maintaining 15.9% TWL at 5 years.4 Third, an EBMT is a one-time procedure. In contrast, AOMs rely on patients’ compliance with taking the medication(s) reliably and indefinitely. A study based on HMO pharmacy data of over a million patients who were prescribed AOMs showed that fewer than 2% completed 12 months of weight loss medication therapy.5 The long-term use of AOMs also has cost implications. Specifically, a month supply of semaglutide costs about $1,400, which translates to $16,800 in 1 year and $84,000 in 5 years, which clearly outweighs the cost of ESG/POSE that has been demonstrated to be durable up to at least 5 years. IGBs have limitations similar to those of AOMs upon removal. Nevertheless, with the average cost of an IGB being $8,000, placing one every year would still be less costly, although this would likely be unnecessary considering the weight loss trend after IGB.
There are a few hurdles that need to be overcome before EBMTs are widely adopted. Reimbursement remains a major issue at most centers in the United States. Currently, most EBMTs are offered as a self-pay procedure, making the majority of patients who are otherwise eligible and interested not able to afford the procedure. With the recently published MERIT trial, long-term data on ESG as well as several upcoming society guidelines on EBMTs, we are hopeful that insurance coverage for EBMTs is nearing. Another important aspect is training. While IGB placement and removal are simple procedures, performing a high-quality ESG/POSE requires rigorous training to ensure safety and optimal outcomes. Several professional societies are working hard to develop curriculums on EBMTs with a focus on hands-on training to ensure endoscopists are properly trained prior to starting their bariatric endoscopy program. At our institution, we have a dedicated training program focusing on bariatric endoscopy (i.e. separate from the traditional advanced endoscopy fellowship), where fellows learn advanced bariatric suturing and plication as well as multidisciplinary care for this patient population. I am hopeful that this kind of training will become more prevalent in the near future.
With mounting evidence supporting the benefits of EBMTs, bariatric endoscopy has revolutionized the care of patients suffering from obesity and its related comorbidities. Moving forward, the field will continue to evolve, and EBMT procedures will only become simpler, safer, and more effective. It is an exciting time for gastroenterologists to get involved.
Dr. Jirapinyo is the director of bariatric endoscopy fellowship at Brigham and Women’s Hospital/Harvard Medical School, Boston. She is board certified in internal medicine, gastroenterology, and obesity medicine and completed her bariatric endoscopy and advanced endoscopy fellowships at Brigham and Women’s Hospital. She serves as a consultant for Apollo Endosurgery, Spatz Medical, and ERBE, and she receives research support from USGI Medical, GI Dynamics, and Fractyl.
References
1. Abu Dayyeh BK et al. Lancet. 2022;400(10350):441-51.
2. Wilding JPH et al. N Engl J Med. 2021;384:989-1002.
3. Jirapinyo P and Thompson CC. Gastrointest Endosc. 2022;96(3):479-86.
4. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2021;19(5):1051-57.
5. Hemo B et al. Diabetes Res Clin Pract. 2011;94(2):269-75.
A new frontier for weight management: Assess your options carefully
BY CAROLYN NEWBERRY, MD
Considering the continued rise in obesity rates in this country coupled with an increase in associated digestive disease burden from conditions such as nonalcoholic fatty liver disease (NAFLD), gastroesophageal reflux disease (GERD), and select gastrointestinal malignancies, I believe it is now more important than ever for gastroenterologists to familiarize themselves with weight management principles and incorporation into clinical practice. A growing arsenal of tools is available for addressing excess weight, including medications and novel endobariatric techniques. Although the latter is an important consideration in patients with obesity, lifestyle counseling with or without weight loss medications sets the stage for sustainable weight loss success and may eliminate the need for procedural intervention. As such, current guidelines set forth by multiple societies, including the American Gastroenterological Association (AGA), emphasize the importance of lifestyle counseling targeting caloric restriction and increased physical activity along with medical augmentation via pharmacological agents in eligible patients.1,2 These guidelines underline the importance of medical weight management prior to consideration of procedural options, including both endobariatrics and more classic bariatric surgeries. This ensures patients understand approaches to weight loss via noninvasive means, reduces risk of weight regain by building foundational habits, and enhances overall success of procedures long term if they are pursued. In addition, newer pharmacological agents are now approaching total body weight loss percentages of currently available endobariatric techniques while still showing high tolerance rates and long-term efficacy, indicating some patients who previously would require procedures to meet weight loss goals may no longer need them.3 Alternatively, these medications may augment efforts prior to procedures, enhancing overall total body weight loss achieved. If patients are not introduced to such options initially and as a part of comprehensive care management planning, they may not achieve the same degree of weight loss success and metabolic optimization.
As a gastroenterologist co-leading a multidisciplinary weight management and lifestyle clinic, I have witnessed firsthand the enhanced outcomes in patients who pursue endobariatric procedures after establishing care with a clinical team and attempting (and succeeding) in weight loss via changes in diet, physical activity, and medication use. Patients should be encouraged to gain understanding of one’s own “personal relationship” with food and/or address medical and social barriers to weight loss maintenance prior to procedural intervention, which requires some lead time and ideally professional expertise from multiple team members, including a dietitian. Weight regain after anti-obesity surgery is common, with significant gain occurring in up to half of patients. Several factors have been associated with weight regain, including lack of consistent follow-up, excess calorie and simple carbohydrate intake, and inconsistent physical activity.4 As such, most insurance companies mandate a trial of at least 6 months of lifestyle and/or medical weight management prior to considering procedural reimbursement. Although robust longitudinal data for endobariatric outcomes is not yet available, it is reasonable to believe similar concepts may be in play. In fact, since endobariatric procedures are less invasive but also therefore more temporal (as in the case of endoscopic balloon placement, which is only approved for 6 months of continuous use), behavioral modification and medical management to reduce risk of significant weight regain is even more imperative. Even in the case of more durable procedures, such as endoscopic gastroplasty, lack of compliance with recommended dietary protocols can reduce efficacy by loosening and even ripping sutures prior to establishment of bridging fibrotic mucosal changes, which enhance longevity of the procedure and support continued gastric restriction and reduction in motility. Some patients who undergo endoscopic gastroplasty end up seeking out revision and repeat procedure later due to lack of results, which may be avoided with alternative dietary and lifestyle decisions in the postprocedural state.
The landscape of non-procedural weight management tools has changed in the last 1-2 years with the approval of newer injectable medications that disrupt insulin and hormonal pathways and produce sustainable weight loss similar to reported outcomes achieved with endobariatric procedures. These medications are becoming increasingly accessible and of interest to patients, with continued destigmatization of the use of weight loss drugs in practice, which had previous negative connotations and concerns regarding safety. New guidelines put forth by the AGA recommend adding pharmacological agents to lifestyle interventions over continuing lifestyle interventions alone if adequate weight loss has not been achieved with the latter.3 This further exemplifies the importance of a multifaceted approach to optimize medical weight management as first-line therapy for obesity and associated comorbidities.
In summary, although endobariatric procedures are an important tool for gastroenterologists to incorporate into their weight management plans, they must be implemented with care and only after lifestyle and medical interventions have failed to produce desired results. Shared decision making among providers and patients enhances weight loss efforts and augments sustainability of outcomes. Considering the rapidly evolving landscape of obesity medicine, gastroenterologists need to continue to stay up to date on best practices to improve patient care, reduce associated morbidity, and enhance outcomes of novel endobariatric procedures.
Dr. Newberry is with the Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), division of gastroenterology, Weill Cornell Medical Center, New York. She disclosed receiving speaker honorariums from Baxter International and InBody USA.
References
1. Acosta et al. Clin Gastroenterol Hepatol. 2017 May;15(5):631-49.
2. Jensen et al. Circulation. 2014;129:S102-38.
3. Grunvald et al. Gastroenterology. 2022;163(5):1198-225.
4. Athansiadis et al. Surg Endosc. 2021 Aug;35(8):4069-84.
Dear colleagues,
Treating obesity easily falls under our purview as gastroenterologists. But like the mouse who would bell the cat, our direct involvement has been limited. However, over the past decade, advances in endobariatrics and medical management have given us many options. But how do we choose from this growing armamentarium of minimally invasive procedures and weight loss medicines? What combination is best? And what about the standard “diet and exercise”?
In this issue of perspectives, Carolyn Newberry, MD, director of GI nutrition at Innovation Center for Health and Nutrition in Gastroenterology, Weill Cornell Medicine, New York, will emphasize the benefits of medical and lifestyle management. Pichamol Jirapinyo, MD, MPH, ABOM, director of bariatric endoscopy fellowship at Brigham and Women’s Hospital/Harvard Medical School, Boston, responds with robust data for endoscopic therapies. We hope that their expert perspectives will help guide you in your own approach to obesity management – certainly no one size fits all. I welcome your thoughts on this growing field in gastroenterology – share with us on Twitter @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Exciting time for endoscopic bariatric and metabolic therapies (EBMTs)
BY PICHAMOL JIRAPINYO, MD, MPH, ABOM
2022 was an exciting year for our field of endoscopic bariatric and metabolic therapy (EBMT). Not only did it mark the 10th year anniversary since the very first-in-human endoscopic sleeve gastroplasty (ESG) performed by Christopher Thompson and Robert Hawes in India, but also the MERIT trial (a randomized-controlled trial on ESG) was published.1 This decade of work led to the OverStitch Endoscopic Suturing System (Apollo Endosurgery, Austin, Tex.) being granted de novo authorization from the Food and Drug Administration for the treatment of obesity and weight regain following bariatric surgery.
Currently, at our institution, we offer four primary EBMTs for patients who are seeking endoscopic weight loss therapy and have not yet undergone prior bariatric surgery. These include the Orbera intragastric balloon (IGB) (Apollo Endosurgery), ESG (Apollo Endosurgery), primary obesity surgery endoluminal (POSE: USGI Medical, San Clemente, Calif.), and a gastric plication procedure using Endomina (Endo Tools Therapeutics, Gosselies, Belgium). While the former two have FDA approval, the latter two devices have FDA clearance for tissue approximation. The indication for primary EBMTs includes having a body mass index of at least 30 kg/m2.
From our experience, patients who present to our bariatric endoscopy clinic consist of three groups. First are those who have tried several anti-obesity medications (AOMs), but are unable to tolerate the side effects or their BMI remains greater than 30 kg/m2. Second are those who have heard about EBMTs and are interested in the procedures. Usually, these patients are either too light to qualify for bariatric surgery (BMI 30-35 kg/m2 or 35-40 kg/m2 without an obesity-related comorbidity) or are not interested in bariatric surgery for a variety of reasons, including its perceived invasiveness. The last group are those whose BMI falls within the “super obese” category, defined as a BMI ≥ 50 kg/m2, who are deemed too high risk to undergo medically necessary procedures, such as an orthopedic, colorectal, or transplant surgery.
During the initial consultation, I always discuss pros and cons of all treatment modalities for obesity with the patients, ranging from lifestyle modification to AOMs, EBMTs, and bariatric surgeries. While the data on AOMs are promising, especially with the most recent FDA-approved semaglutide (Wegovy: Novo Nordisk, Bagsvaerd, Denmark) yielding 14.9% total weight loss (TWL) at 1 year, in reality, the starting doses of this medication have been out of stock for over a year.2 Other AOMs, on the other hand, are associated with 6%-8% TWL and are frequently associated with intolerance due to side effects. In comparison, meta-analyses demonstrate that an IGB is associated with 11.3% TWL and ESG with 16.5% TWL at 1 year. Our recent publication describing a new technique for POSE, also known as a distal POSE procedure with a double-helix technique, demonstrates a 20.3% TWL at 1 year.3 The rate of serious adverse events for EBMTs is low with 0.1% for IGB and 1%-2% for ESG/POSE.
The question regarding a comparison between AOMs and EBMTs comes up quite frequently in clinical practice. In reality, I often encourage my patients to consider combination therapy where I prescribe an AOM at 3-6 months following EBMTs to augment the amount of weight loss. However, since this is a debate, I will highlight a few advantages of EBMTs. First, the amount of weight loss following EBMTs, especially with ESG/POSE (which is currently the most commonly-requested procedure in our practice), tends to be higher than that of most AOMs. Second, while we are eagerly awaiting the long-term safety and efficacy data for semaglutide, ESG has been shown to be durable with the patients maintaining 15.9% TWL at 5 years.4 Third, an EBMT is a one-time procedure. In contrast, AOMs rely on patients’ compliance with taking the medication(s) reliably and indefinitely. A study based on HMO pharmacy data of over a million patients who were prescribed AOMs showed that fewer than 2% completed 12 months of weight loss medication therapy.5 The long-term use of AOMs also has cost implications. Specifically, a month supply of semaglutide costs about $1,400, which translates to $16,800 in 1 year and $84,000 in 5 years, which clearly outweighs the cost of ESG/POSE that has been demonstrated to be durable up to at least 5 years. IGBs have limitations similar to those of AOMs upon removal. Nevertheless, with the average cost of an IGB being $8,000, placing one every year would still be less costly, although this would likely be unnecessary considering the weight loss trend after IGB.
There are a few hurdles that need to be overcome before EBMTs are widely adopted. Reimbursement remains a major issue at most centers in the United States. Currently, most EBMTs are offered as a self-pay procedure, making the majority of patients who are otherwise eligible and interested not able to afford the procedure. With the recently published MERIT trial, long-term data on ESG as well as several upcoming society guidelines on EBMTs, we are hopeful that insurance coverage for EBMTs is nearing. Another important aspect is training. While IGB placement and removal are simple procedures, performing a high-quality ESG/POSE requires rigorous training to ensure safety and optimal outcomes. Several professional societies are working hard to develop curriculums on EBMTs with a focus on hands-on training to ensure endoscopists are properly trained prior to starting their bariatric endoscopy program. At our institution, we have a dedicated training program focusing on bariatric endoscopy (i.e. separate from the traditional advanced endoscopy fellowship), where fellows learn advanced bariatric suturing and plication as well as multidisciplinary care for this patient population. I am hopeful that this kind of training will become more prevalent in the near future.
With mounting evidence supporting the benefits of EBMTs, bariatric endoscopy has revolutionized the care of patients suffering from obesity and its related comorbidities. Moving forward, the field will continue to evolve, and EBMT procedures will only become simpler, safer, and more effective. It is an exciting time for gastroenterologists to get involved.
Dr. Jirapinyo is the director of bariatric endoscopy fellowship at Brigham and Women’s Hospital/Harvard Medical School, Boston. She is board certified in internal medicine, gastroenterology, and obesity medicine and completed her bariatric endoscopy and advanced endoscopy fellowships at Brigham and Women’s Hospital. She serves as a consultant for Apollo Endosurgery, Spatz Medical, and ERBE, and she receives research support from USGI Medical, GI Dynamics, and Fractyl.
References
1. Abu Dayyeh BK et al. Lancet. 2022;400(10350):441-51.
2. Wilding JPH et al. N Engl J Med. 2021;384:989-1002.
3. Jirapinyo P and Thompson CC. Gastrointest Endosc. 2022;96(3):479-86.
4. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2021;19(5):1051-57.
5. Hemo B et al. Diabetes Res Clin Pract. 2011;94(2):269-75.
A new frontier for weight management: Assess your options carefully
BY CAROLYN NEWBERRY, MD
Considering the continued rise in obesity rates in this country coupled with an increase in associated digestive disease burden from conditions such as nonalcoholic fatty liver disease (NAFLD), gastroesophageal reflux disease (GERD), and select gastrointestinal malignancies, I believe it is now more important than ever for gastroenterologists to familiarize themselves with weight management principles and incorporation into clinical practice. A growing arsenal of tools is available for addressing excess weight, including medications and novel endobariatric techniques. Although the latter is an important consideration in patients with obesity, lifestyle counseling with or without weight loss medications sets the stage for sustainable weight loss success and may eliminate the need for procedural intervention. As such, current guidelines set forth by multiple societies, including the American Gastroenterological Association (AGA), emphasize the importance of lifestyle counseling targeting caloric restriction and increased physical activity along with medical augmentation via pharmacological agents in eligible patients.1,2 These guidelines underline the importance of medical weight management prior to consideration of procedural options, including both endobariatrics and more classic bariatric surgeries. This ensures patients understand approaches to weight loss via noninvasive means, reduces risk of weight regain by building foundational habits, and enhances overall success of procedures long term if they are pursued. In addition, newer pharmacological agents are now approaching total body weight loss percentages of currently available endobariatric techniques while still showing high tolerance rates and long-term efficacy, indicating some patients who previously would require procedures to meet weight loss goals may no longer need them.3 Alternatively, these medications may augment efforts prior to procedures, enhancing overall total body weight loss achieved. If patients are not introduced to such options initially and as a part of comprehensive care management planning, they may not achieve the same degree of weight loss success and metabolic optimization.
As a gastroenterologist co-leading a multidisciplinary weight management and lifestyle clinic, I have witnessed firsthand the enhanced outcomes in patients who pursue endobariatric procedures after establishing care with a clinical team and attempting (and succeeding) in weight loss via changes in diet, physical activity, and medication use. Patients should be encouraged to gain understanding of one’s own “personal relationship” with food and/or address medical and social barriers to weight loss maintenance prior to procedural intervention, which requires some lead time and ideally professional expertise from multiple team members, including a dietitian. Weight regain after anti-obesity surgery is common, with significant gain occurring in up to half of patients. Several factors have been associated with weight regain, including lack of consistent follow-up, excess calorie and simple carbohydrate intake, and inconsistent physical activity.4 As such, most insurance companies mandate a trial of at least 6 months of lifestyle and/or medical weight management prior to considering procedural reimbursement. Although robust longitudinal data for endobariatric outcomes is not yet available, it is reasonable to believe similar concepts may be in play. In fact, since endobariatric procedures are less invasive but also therefore more temporal (as in the case of endoscopic balloon placement, which is only approved for 6 months of continuous use), behavioral modification and medical management to reduce risk of significant weight regain is even more imperative. Even in the case of more durable procedures, such as endoscopic gastroplasty, lack of compliance with recommended dietary protocols can reduce efficacy by loosening and even ripping sutures prior to establishment of bridging fibrotic mucosal changes, which enhance longevity of the procedure and support continued gastric restriction and reduction in motility. Some patients who undergo endoscopic gastroplasty end up seeking out revision and repeat procedure later due to lack of results, which may be avoided with alternative dietary and lifestyle decisions in the postprocedural state.
The landscape of non-procedural weight management tools has changed in the last 1-2 years with the approval of newer injectable medications that disrupt insulin and hormonal pathways and produce sustainable weight loss similar to reported outcomes achieved with endobariatric procedures. These medications are becoming increasingly accessible and of interest to patients, with continued destigmatization of the use of weight loss drugs in practice, which had previous negative connotations and concerns regarding safety. New guidelines put forth by the AGA recommend adding pharmacological agents to lifestyle interventions over continuing lifestyle interventions alone if adequate weight loss has not been achieved with the latter.3 This further exemplifies the importance of a multifaceted approach to optimize medical weight management as first-line therapy for obesity and associated comorbidities.
In summary, although endobariatric procedures are an important tool for gastroenterologists to incorporate into their weight management plans, they must be implemented with care and only after lifestyle and medical interventions have failed to produce desired results. Shared decision making among providers and patients enhances weight loss efforts and augments sustainability of outcomes. Considering the rapidly evolving landscape of obesity medicine, gastroenterologists need to continue to stay up to date on best practices to improve patient care, reduce associated morbidity, and enhance outcomes of novel endobariatric procedures.
Dr. Newberry is with the Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), division of gastroenterology, Weill Cornell Medical Center, New York. She disclosed receiving speaker honorariums from Baxter International and InBody USA.
References
1. Acosta et al. Clin Gastroenterol Hepatol. 2017 May;15(5):631-49.
2. Jensen et al. Circulation. 2014;129:S102-38.
3. Grunvald et al. Gastroenterology. 2022;163(5):1198-225.
4. Athansiadis et al. Surg Endosc. 2021 Aug;35(8):4069-84.
Dear colleagues,
Treating obesity easily falls under our purview as gastroenterologists. But like the mouse who would bell the cat, our direct involvement has been limited. However, over the past decade, advances in endobariatrics and medical management have given us many options. But how do we choose from this growing armamentarium of minimally invasive procedures and weight loss medicines? What combination is best? And what about the standard “diet and exercise”?
In this issue of perspectives, Carolyn Newberry, MD, director of GI nutrition at Innovation Center for Health and Nutrition in Gastroenterology, Weill Cornell Medicine, New York, will emphasize the benefits of medical and lifestyle management. Pichamol Jirapinyo, MD, MPH, ABOM, director of bariatric endoscopy fellowship at Brigham and Women’s Hospital/Harvard Medical School, Boston, responds with robust data for endoscopic therapies. We hope that their expert perspectives will help guide you in your own approach to obesity management – certainly no one size fits all. I welcome your thoughts on this growing field in gastroenterology – share with us on Twitter @AGA_GIHN.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.
Exciting time for endoscopic bariatric and metabolic therapies (EBMTs)
BY PICHAMOL JIRAPINYO, MD, MPH, ABOM
2022 was an exciting year for our field of endoscopic bariatric and metabolic therapy (EBMT). Not only did it mark the 10th year anniversary since the very first-in-human endoscopic sleeve gastroplasty (ESG) performed by Christopher Thompson and Robert Hawes in India, but also the MERIT trial (a randomized-controlled trial on ESG) was published.1 This decade of work led to the OverStitch Endoscopic Suturing System (Apollo Endosurgery, Austin, Tex.) being granted de novo authorization from the Food and Drug Administration for the treatment of obesity and weight regain following bariatric surgery.
Currently, at our institution, we offer four primary EBMTs for patients who are seeking endoscopic weight loss therapy and have not yet undergone prior bariatric surgery. These include the Orbera intragastric balloon (IGB) (Apollo Endosurgery), ESG (Apollo Endosurgery), primary obesity surgery endoluminal (POSE: USGI Medical, San Clemente, Calif.), and a gastric plication procedure using Endomina (Endo Tools Therapeutics, Gosselies, Belgium). While the former two have FDA approval, the latter two devices have FDA clearance for tissue approximation. The indication for primary EBMTs includes having a body mass index of at least 30 kg/m2.
From our experience, patients who present to our bariatric endoscopy clinic consist of three groups. First are those who have tried several anti-obesity medications (AOMs), but are unable to tolerate the side effects or their BMI remains greater than 30 kg/m2. Second are those who have heard about EBMTs and are interested in the procedures. Usually, these patients are either too light to qualify for bariatric surgery (BMI 30-35 kg/m2 or 35-40 kg/m2 without an obesity-related comorbidity) or are not interested in bariatric surgery for a variety of reasons, including its perceived invasiveness. The last group are those whose BMI falls within the “super obese” category, defined as a BMI ≥ 50 kg/m2, who are deemed too high risk to undergo medically necessary procedures, such as an orthopedic, colorectal, or transplant surgery.
During the initial consultation, I always discuss pros and cons of all treatment modalities for obesity with the patients, ranging from lifestyle modification to AOMs, EBMTs, and bariatric surgeries. While the data on AOMs are promising, especially with the most recent FDA-approved semaglutide (Wegovy: Novo Nordisk, Bagsvaerd, Denmark) yielding 14.9% total weight loss (TWL) at 1 year, in reality, the starting doses of this medication have been out of stock for over a year.2 Other AOMs, on the other hand, are associated with 6%-8% TWL and are frequently associated with intolerance due to side effects. In comparison, meta-analyses demonstrate that an IGB is associated with 11.3% TWL and ESG with 16.5% TWL at 1 year. Our recent publication describing a new technique for POSE, also known as a distal POSE procedure with a double-helix technique, demonstrates a 20.3% TWL at 1 year.3 The rate of serious adverse events for EBMTs is low with 0.1% for IGB and 1%-2% for ESG/POSE.
The question regarding a comparison between AOMs and EBMTs comes up quite frequently in clinical practice. In reality, I often encourage my patients to consider combination therapy where I prescribe an AOM at 3-6 months following EBMTs to augment the amount of weight loss. However, since this is a debate, I will highlight a few advantages of EBMTs. First, the amount of weight loss following EBMTs, especially with ESG/POSE (which is currently the most commonly-requested procedure in our practice), tends to be higher than that of most AOMs. Second, while we are eagerly awaiting the long-term safety and efficacy data for semaglutide, ESG has been shown to be durable with the patients maintaining 15.9% TWL at 5 years.4 Third, an EBMT is a one-time procedure. In contrast, AOMs rely on patients’ compliance with taking the medication(s) reliably and indefinitely. A study based on HMO pharmacy data of over a million patients who were prescribed AOMs showed that fewer than 2% completed 12 months of weight loss medication therapy.5 The long-term use of AOMs also has cost implications. Specifically, a month supply of semaglutide costs about $1,400, which translates to $16,800 in 1 year and $84,000 in 5 years, which clearly outweighs the cost of ESG/POSE that has been demonstrated to be durable up to at least 5 years. IGBs have limitations similar to those of AOMs upon removal. Nevertheless, with the average cost of an IGB being $8,000, placing one every year would still be less costly, although this would likely be unnecessary considering the weight loss trend after IGB.
There are a few hurdles that need to be overcome before EBMTs are widely adopted. Reimbursement remains a major issue at most centers in the United States. Currently, most EBMTs are offered as a self-pay procedure, making the majority of patients who are otherwise eligible and interested not able to afford the procedure. With the recently published MERIT trial, long-term data on ESG as well as several upcoming society guidelines on EBMTs, we are hopeful that insurance coverage for EBMTs is nearing. Another important aspect is training. While IGB placement and removal are simple procedures, performing a high-quality ESG/POSE requires rigorous training to ensure safety and optimal outcomes. Several professional societies are working hard to develop curriculums on EBMTs with a focus on hands-on training to ensure endoscopists are properly trained prior to starting their bariatric endoscopy program. At our institution, we have a dedicated training program focusing on bariatric endoscopy (i.e. separate from the traditional advanced endoscopy fellowship), where fellows learn advanced bariatric suturing and plication as well as multidisciplinary care for this patient population. I am hopeful that this kind of training will become more prevalent in the near future.
With mounting evidence supporting the benefits of EBMTs, bariatric endoscopy has revolutionized the care of patients suffering from obesity and its related comorbidities. Moving forward, the field will continue to evolve, and EBMT procedures will only become simpler, safer, and more effective. It is an exciting time for gastroenterologists to get involved.
Dr. Jirapinyo is the director of bariatric endoscopy fellowship at Brigham and Women’s Hospital/Harvard Medical School, Boston. She is board certified in internal medicine, gastroenterology, and obesity medicine and completed her bariatric endoscopy and advanced endoscopy fellowships at Brigham and Women’s Hospital. She serves as a consultant for Apollo Endosurgery, Spatz Medical, and ERBE, and she receives research support from USGI Medical, GI Dynamics, and Fractyl.
References
1. Abu Dayyeh BK et al. Lancet. 2022;400(10350):441-51.
2. Wilding JPH et al. N Engl J Med. 2021;384:989-1002.
3. Jirapinyo P and Thompson CC. Gastrointest Endosc. 2022;96(3):479-86.
4. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2021;19(5):1051-57.
5. Hemo B et al. Diabetes Res Clin Pract. 2011;94(2):269-75.
A new frontier for weight management: Assess your options carefully
BY CAROLYN NEWBERRY, MD
Considering the continued rise in obesity rates in this country coupled with an increase in associated digestive disease burden from conditions such as nonalcoholic fatty liver disease (NAFLD), gastroesophageal reflux disease (GERD), and select gastrointestinal malignancies, I believe it is now more important than ever for gastroenterologists to familiarize themselves with weight management principles and incorporation into clinical practice. A growing arsenal of tools is available for addressing excess weight, including medications and novel endobariatric techniques. Although the latter is an important consideration in patients with obesity, lifestyle counseling with or without weight loss medications sets the stage for sustainable weight loss success and may eliminate the need for procedural intervention. As such, current guidelines set forth by multiple societies, including the American Gastroenterological Association (AGA), emphasize the importance of lifestyle counseling targeting caloric restriction and increased physical activity along with medical augmentation via pharmacological agents in eligible patients.1,2 These guidelines underline the importance of medical weight management prior to consideration of procedural options, including both endobariatrics and more classic bariatric surgeries. This ensures patients understand approaches to weight loss via noninvasive means, reduces risk of weight regain by building foundational habits, and enhances overall success of procedures long term if they are pursued. In addition, newer pharmacological agents are now approaching total body weight loss percentages of currently available endobariatric techniques while still showing high tolerance rates and long-term efficacy, indicating some patients who previously would require procedures to meet weight loss goals may no longer need them.3 Alternatively, these medications may augment efforts prior to procedures, enhancing overall total body weight loss achieved. If patients are not introduced to such options initially and as a part of comprehensive care management planning, they may not achieve the same degree of weight loss success and metabolic optimization.
As a gastroenterologist co-leading a multidisciplinary weight management and lifestyle clinic, I have witnessed firsthand the enhanced outcomes in patients who pursue endobariatric procedures after establishing care with a clinical team and attempting (and succeeding) in weight loss via changes in diet, physical activity, and medication use. Patients should be encouraged to gain understanding of one’s own “personal relationship” with food and/or address medical and social barriers to weight loss maintenance prior to procedural intervention, which requires some lead time and ideally professional expertise from multiple team members, including a dietitian. Weight regain after anti-obesity surgery is common, with significant gain occurring in up to half of patients. Several factors have been associated with weight regain, including lack of consistent follow-up, excess calorie and simple carbohydrate intake, and inconsistent physical activity.4 As such, most insurance companies mandate a trial of at least 6 months of lifestyle and/or medical weight management prior to considering procedural reimbursement. Although robust longitudinal data for endobariatric outcomes is not yet available, it is reasonable to believe similar concepts may be in play. In fact, since endobariatric procedures are less invasive but also therefore more temporal (as in the case of endoscopic balloon placement, which is only approved for 6 months of continuous use), behavioral modification and medical management to reduce risk of significant weight regain is even more imperative. Even in the case of more durable procedures, such as endoscopic gastroplasty, lack of compliance with recommended dietary protocols can reduce efficacy by loosening and even ripping sutures prior to establishment of bridging fibrotic mucosal changes, which enhance longevity of the procedure and support continued gastric restriction and reduction in motility. Some patients who undergo endoscopic gastroplasty end up seeking out revision and repeat procedure later due to lack of results, which may be avoided with alternative dietary and lifestyle decisions in the postprocedural state.
The landscape of non-procedural weight management tools has changed in the last 1-2 years with the approval of newer injectable medications that disrupt insulin and hormonal pathways and produce sustainable weight loss similar to reported outcomes achieved with endobariatric procedures. These medications are becoming increasingly accessible and of interest to patients, with continued destigmatization of the use of weight loss drugs in practice, which had previous negative connotations and concerns regarding safety. New guidelines put forth by the AGA recommend adding pharmacological agents to lifestyle interventions over continuing lifestyle interventions alone if adequate weight loss has not been achieved with the latter.3 This further exemplifies the importance of a multifaceted approach to optimize medical weight management as first-line therapy for obesity and associated comorbidities.
In summary, although endobariatric procedures are an important tool for gastroenterologists to incorporate into their weight management plans, they must be implemented with care and only after lifestyle and medical interventions have failed to produce desired results. Shared decision making among providers and patients enhances weight loss efforts and augments sustainability of outcomes. Considering the rapidly evolving landscape of obesity medicine, gastroenterologists need to continue to stay up to date on best practices to improve patient care, reduce associated morbidity, and enhance outcomes of novel endobariatric procedures.
Dr. Newberry is with the Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), division of gastroenterology, Weill Cornell Medical Center, New York. She disclosed receiving speaker honorariums from Baxter International and InBody USA.
References
1. Acosta et al. Clin Gastroenterol Hepatol. 2017 May;15(5):631-49.
2. Jensen et al. Circulation. 2014;129:S102-38.
3. Grunvald et al. Gastroenterology. 2022;163(5):1198-225.
4. Athansiadis et al. Surg Endosc. 2021 Aug;35(8):4069-84.
Mild shortness of breath
This patient's clinical presentation of weight gain and associated symptoms are most closely related to a diagnosis of obesity. In addition, her laboratory findings are consistent with common obesity complications, including prediabetes and dyslipidemia, and her blood pressure is borderline high.
Obesity is a chronic, multifactorial disease with a complex pathogenesis comprising of genetic, biological, psychosocial, socioeconomic, and environmental factors. It is a heterogeneous disease characterized by a dysfunction of the normal pathways and mechanisms that are involved in body fat regulation (often referred to as weight regulation), which may lead to variable presentation and complications. According to the US Centers for Disease Control and Prevention, the highest age-adjusted prevalence of obesity is seen in non-Hispanic Black adults (49.9%), followed by Hispanic adults (45.6%), non-Hispanic White adults (41.4%), and non-Hispanic Asian adults (16.1%).
Epidemiologic studies have defined obesity as a BMI > 30, which is then subclassified into class 1 (BMI of 30-34.9), class 2 (BMI of 35-39.9), or class 3 (BMI ≥ 40) obesity. Though BMI is widely used to evaluate and classify obesity, it mainly represents general adiposity and can be confounded by excessive muscle mass or frailty. Guidelines from the American Diabetes Association state that in addition to weight and BMI, clinicians should consider weight distribution (including predisposition for central/visceral adipose deposition) and weight gain pattern and trajectory because these can help guide risk stratification and treatment options.
Increasingly, evidence supports visceral adiposity, or abdominal obesity, as a marker of cardiovascular risk. Abdominal obesity has been shown to be a strong independent predictor of mortality. On its own, BMI is an insufficient biomarker of abdominal obesity. Not all individuals with obesity have a central distribution of their weight; some individuals may have central obesity without meeting the criteria for the BMI definition of obesity. This can lead to misclassification and underdiagnosis of health risks in clinical practice. Consequently, numerous organizations and expert panels have recommended that waist circumference be measured along with BMI, specifically when the BMI < 35. Measurement of both BMI and waist circumference provides valuable opportunities to counsel patients regarding their risk for cardiovascular disease and other complications of obesity. Waist-to-hip ratio has also been shown to be a stronger predictor for mortality compared with BMI; however, it is rarely measured in clinical practice.
Although rarely performed outside of research settings, measurement of epicardial and pericardial fat via CT is also emerging as a potentially useful approach for informing predictive and precision medicine strategies. Recently, the Jackson Heart Study showed pericardial and visceral fat volumes were associated with incident heart failure, particularly heart failure with preserved ejection fraction, and all-cause mortality among Black participants even after adjusting for age, sex, education, and smoking status. Another recent study showed an increased risk of heart failure, particularly heart failure with preserved ejection fraction, among men and women with high pericardial fat volume. The Multi-Ethnic Study of Atherosclerosis showed that pericardial fat was associated with a higher risk of all-cause cardiovascular disease, hard atherosclerotic cardiovascular disease, and heart failure. Epicardial fat is directly correlated with BMI, visceral adiposity, and waist circumference.
Best practices for the management of obesity begin with recognizing and treating it as a complex chronic disease rather than the result of an individual's lifestyle choices. According to a 2020 joint international consensus statement for ending the stigma of obesity, the assumption that choosing to eat less and/or exercise more can entirely prevent or reverse obesity is contradicted by a definitive body of biological and clinical evidence that shows obesity results primarily from a complex combination of genetic, epigenetic, and environmental factors. When diagnosing patients with obesity, it may be helpful for clinicians to acknowledge that the term obesity is often perceived as an undesirable term because it has been associated with stigma but that it is in fact a clinical diagnosis, not a judgement. Many patients prefer the neutral term unhealthy weight over obesity.
As with other chronic diseases, individualized treatment and long-term support along with shared decision-making are essential for optimizing outcomes. Key components of obesity management include diet, exercise, and behavioral modification. In addition, an increasing array of pharmacologic therapies are also showing unprecedented efficacy for weight management, including several drugs that are also approved for the management of type 2 diabetes. In particular, the glucagonlike peptide 1 (GLP-1) agonists, semaglutide and liraglutide, and the novel glucose-dependent insulinotropic polypeptide (GIP)–GLP-1 receptor agonist, tirzepatide have been associated with significant weight loss. Semaglutide and liraglutide have been US Food and Drug Administration (FDA)–approved for chronic weight management and tirzepatide was granted fast track designation for the treatment of obesity by the FDA in October 2022. These drugs may also help to prevent the progression of prediabetes to diabetes. For individuals with severe obesity, metabolic and bariatric surgery is an effective treatment option that is associated with clinically significant and relatively sustained weight reduction in addition to significant amelioration of related complications.
W. Scott Butsch, MD, MSc, Director of Obesity Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.
Dr. Butsch has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novo Nordisk, Inc.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
This patient's clinical presentation of weight gain and associated symptoms are most closely related to a diagnosis of obesity. In addition, her laboratory findings are consistent with common obesity complications, including prediabetes and dyslipidemia, and her blood pressure is borderline high.
Obesity is a chronic, multifactorial disease with a complex pathogenesis comprising of genetic, biological, psychosocial, socioeconomic, and environmental factors. It is a heterogeneous disease characterized by a dysfunction of the normal pathways and mechanisms that are involved in body fat regulation (often referred to as weight regulation), which may lead to variable presentation and complications. According to the US Centers for Disease Control and Prevention, the highest age-adjusted prevalence of obesity is seen in non-Hispanic Black adults (49.9%), followed by Hispanic adults (45.6%), non-Hispanic White adults (41.4%), and non-Hispanic Asian adults (16.1%).
Epidemiologic studies have defined obesity as a BMI > 30, which is then subclassified into class 1 (BMI of 30-34.9), class 2 (BMI of 35-39.9), or class 3 (BMI ≥ 40) obesity. Though BMI is widely used to evaluate and classify obesity, it mainly represents general adiposity and can be confounded by excessive muscle mass or frailty. Guidelines from the American Diabetes Association state that in addition to weight and BMI, clinicians should consider weight distribution (including predisposition for central/visceral adipose deposition) and weight gain pattern and trajectory because these can help guide risk stratification and treatment options.
Increasingly, evidence supports visceral adiposity, or abdominal obesity, as a marker of cardiovascular risk. Abdominal obesity has been shown to be a strong independent predictor of mortality. On its own, BMI is an insufficient biomarker of abdominal obesity. Not all individuals with obesity have a central distribution of their weight; some individuals may have central obesity without meeting the criteria for the BMI definition of obesity. This can lead to misclassification and underdiagnosis of health risks in clinical practice. Consequently, numerous organizations and expert panels have recommended that waist circumference be measured along with BMI, specifically when the BMI < 35. Measurement of both BMI and waist circumference provides valuable opportunities to counsel patients regarding their risk for cardiovascular disease and other complications of obesity. Waist-to-hip ratio has also been shown to be a stronger predictor for mortality compared with BMI; however, it is rarely measured in clinical practice.
Although rarely performed outside of research settings, measurement of epicardial and pericardial fat via CT is also emerging as a potentially useful approach for informing predictive and precision medicine strategies. Recently, the Jackson Heart Study showed pericardial and visceral fat volumes were associated with incident heart failure, particularly heart failure with preserved ejection fraction, and all-cause mortality among Black participants even after adjusting for age, sex, education, and smoking status. Another recent study showed an increased risk of heart failure, particularly heart failure with preserved ejection fraction, among men and women with high pericardial fat volume. The Multi-Ethnic Study of Atherosclerosis showed that pericardial fat was associated with a higher risk of all-cause cardiovascular disease, hard atherosclerotic cardiovascular disease, and heart failure. Epicardial fat is directly correlated with BMI, visceral adiposity, and waist circumference.
Best practices for the management of obesity begin with recognizing and treating it as a complex chronic disease rather than the result of an individual's lifestyle choices. According to a 2020 joint international consensus statement for ending the stigma of obesity, the assumption that choosing to eat less and/or exercise more can entirely prevent or reverse obesity is contradicted by a definitive body of biological and clinical evidence that shows obesity results primarily from a complex combination of genetic, epigenetic, and environmental factors. When diagnosing patients with obesity, it may be helpful for clinicians to acknowledge that the term obesity is often perceived as an undesirable term because it has been associated with stigma but that it is in fact a clinical diagnosis, not a judgement. Many patients prefer the neutral term unhealthy weight over obesity.
As with other chronic diseases, individualized treatment and long-term support along with shared decision-making are essential for optimizing outcomes. Key components of obesity management include diet, exercise, and behavioral modification. In addition, an increasing array of pharmacologic therapies are also showing unprecedented efficacy for weight management, including several drugs that are also approved for the management of type 2 diabetes. In particular, the glucagonlike peptide 1 (GLP-1) agonists, semaglutide and liraglutide, and the novel glucose-dependent insulinotropic polypeptide (GIP)–GLP-1 receptor agonist, tirzepatide have been associated with significant weight loss. Semaglutide and liraglutide have been US Food and Drug Administration (FDA)–approved for chronic weight management and tirzepatide was granted fast track designation for the treatment of obesity by the FDA in October 2022. These drugs may also help to prevent the progression of prediabetes to diabetes. For individuals with severe obesity, metabolic and bariatric surgery is an effective treatment option that is associated with clinically significant and relatively sustained weight reduction in addition to significant amelioration of related complications.
W. Scott Butsch, MD, MSc, Director of Obesity Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.
Dr. Butsch has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novo Nordisk, Inc.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
This patient's clinical presentation of weight gain and associated symptoms are most closely related to a diagnosis of obesity. In addition, her laboratory findings are consistent with common obesity complications, including prediabetes and dyslipidemia, and her blood pressure is borderline high.
Obesity is a chronic, multifactorial disease with a complex pathogenesis comprising of genetic, biological, psychosocial, socioeconomic, and environmental factors. It is a heterogeneous disease characterized by a dysfunction of the normal pathways and mechanisms that are involved in body fat regulation (often referred to as weight regulation), which may lead to variable presentation and complications. According to the US Centers for Disease Control and Prevention, the highest age-adjusted prevalence of obesity is seen in non-Hispanic Black adults (49.9%), followed by Hispanic adults (45.6%), non-Hispanic White adults (41.4%), and non-Hispanic Asian adults (16.1%).
Epidemiologic studies have defined obesity as a BMI > 30, which is then subclassified into class 1 (BMI of 30-34.9), class 2 (BMI of 35-39.9), or class 3 (BMI ≥ 40) obesity. Though BMI is widely used to evaluate and classify obesity, it mainly represents general adiposity and can be confounded by excessive muscle mass or frailty. Guidelines from the American Diabetes Association state that in addition to weight and BMI, clinicians should consider weight distribution (including predisposition for central/visceral adipose deposition) and weight gain pattern and trajectory because these can help guide risk stratification and treatment options.
Increasingly, evidence supports visceral adiposity, or abdominal obesity, as a marker of cardiovascular risk. Abdominal obesity has been shown to be a strong independent predictor of mortality. On its own, BMI is an insufficient biomarker of abdominal obesity. Not all individuals with obesity have a central distribution of their weight; some individuals may have central obesity without meeting the criteria for the BMI definition of obesity. This can lead to misclassification and underdiagnosis of health risks in clinical practice. Consequently, numerous organizations and expert panels have recommended that waist circumference be measured along with BMI, specifically when the BMI < 35. Measurement of both BMI and waist circumference provides valuable opportunities to counsel patients regarding their risk for cardiovascular disease and other complications of obesity. Waist-to-hip ratio has also been shown to be a stronger predictor for mortality compared with BMI; however, it is rarely measured in clinical practice.
Although rarely performed outside of research settings, measurement of epicardial and pericardial fat via CT is also emerging as a potentially useful approach for informing predictive and precision medicine strategies. Recently, the Jackson Heart Study showed pericardial and visceral fat volumes were associated with incident heart failure, particularly heart failure with preserved ejection fraction, and all-cause mortality among Black participants even after adjusting for age, sex, education, and smoking status. Another recent study showed an increased risk of heart failure, particularly heart failure with preserved ejection fraction, among men and women with high pericardial fat volume. The Multi-Ethnic Study of Atherosclerosis showed that pericardial fat was associated with a higher risk of all-cause cardiovascular disease, hard atherosclerotic cardiovascular disease, and heart failure. Epicardial fat is directly correlated with BMI, visceral adiposity, and waist circumference.
Best practices for the management of obesity begin with recognizing and treating it as a complex chronic disease rather than the result of an individual's lifestyle choices. According to a 2020 joint international consensus statement for ending the stigma of obesity, the assumption that choosing to eat less and/or exercise more can entirely prevent or reverse obesity is contradicted by a definitive body of biological and clinical evidence that shows obesity results primarily from a complex combination of genetic, epigenetic, and environmental factors. When diagnosing patients with obesity, it may be helpful for clinicians to acknowledge that the term obesity is often perceived as an undesirable term because it has been associated with stigma but that it is in fact a clinical diagnosis, not a judgement. Many patients prefer the neutral term unhealthy weight over obesity.
As with other chronic diseases, individualized treatment and long-term support along with shared decision-making are essential for optimizing outcomes. Key components of obesity management include diet, exercise, and behavioral modification. In addition, an increasing array of pharmacologic therapies are also showing unprecedented efficacy for weight management, including several drugs that are also approved for the management of type 2 diabetes. In particular, the glucagonlike peptide 1 (GLP-1) agonists, semaglutide and liraglutide, and the novel glucose-dependent insulinotropic polypeptide (GIP)–GLP-1 receptor agonist, tirzepatide have been associated with significant weight loss. Semaglutide and liraglutide have been US Food and Drug Administration (FDA)–approved for chronic weight management and tirzepatide was granted fast track designation for the treatment of obesity by the FDA in October 2022. These drugs may also help to prevent the progression of prediabetes to diabetes. For individuals with severe obesity, metabolic and bariatric surgery is an effective treatment option that is associated with clinically significant and relatively sustained weight reduction in addition to significant amelioration of related complications.
W. Scott Butsch, MD, MSc, Director of Obesity Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio.
Dr. Butsch has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novo Nordisk, Inc.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
A 33-year-old African American woman presents for an initial consultation. The patient states that it has been several years since she received regular medical care because she did not have health insurance. She recently started a new job as an IT professional that has healthcare benefits. She does not currently take any medications. She reports mild shortness of breath upon exertion, which has worsened in the last year. She denies dizziness, chest pain, wheezing, cough, fever, or other associated symptoms. There is no history of any cardiac or pulmonary diseases as a child. The patient does not smoke or engage in recreational drug use. She is conscious of her diet and avoids red meat as well as sugary and processed foods. Although she was active in the past, she notes that she has been less intentional with her physical activity and has been living a more sedentary lifestyle recently. She has gained more than 40 lb over the past 3 years.
The patient is 5 ft 8 in, her weight is 266 lb (BMI 40.4), and her blood pressure is 140/90 mm Hg. Her pulse oximeter is 97%; however, this result should be interpreted with caution and in consideration of the patient's other signs and symptoms because numerous studies have shown inaccuracies in pulse oximeter readings among people with darker skin. Her physical exam is unremarkable except for a waist circumference of 49 in; breathing sounds are normal and no dermatologic abnormalities are noted.
An ECG is performed and is normal. A chest radiograph shows normal heart and blood vessel structures and airways of the lungs. Pertinent laboratory findings include A1c of 6.4%, HDL cholesterol of 37 mg/dL, LDL cholesterol of 185 mg/dL, serum creatinine of 1.1 mg/dL; AST of 27 U/L; ALT of 35 IU/L; and TSH of 4.2 mIU/L.
Does vitamin D deficiency cause obesity or vice versa?
A recent study found that people with obesity have lower blood levels of vitamin D than people of healthy weight. This association of obesity with low vitamin D levels has led to much speculation on whether low vitamin D levels cause obesity or whether obesity causes low vitamin D levels. The interest in this topic is piqued by the possibility that if vitamin D deficiency causes obesity, perhaps treatment could be as simple as providing vitamin D supplementation to enhance weight loss.
What is known about vitamin D’s role in the body?
It’s well known that vitamin D is essential for bone health as well as balancing the minerals calcium and phosphorus, but what is its role in weight management? Approximately 80%-90% of vitamin D in the body is from the skin synthesis of cholecalciferol through ultraviolet B radiation from sun exposure. The normal range of 25-hydroxy vitamin D is measured as nanograms per milliliter (ng/mL). Most experts recommend a level between 20 and 40 ng/mL, but this has been a controversial topic of never-ending debate in the medical literature.
Vitamin D levels and obesity
This has been noted for many years without identifying the underlying reasons beyond the sequestering of vitamin D in adipose tissue, although I’ll discuss other possibilities.
The inverse correlation between vitamin D and obesity has been seen in other diseases, such as cardiovascular disease, hypertension, prediabetes, and insulin resistance, as well as in sarcopenia and aging. Most studies emphasized the correlation between increasing adiposity with vitamin D deficiency in all ethnic and age groups. The causes and potential direct consequences of the vitamin D deficiency state in obesity are not well understood.
Vitamin D and adipose tissue
It’s been proposed that low vitamin D status in obesity might be due to increased vitamin D clearance from serum and enhanced storage of vitamin D by adipose tissue.
In adipose tissue, vitamin D exerts a variety of effects on inflammation, innate immunity, metabolism, and differentiation and apoptosis in many cell types. There is a stronger association between 25(OH)D and visceral fat as compared to subcutaneous adipose tissue, which suggests an influence of inflammation and components of the metabolic syndrome on vitamin D metabolism.
Because vitamin D has anti-inflammatory properties, it’s possible that low vitamin D status contributes to adipose tissue inflammation, a key link between obesity and its associated metabolic complications in obesity. A higher storage of vitamin D in adipose tissue, if accompanied by a parallel increase in the local synthesis of 1,25(OH)2D3 and action, may conceivably modulate adipocyte function as well as the activity of adipose tissue macrophages and hence the level of adipose tissue inflammation. In addition, it seems likely that 1,25(OH)2D3 also regulates the function of macrophages and other immune cell populations within adipose tissue.
It’s well known that vitamin D is stored in body fat, leading to the assumption that this was important in the evolution of vertebrates, including humans, who lived at latitudes where vitamin D could not be made in the winter and vitamin D stores had to be mobilized to maintain vitamin D sufficiency.
What is vitamin D’s role in obesity?
The main question that has eluded an answer so far is this one: Is vitamin D deficiency only a coincidental finding in obesity due to sequestration of the vitamin in fat, or does it have a role in the development of obesity and its complications, such as cardiovascular disease, type 2 diabetes, and hypertension?
Low vitamin D usually leads to impaired calcium absorption in the intestine and a lower calcium level, and eventually enhanced bone turnover and impaired bone mineral density (BMD).
However, it is known that in obesity there is greater BMD than in those who are lean. This leads to the conclusion that because there is a lack of vitamin D deficiency effects on bone in those with obesity, there is not really a vitamin D deficiency, and it may be that the sequestration in adipose tissue leads to a permanent supply that can maintain bone health.
An alternative explanation is that there is greater skeletal loading in obesity, and elevations in hormones such as estrogen and leptin could compensate for the vitamin D deficiency, leading to greater BMD in obesity.
Several other potential mechanisms besides sequestration of vitamin D in adipose tissue have been identified for low vitamin D and obesity. These include impaired hepatic 25-hydroxylation in nonalcoholic fatty liver disease, less sunlight exposure due to lower mobility and different clothing habits in people with obesity vs. their lean counterparts, and adverse dietary habits. For example, people with higher BMIs spend less time exercising outdoors and are more sedentary in general than their lean counterparts. Therefore, they are less likely to get sun exposure because of a decrease in time spent outdoors. Those with higher BMIs also tend to cover their bodies, showing less skin when outdoors than their leaner counterparts, and thus there is likely to be less conversion to vitamin D via skin and sun exposure in people with obesity.
Some studies suggest that an increased level of parathyroid hormone due to vitamin D deficiency promotes lipogenesis because of greater calcium influx in adipocytes. Another hypothesis is that the active form of vitamin D, 1,25(OH) D, inhibits adipogenesis through actions modulated by vitamin D receptors. These studies are promising, but prospective randomized trials are needed to determine whether vitamin D supplementation is a treatment option in preventing obesity. So far, vitamin D supplementation shows inconsistent results.
To conclude, there is a high prevalence of vitamin D deficiency in obesity, most likely because of dilution and sequestration in greater volumes of fat, blood muscle, and liver in obesity. Low vitamin D levels can’t be ruled out as a cause of obesity because of the research showing some interesting findings in vitamin D receptors in adipose tissue. Vitamin D deficiency in obesity doesn’t seem to affect bone mass but could have deleterious effects on other organ systems.
Weight loss improves obesity and complications, including the risk for cardiovascular disease and type 2 diabetes as well as vitamin D deficiency.
What do the guidelines say?
Treatment of vitamin D deficiency requires higher doses in obesity to achieve the same serum concentration compared with lean persons. Maintenance doses should not differ between those with obesity and lean persons.
The association of vitamin D and obesity remains elusive. Studies need to focus on vitamin D, vitamin D receptors, and actions of vitamin D in adipose tissue to investigate this relationship further.
In the meantime, media attention remains focused on the potential treatment and prevention of obesity with the mighty, all-purpose vitamin D, even though there is scant evidence.
Dr. Apovian is codirector at the Center for Weight Management and Wellness at Brigham and Women’s Hospital and professor of medicine in the division of endocrinology, diabetes and hypertension at Harvard University, Boston. She disclosed conflicts of interest with Abbott, Allergan, Altimmune, Bariatrix Nutrition, Cowen and Company, Curavit, Rhythm Pharma, Jazz, Nutrisystem, Roman, Novo Nordisk, EnteroMedics, Gelesis Srl, Zafgen, Xeno, L-Nutra, Tivity, and Real Appeal.
A version of this article first appeared on Medscape.com.
A recent study found that people with obesity have lower blood levels of vitamin D than people of healthy weight. This association of obesity with low vitamin D levels has led to much speculation on whether low vitamin D levels cause obesity or whether obesity causes low vitamin D levels. The interest in this topic is piqued by the possibility that if vitamin D deficiency causes obesity, perhaps treatment could be as simple as providing vitamin D supplementation to enhance weight loss.
What is known about vitamin D’s role in the body?
It’s well known that vitamin D is essential for bone health as well as balancing the minerals calcium and phosphorus, but what is its role in weight management? Approximately 80%-90% of vitamin D in the body is from the skin synthesis of cholecalciferol through ultraviolet B radiation from sun exposure. The normal range of 25-hydroxy vitamin D is measured as nanograms per milliliter (ng/mL). Most experts recommend a level between 20 and 40 ng/mL, but this has been a controversial topic of never-ending debate in the medical literature.
Vitamin D levels and obesity
This has been noted for many years without identifying the underlying reasons beyond the sequestering of vitamin D in adipose tissue, although I’ll discuss other possibilities.
The inverse correlation between vitamin D and obesity has been seen in other diseases, such as cardiovascular disease, hypertension, prediabetes, and insulin resistance, as well as in sarcopenia and aging. Most studies emphasized the correlation between increasing adiposity with vitamin D deficiency in all ethnic and age groups. The causes and potential direct consequences of the vitamin D deficiency state in obesity are not well understood.
Vitamin D and adipose tissue
It’s been proposed that low vitamin D status in obesity might be due to increased vitamin D clearance from serum and enhanced storage of vitamin D by adipose tissue.
In adipose tissue, vitamin D exerts a variety of effects on inflammation, innate immunity, metabolism, and differentiation and apoptosis in many cell types. There is a stronger association between 25(OH)D and visceral fat as compared to subcutaneous adipose tissue, which suggests an influence of inflammation and components of the metabolic syndrome on vitamin D metabolism.
Because vitamin D has anti-inflammatory properties, it’s possible that low vitamin D status contributes to adipose tissue inflammation, a key link between obesity and its associated metabolic complications in obesity. A higher storage of vitamin D in adipose tissue, if accompanied by a parallel increase in the local synthesis of 1,25(OH)2D3 and action, may conceivably modulate adipocyte function as well as the activity of adipose tissue macrophages and hence the level of adipose tissue inflammation. In addition, it seems likely that 1,25(OH)2D3 also regulates the function of macrophages and other immune cell populations within adipose tissue.
It’s well known that vitamin D is stored in body fat, leading to the assumption that this was important in the evolution of vertebrates, including humans, who lived at latitudes where vitamin D could not be made in the winter and vitamin D stores had to be mobilized to maintain vitamin D sufficiency.
What is vitamin D’s role in obesity?
The main question that has eluded an answer so far is this one: Is vitamin D deficiency only a coincidental finding in obesity due to sequestration of the vitamin in fat, or does it have a role in the development of obesity and its complications, such as cardiovascular disease, type 2 diabetes, and hypertension?
Low vitamin D usually leads to impaired calcium absorption in the intestine and a lower calcium level, and eventually enhanced bone turnover and impaired bone mineral density (BMD).
However, it is known that in obesity there is greater BMD than in those who are lean. This leads to the conclusion that because there is a lack of vitamin D deficiency effects on bone in those with obesity, there is not really a vitamin D deficiency, and it may be that the sequestration in adipose tissue leads to a permanent supply that can maintain bone health.
An alternative explanation is that there is greater skeletal loading in obesity, and elevations in hormones such as estrogen and leptin could compensate for the vitamin D deficiency, leading to greater BMD in obesity.
Several other potential mechanisms besides sequestration of vitamin D in adipose tissue have been identified for low vitamin D and obesity. These include impaired hepatic 25-hydroxylation in nonalcoholic fatty liver disease, less sunlight exposure due to lower mobility and different clothing habits in people with obesity vs. their lean counterparts, and adverse dietary habits. For example, people with higher BMIs spend less time exercising outdoors and are more sedentary in general than their lean counterparts. Therefore, they are less likely to get sun exposure because of a decrease in time spent outdoors. Those with higher BMIs also tend to cover their bodies, showing less skin when outdoors than their leaner counterparts, and thus there is likely to be less conversion to vitamin D via skin and sun exposure in people with obesity.
Some studies suggest that an increased level of parathyroid hormone due to vitamin D deficiency promotes lipogenesis because of greater calcium influx in adipocytes. Another hypothesis is that the active form of vitamin D, 1,25(OH) D, inhibits adipogenesis through actions modulated by vitamin D receptors. These studies are promising, but prospective randomized trials are needed to determine whether vitamin D supplementation is a treatment option in preventing obesity. So far, vitamin D supplementation shows inconsistent results.
To conclude, there is a high prevalence of vitamin D deficiency in obesity, most likely because of dilution and sequestration in greater volumes of fat, blood muscle, and liver in obesity. Low vitamin D levels can’t be ruled out as a cause of obesity because of the research showing some interesting findings in vitamin D receptors in adipose tissue. Vitamin D deficiency in obesity doesn’t seem to affect bone mass but could have deleterious effects on other organ systems.
Weight loss improves obesity and complications, including the risk for cardiovascular disease and type 2 diabetes as well as vitamin D deficiency.
What do the guidelines say?
Treatment of vitamin D deficiency requires higher doses in obesity to achieve the same serum concentration compared with lean persons. Maintenance doses should not differ between those with obesity and lean persons.
The association of vitamin D and obesity remains elusive. Studies need to focus on vitamin D, vitamin D receptors, and actions of vitamin D in adipose tissue to investigate this relationship further.
In the meantime, media attention remains focused on the potential treatment and prevention of obesity with the mighty, all-purpose vitamin D, even though there is scant evidence.
Dr. Apovian is codirector at the Center for Weight Management and Wellness at Brigham and Women’s Hospital and professor of medicine in the division of endocrinology, diabetes and hypertension at Harvard University, Boston. She disclosed conflicts of interest with Abbott, Allergan, Altimmune, Bariatrix Nutrition, Cowen and Company, Curavit, Rhythm Pharma, Jazz, Nutrisystem, Roman, Novo Nordisk, EnteroMedics, Gelesis Srl, Zafgen, Xeno, L-Nutra, Tivity, and Real Appeal.
A version of this article first appeared on Medscape.com.
A recent study found that people with obesity have lower blood levels of vitamin D than people of healthy weight. This association of obesity with low vitamin D levels has led to much speculation on whether low vitamin D levels cause obesity or whether obesity causes low vitamin D levels. The interest in this topic is piqued by the possibility that if vitamin D deficiency causes obesity, perhaps treatment could be as simple as providing vitamin D supplementation to enhance weight loss.
What is known about vitamin D’s role in the body?
It’s well known that vitamin D is essential for bone health as well as balancing the minerals calcium and phosphorus, but what is its role in weight management? Approximately 80%-90% of vitamin D in the body is from the skin synthesis of cholecalciferol through ultraviolet B radiation from sun exposure. The normal range of 25-hydroxy vitamin D is measured as nanograms per milliliter (ng/mL). Most experts recommend a level between 20 and 40 ng/mL, but this has been a controversial topic of never-ending debate in the medical literature.
Vitamin D levels and obesity
This has been noted for many years without identifying the underlying reasons beyond the sequestering of vitamin D in adipose tissue, although I’ll discuss other possibilities.
The inverse correlation between vitamin D and obesity has been seen in other diseases, such as cardiovascular disease, hypertension, prediabetes, and insulin resistance, as well as in sarcopenia and aging. Most studies emphasized the correlation between increasing adiposity with vitamin D deficiency in all ethnic and age groups. The causes and potential direct consequences of the vitamin D deficiency state in obesity are not well understood.
Vitamin D and adipose tissue
It’s been proposed that low vitamin D status in obesity might be due to increased vitamin D clearance from serum and enhanced storage of vitamin D by adipose tissue.
In adipose tissue, vitamin D exerts a variety of effects on inflammation, innate immunity, metabolism, and differentiation and apoptosis in many cell types. There is a stronger association between 25(OH)D and visceral fat as compared to subcutaneous adipose tissue, which suggests an influence of inflammation and components of the metabolic syndrome on vitamin D metabolism.
Because vitamin D has anti-inflammatory properties, it’s possible that low vitamin D status contributes to adipose tissue inflammation, a key link between obesity and its associated metabolic complications in obesity. A higher storage of vitamin D in adipose tissue, if accompanied by a parallel increase in the local synthesis of 1,25(OH)2D3 and action, may conceivably modulate adipocyte function as well as the activity of adipose tissue macrophages and hence the level of adipose tissue inflammation. In addition, it seems likely that 1,25(OH)2D3 also regulates the function of macrophages and other immune cell populations within adipose tissue.
It’s well known that vitamin D is stored in body fat, leading to the assumption that this was important in the evolution of vertebrates, including humans, who lived at latitudes where vitamin D could not be made in the winter and vitamin D stores had to be mobilized to maintain vitamin D sufficiency.
What is vitamin D’s role in obesity?
The main question that has eluded an answer so far is this one: Is vitamin D deficiency only a coincidental finding in obesity due to sequestration of the vitamin in fat, or does it have a role in the development of obesity and its complications, such as cardiovascular disease, type 2 diabetes, and hypertension?
Low vitamin D usually leads to impaired calcium absorption in the intestine and a lower calcium level, and eventually enhanced bone turnover and impaired bone mineral density (BMD).
However, it is known that in obesity there is greater BMD than in those who are lean. This leads to the conclusion that because there is a lack of vitamin D deficiency effects on bone in those with obesity, there is not really a vitamin D deficiency, and it may be that the sequestration in adipose tissue leads to a permanent supply that can maintain bone health.
An alternative explanation is that there is greater skeletal loading in obesity, and elevations in hormones such as estrogen and leptin could compensate for the vitamin D deficiency, leading to greater BMD in obesity.
Several other potential mechanisms besides sequestration of vitamin D in adipose tissue have been identified for low vitamin D and obesity. These include impaired hepatic 25-hydroxylation in nonalcoholic fatty liver disease, less sunlight exposure due to lower mobility and different clothing habits in people with obesity vs. their lean counterparts, and adverse dietary habits. For example, people with higher BMIs spend less time exercising outdoors and are more sedentary in general than their lean counterparts. Therefore, they are less likely to get sun exposure because of a decrease in time spent outdoors. Those with higher BMIs also tend to cover their bodies, showing less skin when outdoors than their leaner counterparts, and thus there is likely to be less conversion to vitamin D via skin and sun exposure in people with obesity.
Some studies suggest that an increased level of parathyroid hormone due to vitamin D deficiency promotes lipogenesis because of greater calcium influx in adipocytes. Another hypothesis is that the active form of vitamin D, 1,25(OH) D, inhibits adipogenesis through actions modulated by vitamin D receptors. These studies are promising, but prospective randomized trials are needed to determine whether vitamin D supplementation is a treatment option in preventing obesity. So far, vitamin D supplementation shows inconsistent results.
To conclude, there is a high prevalence of vitamin D deficiency in obesity, most likely because of dilution and sequestration in greater volumes of fat, blood muscle, and liver in obesity. Low vitamin D levels can’t be ruled out as a cause of obesity because of the research showing some interesting findings in vitamin D receptors in adipose tissue. Vitamin D deficiency in obesity doesn’t seem to affect bone mass but could have deleterious effects on other organ systems.
Weight loss improves obesity and complications, including the risk for cardiovascular disease and type 2 diabetes as well as vitamin D deficiency.
What do the guidelines say?
Treatment of vitamin D deficiency requires higher doses in obesity to achieve the same serum concentration compared with lean persons. Maintenance doses should not differ between those with obesity and lean persons.
The association of vitamin D and obesity remains elusive. Studies need to focus on vitamin D, vitamin D receptors, and actions of vitamin D in adipose tissue to investigate this relationship further.
In the meantime, media attention remains focused on the potential treatment and prevention of obesity with the mighty, all-purpose vitamin D, even though there is scant evidence.
Dr. Apovian is codirector at the Center for Weight Management and Wellness at Brigham and Women’s Hospital and professor of medicine in the division of endocrinology, diabetes and hypertension at Harvard University, Boston. She disclosed conflicts of interest with Abbott, Allergan, Altimmune, Bariatrix Nutrition, Cowen and Company, Curavit, Rhythm Pharma, Jazz, Nutrisystem, Roman, Novo Nordisk, EnteroMedics, Gelesis Srl, Zafgen, Xeno, L-Nutra, Tivity, and Real Appeal.
A version of this article first appeared on Medscape.com.
FMT doesn’t appear to affect weight loss after bariatric surgery
according to results of a randomized controlled trial.
The small study by Perttu Lahtinen, MD, with Päijät-Häme Central Hospital in Lahti, Finland, and colleagues was published online in JAMA Network Open.
Bariatric surgery remains the most effective strategy for treating severe obesity. Yet some patients achieve only minimal weight loss or regain weight after surgery, the researchers noted.
There is much interest in the gut microbiota as a potential target for the treatment of obesity. FMT from a lean donor has shown promise in treating obesity in mouse models (Science. 2013 Sep 6. doi: 10.1126/science.1241214).
The Finnish trial, however, does not support that conclusion.
The study included 41 adults (71% women; mean age, 48.7 years) with severe obesity (mean body mass index, 42.5 kg/m2). Twenty-one received FMT from a lean donor, and 20 received FMT from their own feces (autologous placebo). FMT was administered by gastroscopy into the duodenum 6 months before laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. All patients also consumed a very-low-calorie diet approximately 4 weeks before the surgery.
Bariatric surgery led to equal weight reductions for both groups, but there was no additive benefit in terms of weight loss with FMT.
Six months after the administration of FMT, and before the surgery was performed, the percentage of total weight loss, the main outcome, was 4.8% (P < .001) in the FMT group and 4.6% (P = .006) in the placebo group. There was no statistically significant difference between the groups (absolute difference, 0.2%).
At 18 months (12 months after surgery), the percentage of total weight loss was 25.3% (P < .001) in the FMT group and 25.2% (P < .001) in the placebo group – an absolute difference of 0.1%.
The researchers said the main limitation of their study is the small number of patients. Because there were few patients, the study may be inadequate to show possible minor effects of FMT on weight; it’s unclear whether a much larger sample size would have yielded any differences between the groups.
Nonetheless, the study suggests that FMT does not affect weight loss for patients who undergo bariatric surgery, the researchers said.
The study was supported by governmental research grants and the Sigrid Juselius Foundation. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to results of a randomized controlled trial.
The small study by Perttu Lahtinen, MD, with Päijät-Häme Central Hospital in Lahti, Finland, and colleagues was published online in JAMA Network Open.
Bariatric surgery remains the most effective strategy for treating severe obesity. Yet some patients achieve only minimal weight loss or regain weight after surgery, the researchers noted.
There is much interest in the gut microbiota as a potential target for the treatment of obesity. FMT from a lean donor has shown promise in treating obesity in mouse models (Science. 2013 Sep 6. doi: 10.1126/science.1241214).
The Finnish trial, however, does not support that conclusion.
The study included 41 adults (71% women; mean age, 48.7 years) with severe obesity (mean body mass index, 42.5 kg/m2). Twenty-one received FMT from a lean donor, and 20 received FMT from their own feces (autologous placebo). FMT was administered by gastroscopy into the duodenum 6 months before laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. All patients also consumed a very-low-calorie diet approximately 4 weeks before the surgery.
Bariatric surgery led to equal weight reductions for both groups, but there was no additive benefit in terms of weight loss with FMT.
Six months after the administration of FMT, and before the surgery was performed, the percentage of total weight loss, the main outcome, was 4.8% (P < .001) in the FMT group and 4.6% (P = .006) in the placebo group. There was no statistically significant difference between the groups (absolute difference, 0.2%).
At 18 months (12 months after surgery), the percentage of total weight loss was 25.3% (P < .001) in the FMT group and 25.2% (P < .001) in the placebo group – an absolute difference of 0.1%.
The researchers said the main limitation of their study is the small number of patients. Because there were few patients, the study may be inadequate to show possible minor effects of FMT on weight; it’s unclear whether a much larger sample size would have yielded any differences between the groups.
Nonetheless, the study suggests that FMT does not affect weight loss for patients who undergo bariatric surgery, the researchers said.
The study was supported by governmental research grants and the Sigrid Juselius Foundation. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to results of a randomized controlled trial.
The small study by Perttu Lahtinen, MD, with Päijät-Häme Central Hospital in Lahti, Finland, and colleagues was published online in JAMA Network Open.
Bariatric surgery remains the most effective strategy for treating severe obesity. Yet some patients achieve only minimal weight loss or regain weight after surgery, the researchers noted.
There is much interest in the gut microbiota as a potential target for the treatment of obesity. FMT from a lean donor has shown promise in treating obesity in mouse models (Science. 2013 Sep 6. doi: 10.1126/science.1241214).
The Finnish trial, however, does not support that conclusion.
The study included 41 adults (71% women; mean age, 48.7 years) with severe obesity (mean body mass index, 42.5 kg/m2). Twenty-one received FMT from a lean donor, and 20 received FMT from their own feces (autologous placebo). FMT was administered by gastroscopy into the duodenum 6 months before laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. All patients also consumed a very-low-calorie diet approximately 4 weeks before the surgery.
Bariatric surgery led to equal weight reductions for both groups, but there was no additive benefit in terms of weight loss with FMT.
Six months after the administration of FMT, and before the surgery was performed, the percentage of total weight loss, the main outcome, was 4.8% (P < .001) in the FMT group and 4.6% (P = .006) in the placebo group. There was no statistically significant difference between the groups (absolute difference, 0.2%).
At 18 months (12 months after surgery), the percentage of total weight loss was 25.3% (P < .001) in the FMT group and 25.2% (P < .001) in the placebo group – an absolute difference of 0.1%.
The researchers said the main limitation of their study is the small number of patients. Because there were few patients, the study may be inadequate to show possible minor effects of FMT on weight; it’s unclear whether a much larger sample size would have yielded any differences between the groups.
Nonetheless, the study suggests that FMT does not affect weight loss for patients who undergo bariatric surgery, the researchers said.
The study was supported by governmental research grants and the Sigrid Juselius Foundation. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN