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GIs Need to Find Their Seat at the Obesity Treatment Table
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Obesity is reaching epidemic proportions both in the United States and worldwide, and its treatment is well within gastroenterologists’ area of expertise, so we need to familiarize ourselves with emerging treatment options.
Our cover story summarizes nicely the reasons why GI physicians should get involved with the management of obesity.
The gastrointestinal tract is involved with the pathogenesis of obesity, and we know it is not just a simple calories-in-calories-out equation. There are alterations that are occurring in the gastrointestinal hormones that regulate appetite and there may also be alterations in the intestinal microbiome, which is a rapidly expanding area of interest and research for gastroenterologists.
Not only is the cause of obesity likely GI related, but many of the complications of obesity occur in the GI tract. Acid reflux, fatty liver and even some GI malignancies may be directly related to obesity.
For all of these reasons, GIs should be involved.
Bridging the Gap
The analogy between interventional cardiology and bariatric endoscopy is a good one. There was a time when the only treatment for coronary artery disease was bypass surgery. That’s a big, invasive surgery, but eventually, cardiologists bridged the gap by developing angioplasty, stents, etc.
As Barham K. Abu Dayyeh, MD, MPH, who works with me at Mayo Clinic in Rochester, Minn., said, “Only 2% of patients who qualify for [bariatric] surgery opt for this option, so as you can imagine the field is wide open.”
Some of the reluctance for surgery involves cost because insurance companies may not reimburse fully for these surgeries, but there is also a fear of surgery and that the procedure could lead to complications. These bariatric endoscopic treatments bridge the gap between non-invasive, but relatively ineffective, lifestyle modifications and a big surgery with its possible complications.
The intragastric balloons may be the first step for GIs. They’re reasonably safe. They’re temporary. They can be deployed and then removed. But, as pointed out by Abu Dayyeh, we may ultimately combine different therapies because some of the therapies are more focused on the stomach, like the balloons, while others impact the small intestine. Some of the devices are more analogous to a sleeve where you’re limiting absorption in the small bowel. Perhaps one would induce short-term weight loss with a balloon, and then, for the longer term, one would maintain weight loss with a small bowel device. More clinical experience will guide our practice in the future.
Diversified Interests, Cooperation
These new endoscopic obesity devices also benefit GIs because they diversify our interests while providing a service to our patients. New is interesting and keeps us engaged. These life-altering interventions will provide both patients and physicians gratification. One can impact patients’ lives in a meaningful, positive way.
If there are worries or uncertainties about the gastroenterologist’s future role in colorectal screening, getting involved in endoscopic obesity treatments may diversify the interests of gastroenterologists as well as the types of patients they see.
My colleague at Mayo Clinic, Abu Dayyeh, has been very involved in the assessment of these treatments over the last several years. Observing him, I’ve learned the key to excellence is to identify and partner with colleagues in other specialties who are similarly interested in treating the patient with obesity. Like many complex conditions (e.g., inflammatory bowel disease), obesity requires a multidisciplinary approach.
You need to have collaboration with an endocrinologist, for instance, who may already have an obesity treatment program. It would be great to have a surgical colleague who does bariatric surgery. Locally, you could create a team of colleagues, bringing together the gastroenterologist, the endocrinologist and the surgeon. It’s not something we should embark without that cooperation. The best beginnings may be within the context of an existing obesity treatment program.
To get up to speed, I suggest attending an endoscopic therapy course in which these techniques are demonstrated. Look at the calendar of conferences to find a conference on endoscopic bariatric techniques such as those put on by the Association for Bariatric Endoscopy, a division of the ASGE (www.bariendo.org). They will be a good resource for a physician looking to become involved.
Also, when the Digestive Disease Week program comes out, pay attention to the obesity and nutrition track, where advancements in the field of obesity management will be discussed.
Edward V. Loftus Jr., MD, AGAF, FACG, FACP Co-Chief Medical Editor Healio Gastroenterology
Disclosure: Loftus reports consulting with AbbVie, Amgen, Eli Lilly, Janssen, Mesoblast, Pfizer, Salix, Takeda and UCB, and research support from AbbVie, Amgen, Celgene, Genentech, Gilead Sciences, Janssen, MedImmune, Pfizer, Receptos, Robarts Clinical Trials, Seres, Takeda and UCB.