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The Best Weight Loss Solution is What Works for Each Person
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Currently, gastroenterologists and other physicians have quite a few options to treat overweight and obesity, but at times that is overwhelming.
The first step in obesity management is lifestyle intervention including dietary, physical activity and behavioral modifications. However, most patients will not achieve sustained weight loss due to metabolic adaptations leading to weight regain.
Bariatric surgery and medication are the next options to consider when discussing weight loss treatment, but GI physicians are uniquely positioned to offer other options such as gastric balloons, aspiration therapy or off-label endoscopic gastroplasty, which multiple studies have shown as efficacious.
Of note, while bariatric surgery is the most effective, most durable therapy, patients who come to see a gastroenterologist typically do not qualify for it, or do not want to undergo bariatric surgery. They have heard about possible complications and are worried of undergoing major surgery, so they want to try other options before pursuing those more invasive techniques. Often, these are misconceptions based on isolated cases, and after a conversation with a provider familiar with bariatric surgery options, patients may decide to pursue surgery.
Additionally, if a patient goes the least invasive route of weight loss medications, but they don’t achieve the optimal weight loss results or they cannot tolerate the medication, we should then provide an endoscopic therapy.
In reality, endoscopic therapies and pharmacotherapies work best if they’re used together.
There are currently five weight loss medications FDA-approved for long-term use (phentermine/topiramate, bupropion/naltrexone, orlistat, lorcaserin and liraglutide) that we can use in conjunction with endoscopic bariatric therapies, and four approved for short-term weight management (phentermine, diethylpropion, benzphetamine, and phendimetrazine). Additionally, there are other commonly used medications that are either weight-neutral or promote weight reduction that can be tailored according to the patients’ unique needs. Gastroenterologists focusing on obesity treatment should be familiar with the options for pharmacotherapy.
Possible scenarios for combined or sequential pharmacotherapy/ bariatric endoscopic therapies use include failure of one of the two options or insufficient weight loss, and then addition of the second option. For example, patients may want to start with an endoscopic therapy because they tend to lose more weight right away. However, if the weight loss is insufficient or patients have a concern about weight regain, we can add a medication to further the weight loss and/or help sustain the weight. Conversely, a patient may start first with a medication, and then try an endoscopic bariatric option. Combining endoscopic devices with medication, we may expect to see weight loss up to 18% to 20% or even more, depending on the type of procedure.
The best approach is to start with the therapy that works best for each patient. Patients should have a good understanding of how much weight loss is expected with each therapy: 4% to 10% of baseline weight with medications after 12 months of use, 8% to 19% with endoscopic bariatric therapies, and over 25% with bariatric surgery. Patients should be aware that bariatric surgery leads to more profound and durable weight loss than any other currently available therapy. Nevertheless, it is not failsafe – up to 25% of patients may regain all of the weight. It is also important to remember that obesity is a chronic disease with a high risk for relapse. If medications are interrupted, patients will most likely regain the weight. Also, although these drugs appear generally safe and well-tolerated if selected correctly, there is little data on long-term safety beyond 1 year of use.
New Options
In April 2019, the FDA approved a new therapy, Plenity (superabsorbent hydrogel particles; Gelesis). Although Plenity is swallowed like a pill, it is not a drug. It works mechanically by expanding in the stomach, leading to increased satiety. Weight loss with Plenity was approximately 2% greater than placebo (6.4% weight loss from baseline at 24 weeks with Plenity; 4.4% weight loss with placebo on a hypocaloric diet). Few adverse events were reported in the 436 patients that were studied. There is little post-marketing experience with this device, but it may work in synergy with weight loss medications and after endoscopic bariatric therapies. For example, Plenity could improve diet compliance, maintain satiety and prevent weight gain after a gastric balloon is removed.
There are multiple other minimally invasive options that are under investigation such as adjustable gastric balloon, gastric balloon in a capsule, duodenal mucosal ablation, duodenojejunal liner, even incisionless magnetic anastomosis in the gut creating a dual path for nutrients. We can expect new medications that are even more effective, do not require an injection and target multiple satiety mechanisms. With such a multitude of options, it is imperative that we provide at least basic obesity training to our gastroenterology fellows, with bariatric endoscopy subspecialty fellowships for the ones who would like to pursue this as a profession. Studies have shown that, among providers, there are many barriers leading to low use of the available weight loss tools, such as incomplete understanding of the genetic propensity to obesity, the role that our obesogenic environment plays in the epidemiology of the disease, and the physiology of appetite regulation. Thus, we need to train the next generation of doctors to be better equipped to help these patients.
Responsibility of Research
Providers should know that patients’ options are often limited because insurers at present do not cover all therapies.
Most private insurance will not cover endoscopic bariatric therapies at this time and patients have to pay out of pocket, while bariatric surgery is frequently covered. Weight loss medications also fall into the ‘elective’ category and are frequently not covered with few exceptions for a specific condition. In some of the states with the highest rates of obesity, even bariatric surgery is not universally covered.
Bariatric surgeons, endocrinologists, gastroenterologists and anyone who treats patients with obesity must have a structured approach for those patients who need insurance to cover medications, endoscopic therapies and bariatric procedures. Within the Veterans Health Administration (VHA), we have been able to provide all of these options to eligible patients, combining endoscopic, medical and surgical options. Combination therapies can work synergistically achieving long-term weight loss of 18% to 20% and alleviating the need for surgery in many cases.
The more long-term, high-quality data we collect with prospective studies, the more likely insurers are going to pay for those minimally invasive therapies. We have a responsibility to publish more data, and diligently report adverse events and weight loss effectiveness because at the end of the day, that’s what matters most.
Three years ago, gastric balloons and endoscopic gastroplasty were not likely to be paid by insurers. But it is becoming more acceptable, and more and more large payers such as the VHA and others recognize the need to take an urgent action against obesity and its associated comorbidities. Gastroenterologists need to be well-prepared to take care of these patients, understanding the unique challenges, misconceptions, and chronicity and propensity for recidivism of this disease.
By continuing to carve out the gastroenterologist’s role in treating overweight and obesity, we can help more and more patients meet their goals of living healthier lives.
– Violeta Popov, MD, PhD, FACG
Assistant Professor of Medicine,
NYU School of Medicine
Director of Bariatric Endoscopy,
NY VA Harbor Healthcare System (Manhattan)
Disclosures: Popov reports receiving research grants from Apollo Endosurgery; contracted research for Spatz FGIA, and consultancy fees from Obalon Therapeutics.
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