Multidisciplinary care approach benefits endoscopic bariatric therapies
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The CDC estimates that nearly half of the adult population in the United States has obesity.
Despite its prevalence and potential impact on health, interventions for obesity are difficult to access due to stigma, very few providers specializing in this care and their expense.
For those patients seeking weight loss, interventions have been and will continue to be grounded in lifestyle and behavioral changes, and there have been significant advances to medical treatment. On one end of the treatment spectrum are the anti-obesity medications, which range widely in terms of their physiologic target and mechanisms. Newer medications, like the recently approved tirzepatide, show impressive results, with patients achieving 20% total body weight losses (Jastreboff, et al.).
On the other end of the spectrum are metabolic and bariatric surgeries (MBS), the most common of which are the vertical sleeve gastrectomy and the Roux-en-Y gastric bypass. These surgeries entail making the stomach smaller and can involve rerouting the digestive tract. MBS are the most effective and well-studied weight loss therapies, although only 1.1% of eligible patients undergo these interventions (English, et al.).
There is a gap in the current treatment options for obesity for those patients who may not want to take lifelong anti-obesity medication or may not be eligible for MBS, as well as people who feel they may need some extra help in weight loss but do not wish to have a permanent change to their anatomy.
This presents an opportunity for endoscopic bariatric therapies (EBTs), a collection of devices and nonsurgical procedures for weight loss. EBTs vary widely in their mechanisms and can include gastric occupying devices, such as endoscopically placed balloons in the stomach; gastric suturing procedures, like the endoscopic sleeve gastroplasty; and systems that are placed in the body through which stomach contents can be aspirated after eating.
Benefits to these therapies are that they are often temporary and are reversible, minimally invasive and can be performed on an outpatient basis. However, they are not without drawbacks, which include a lack of trained providers; lack of rigorous and long-term research to evaluate their effectiveness; and expense, given that they are not currently covered by insurance.
Interestingly, no “gold-standard” practices currently exist for psychosocial evaluation and monitoring of patients undergoing EBTs. This may be in part because of lack of insurance coverage at this time, as now patients using insurance for MBS are required to have a psychosocial evaluation prior to surgery. The MBS presurgical evaluation is valuable in identifying mental health disorders, eating disorders and substance use problems, which have the potential to impact patient outcomes. It is also an opportunity to ensure that patients have full understanding of their role in their response to the surgery and to teach behavioral strategies to optimize outcomes.
There is clear benefit for patients who connect with a multidisciplinary team prior to and during EBT implementation, as these devices and procedures are designed to be adjunctive to lifestyle change and, in many cases, placed for a limited time frame (approximately 6 months). During the implementation period, patients are most likely to attain the greatest benefits if they can sustain consistent lifestyle changes to complement the temporary anatomical changes. Commitment to frequent contact with a support team — which may include registered dieticians, exercise specialists and mental health professionals — is likely to improve adherence and increase weight and health benefits.
The risks of endoscopists placing devices and performing these therapies without input and assistance from a multidisciplinary team are that patients may have fewer occasions to discuss whether they are responding appropriately and may be less adherent to the necessary behavioral changes, taking a short-term approach rather than taking advantage of the opportunity for long-term lifestyle change.
Obesity is a progressive and relapsing disease, and many people require multiple simultaneous or sequential interventions to manage their weight. The need for novel and accessible treatment options for long-term obesity management is critical and new strategies that augment behavioral changes, like EBTs, are being developed and approved yearly by the FDA.
If EBTs become covered by insurance and more endoscopists are trained in these therapies, we will learn more about how to most appropriately choose among the options for our patients and will develop effective, tailored, multidisciplinary approaches to optimize patient outcomes.
Reference:
- English WJ, et al. Surg Obes Relat Dis. 2020;doi:10.1016/j.soard.2019.12.022.
- Jastreboff AM, et al. N Engl J Med. 2022;doi:10.1056/NEJMoa2206038.
- Mechanick JI, et al. Obesity (Silver Spring). 2020;doi:10.1002/oby.22719.
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