Clinician-to-Clinician Update Clinician-to-Clinician Update

New Approaches to Ameliorating the Health Effects of Obesity

September 2017

The prevalence of obesity is growing worldwide. In 2015, 107 million children and 603.7 million adults were obese (body mass index [BMI] 30 or more).1 In the United States, the Centers for Disease Control and Prevention

estimates that about 37% of adults and 17% of youths (age 2 to 19 years) are obese.2 Obese individuals have increased risks of multiple disorders, including hypertension, dyslipidemia, type 2 diabetes mellitus, coronary heart disease, and stroke, with growing impacts on the healthcare system.1, 2

Obesity arises from complex interactions between behavior, genetics, other diseases, and medications. Contributing factors include diet, low physical activity, and various social factors. Integrated weight management—which includes counseling, medication, exercise, and nutrition and dietary advice— is critical to reducing weight, mitigating associated health problems and stopping weight regain. Treatment regimens may vary, but bariatric surgery can also be an effective option for those who are morbidly obese.

Five medications are currently approved for the treatment of obesity. Medication use should be tailored to a patient’s medical history, currentmedications, insurance coverage, and response, and the treatment goal is 4% to %5 weight loss within 12 to 16 weeks. Researchers at University of Minnesota are currently recruiting adolescent patients for a clinical trial of exenatide (Bydureon), a glucagon-like peptide 1 receptor agonist approved for treating obesity in adults.

Obese patients may benefit from new FDA-approved interventions, including gastric balloon implants (for short-term use), vagal nerve blockade (to suppress appetite), and the gastric aspiration tube. Morbidly obese patients may qualify for primary bariatric procedures, such as adjustable gastric banding, gastric bypass, duodenal switch, and sleeve gastrectomy (to reduce stomach capacity). Vertical sleeve gastrectomy, which does not alter the pathway of the small intestine, has become more common than Roux-en-Y bypass and accounts for over 95% of bariatric procedures performed by University of Minnesota Health surgeons.3 Vertical sleeve gastrectomyvproduces impactful weight loss without some of the long-term complications and side effects of the other 3 primary bariatric procedures. Procedures are all done laparoscopically with low surgical risk and short recovery times.

Consult-Sept-2017-Weight-Mgmt-Feature-In-Article-ORBERA-In-Stomach
— Gastric balloon implant. Image used under license and with permission of Apollo Endosurgery, Inc.

Surgical interventions can improve health outcomes for obese patients with type 2 diabetes. In 1 trial based at University of Minnesota, moderately obese patients with type 2 diabetes mellitus who had gastric bypass surgery and lifestyle and medical management were more likely to achieve the study aim (HbA1c <7.0%, LDL cholesterol < 100 mg/dL, and systolic blood pressure <130 mmHg) than patients who had medical management and lifestyle changes alone.4

The bacterial population of the gut may influence obesity and weight. Microbiome population shifts can ameliorate obesity and type 2 diabetes mellitus in animal models,5 and sleeve gastrectomy can also shift gut microbiomes,6 but only a few studies have been done in humans. In 1 experimental study, fecal infusions from lean healthy male donors to treatment-naïve men with metabolic syndrome produced increased insulin sensitivity.7 University of Minnesota researchers are currently studying patients preand post- sleeve gastrectomy to assess microbiota changes and how they affect patients.8


References

  1. The 2015 GBD Obesity Collaborators. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. July 6, 2017; 377:13-27.
  2. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011-2014. NCHS Data Brief No. 219, United States Department of Health Human Services. Nov. 2105
  3. Kizy S, Jahansouz C, Downey MC, Hevelone N, Ikramuddin S, Leslie D.National trends in bariatric surgery 2012-2015: demographics, procedure selection, readmissions, and cost. Obes Surg. May 22, 2017. DOI:10.1007/s11695-017-2719-1. Epub ahead of print.
  4. Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs. intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: The Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309(21)2240-2249.
  5. Komaroff AL. The microbiome and risk for obesity and diabetes. JAMA. 2017;317(4):355-356.
  6. Jahansouz C, Staley C, Bernlohr DA, Sadowsky MJ, Khoruts A, Ikramuddin S. Sleeve gastrectomy drives persistent shifts in the gut microbiome. Surg Obes Relat Res. 2017;13(6):916-924.
  7. Vrieze A, Van Nood E, Hollerman F, et al. Transfer of intestinal microbiota from lean donors increases insulin sensitivity in individuals with metabolic syndrome. Gastroenterol. 2012;143(4):913-916.e7.
  8. Jahansouz C, Staley C, Leslie D, Sadowsky MJ, Khoruts A, Ikramuddin S. Post-surgical disruption of intestinal microbiota composition attenuates the metabolic efficacy of vertical sleeve gastrectomy. Paper presented at: Clinical Congress of the American College of Surgeons; October 24, 2017; San Diego, CA.

When to refer

Medical weight management is designed for a patient with a BMI of 30 or greater with co-morbidities related to obesity. For the surgical patient, BMI must be 35 or greater with co-morbidities or above 40 without co-morbidities. Surgical patients must be psychologically stable, and all will receive medical weight management. After surgery, patients continue to meet with dietitians and medical weight-management providers throughout their lifespan. Patients can view our free online seminar on our website to learn more. It is required viewing for surgery candidates.

The University of Minnesota Health weight-management clinical team designs comprehensive, individualized weight-management treatment plans rooted in evidencebased practices. We evaluate all factors contributing to obesity and help patients select their best approach to weight management. Our goal is to help patients achieve sustainable weight loss and improvement in overall health and well-being.

The American College of Surgeons and the American Society for Metabolic and Bariatric Surgery (ASMBS) have designated University of Minnesota Medical Center an accredited center in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Blue Cross and Blue Shield has awarded us a Blue Distinction Plus (+) designation for bariatric surgery, which recognizes expertise and efficiency in delivering this specialty care. Our program is in many insurance companies’ preferred networks. Patients should check with their individual policy providers about coverage.

Our surgeons bring in-depth knowledge to patient care and use advanced, minimally invasive interventions, including bariatric endoscopic and laparoscopic approaches and the use of robotic technologies. We offer all ASMBS-approved bariatric surgeries.

We also offer access to social support. The monthly New U Support Group is open to anyone who is considering bariatric surgery and welcomes spouses and family members. For information, call 612-624-1089.

Register Now:
Bariatric Education Days
May 24 - 25, 2018, in Bloomington, MN
mhealth.org/bariatricdays

To request a free copy of the 2017 University of Minnesota Health Adult Specialty Directory, visit mhealth.org/for-medical-professionals/adult-specialty-directory

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