Bariatric surgery
has been around for decades and it is highly effective.
The most commonly performed procedures
are the sleeve gastrectomy and the gastric bypass.
BMI has been generally used as a more
convenient measure
to figure out who has excess adiposity.
But BMI is not a good indicator of severity.
When I'm treating patients, I use BMI
to identify obesity.
But the severity is
then figured out
based on how many comorbidities they have
and what the metabolic consequence of their obesity is.
There are a lot of factors that we have
to consider before recommending bariatric surgery.
Untreated major depression or psychosis,
uncontrolled or untreated eating disorders,
current drug or alcohol abuse, or even smoking.
Severe coagulopathy,
severe cardiac disease, severe liver disease.
All of these,
which would normally be contraindications
for surgery, are a contraindication for bariatric surgery, too.
Some of the most
common side effects that we see include
acid reflux, chronic nausea and vomiting,
inability to eat certain foods, weight gain
or failure to lose weight
with the procedure, bone loss and fractures.
The incidence of vitamin and iron deficiency
anemia is very high
after some of the bariatric surgeries.
It is important
to take replacements for the vitamins
and iron, if necessary.
But also these levels need to be checked regularly.
The other way to treat
people is with medication.
Currently, there are treatments
that produce weight loss
in the range of 5%
to at most 10% of body weight.
But I think things are changing
with the advent of highly effective
injectable and oral therapies.
The history of the development of obesity treatments
has been littered
with medications that have caused
serious complications.
We were trying too hard
to push on a weight-regulating mechanism
when the body was compensating someplace else.
So we overtreated people in some cases,
but in other cases there were toxicities
that occurred from the use of of these medications.
It's taken a very long time to produce
highly effective treatments that also are very safe.
When you have a
treatment that is highly effective,
but not well tolerated and not safe,
they might be impacting something, but not necessarily
the disease mechanism.
When you have therapies that are highly effective
and well tolerated, they're safe.
Then more likely they're impacting the disease mechanisms.
This new generation of antiobesity medications
are nutrient-stimulated, hormone-based therapies.
These therapies
mimic these hormones
that are naturally released in our gut
and that inform our brain about hunger, about satiety,
about how much energy we are carrying.
We're seeing weight reduction
that we've never seen before.
For example, in the SURMOUNT-1 trial,
which was designed to evaluate the efficacy and safety
of a novel GIP, GLP-1 receptor agonist tirzepatide,
what we saw was weight reduction on average of 22.5%
with the highest dose of tirzepatide,
which was 15 milligrams.
An earlier trial
with semaglutide, which is a GLP-1 receptor agonist,
the STEP 1 trial,
also demonstrated remarkable weight reduction,
about 15% of their total body weight.
Other parameters were looked at, specifically
cardiovascular parameters
such as blood pressure or cholesterol.
So blood pressure reduced,
in terms of the cholesterol profile,
there was a marked decrease in triglycerides.
So these different parameters are improving.
There are, of course, certain contraindications
as well as side effects to consider.
The two absolute contraindications are a history of
medullary thyroid cancer
or multiple endocrine neoplasia type 2.
Additionally, if your patient has a history
of pancreatitis or gallbladder disease, specifically
gallstones, those gallstones do need to be removed
before the medication can be initiated.
Potential side effects are mainly gastrointestinal,
feeling nauseated,
having diarrhea, constipation, or vomiting.
Most of these side effects occur
during dose escalation.
The best way that you can help mitigate
that is by slowing the uptitration
of the medication.
As with any therapy for any chronic disease,
we have to continue to monitor our patients
and see them back in clinic regularly.
Obesity is so prevalent
in our society
that we hope to see
a time when more and more primary care
providers are able to address obesity in their clinics.
If we are able to target the right drugs
for the right level of complexity for the patient,
we will be able to cover a lot more patients and
help more people achieve a healthier life.
I think a shift is occurring
because now not only is obesity recognized as a disease
and now hopefully we're helping to shift that landscape
so that it's actually treated as a disease.
But now health care providers
have the tools to effectively treat it
as a disease.