GI Docs Can Play a Critical Role in Obesity Management

As the prevalence of obesity grows in the United States and worldwide, more solutions are needed at more levels of care to help patients, according to a series of presentations during the American Gastroenterological Association (AGA) Postgraduate Course held at Digestive Disease Week® (DDW) in May.

Gastroenterologists can step up as part of a multidisciplinary response to provide treatment — with a range of lifestyle interventions, pharmacological options, and bariatric endoscopic possibilities — based on a patient’s needs and preferences.

“Obesity is in our clinics. We’re usually the first line of obesity, and that’s why we need to know it, learn how to manage it, and understand the complications,” said Andres Acosta, MD, an associate professor of medicine and gastroenterologist at Mayo Clinic, Rochester, Minnesota, and principal investigator of Mayo’s Precision Medicine for Obesity Laboratory.

Obesity tops the charts as the most significant chronic disease in the world, affecting 130 million patients in the United States and 1 billion globally, he said, and those numbers will only climb higher in coming years. By 2030, the United States is projected to have an obesity prevalence of 50% and overweight prevalence of 80%, with every state having a prevalence greater than 35%.

The alarming prevalence rates matter not because of aesthetics or personal preference, he noted, but because of the major associations with premature death, cardiovascular disease, stroke, type 2 diabetes, numerous cancers, and 280 other diseases.

“Choose the organ you like, and obesity is a major contributor to its most important disease,” Dr Acosta said. “Obesity affects every single disease and every single organ in the gastrointestinal system, so it’s essential that we actually manage this.”

Based on current recommendations focused on body mass index (BMI), diet, exercise, and behavioral therapy are suggested for a BMI of 25 or higher, followed by pharmacotherapy for a BMI greater than 27 with comorbidities, endoscopic procedures for a BMI greater than 30, and surgical options for a BMI greater than 40 or BMI greater than 30 with comorbidities. At each step, clinicians can start shared decision-making conversations with patients about the best options for them.

“We’re moving from a pyramid approach where we tell patients to choose one intervention toward multidisciplinary programs where we offer interventions in combination,” Dr Acosta said, recommending AGA’s POWER – Practice Guide on Obesity and Weight Management Education and Resources. Other AGA resources for physicians treating patients with obesity include the AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity, and the Obesity Resource Center on the AGA website.

Progress in Pharmacotherapy

In recent years, developments focused on glucagon-like peptide 1 (GLP-1) receptor agonists, such as semaglutide and tirzepatide, have “changed the conversation about obesity,” Dr Acosta said. For the first time, medications not only reduce weight but also cardiovascular disease risks, which were previously only observed with bariatric surgery.

Additional GLP-1 options are in research pipelines. During the next 3 years, for instance, more medications will focus on how the gut signals to the brain through intestinal hormones, targeting GLP-1, glucose-dependent insulinotropic polypeptide, and other receptors. Leading the pipeline, Eli Lilly’s retatrutide shows promise, with weight loss and comorbidity improvement reported similar to or better than tirzepatide. Additional data from phase 3 trials are forthcoming.

In clinical practice, major conversations remain about gastrointestinal side effects, particularly gastroparesis, that may pose a risk for aspiration in upper endoscopy. Gastroenterologists should feel comfortable about managing these types of side effects when starting patients on these medications, Dr Acosta said, but also continue to ask questions about side effects and the latest research developments.

Of course, major obstacles remain regarding patient access, insurance coverage, cost-effective options, and heterogeneous patient responses. At the Mayo Clinic, Dr Acosta and colleagues are researching and targeting obesity phenotypes — such as the “hungry gut” or “hungry brain” — to improve weight loss outcomes and patient adherence.

Ultimately, he said, the most important obstacle is our healthcare system. “We cannot afford to manage obesity with expensive procedures or expensive medications.”

Efficacy of Endobariatrics

For patients with a BMI of 30 or higher, minimally invasive bariatric endoscopic procedures can lead to weight loss, improvement in metabolic outcomes, and fewer adverse events compared to bariatric surgery, said Violeta Popov, MD, director of bariatric endoscopy at the New York Veterans Affairs Harbor Healthcare System in New York City.

For example, intragastric balloons — marketed under the names Orbera and Spatz — work by altering the rate of gastric emptying. They’re placed temporarily and removed after several months, and Spatz can be adjusted while in place, either by removing or adding volume if needed. Data show that associated weight loss can lead to improvements in insulin resistance, visceral obesity, dyslipidemia, high blood pressure, liver enzymes, metabolic dysfunction–associated steatotic liver disease (MASLD), and metabolic dysfunction–associated steatohepatitis (MASH).

Although the majority of patients undergoing minimally invasive procedures do experience adverse events such as nausea and vomiting, symptoms tend to subside in the first few weeks, Dr Popov said. At the same time, gastroesophageal reflux disease (GERD) can worsen in patients who have experienced it, so proton pump inhibitors are recommended for as long as the balloon is inserted.

Endoscopic sleeve gastroplasty has become the most prevalent endobariatric method in Dr Popov’s practice during the past few years. The procedure uses full thickness sutures placed with an endoscopic suturing device called OverStitch, to decrease the size of the opening into the stomach. In previous trials, patients lost up to 40 pounds, and more than 80% maintained the lost weight up to 5 years. The procedure, which showed no worsening of GERD, works by preserving gastric contractility while delaying gastric emptying.

Dr Popov noted one of the main challenges is training and credentialing, with many patients not having access to those who can perform these procedures. As a diplomate of the American Board of Obesity Medicine, Dr Popov highlighted the need for bariatric endoscopy fellowships or training during GI fellowships, post-fellowship hands-on courses, and competency training with simulators.

“It’s not just technical competency in performing a procedure — it’s also the administrative work of setting up a multidisciplinary program,” she said. “It’s very important to understand obesity as a disease and learn how to manage it.”

Monitoring MASLD

Linked strongly to insulin resistance, MASLD prevalence is increasing worldwide as obesity increases, reaching 30% in the United States and even higher among certain patient populations, said Sonali Paul, MD, an assistant professor of medicine and hepatologist at the Center for Liver Diseases at the University of Chicago Medicine in Illinois.

The good news is that the associations between MASLD and obesity also move the other way — if patients lose weight and improve cardiovascular risk factors, MASLD can improve as well. Notably, steatosis can disappear at 3% weight loss, inflammation decreases at 5% weight loss, MASH resolution occurs at 7% weight loss, and fibrosis improves at 10% weight loss.

Primarily, Dr Paul and colleagues have focused on lifestyle interventions, especially diet, by working carefully with dietitians. A modified Mediterranean diet with olive oil and monounsaturated fats can decrease steatosis on MRI, as compared with a high-fat/low-carb diet, and it also appears to decrease mortality, cardiovascular disease, and obesity. As part of the modified diet, carbohydrates are limited to 30 grams per meal per day.

“We really want to tailor the diet to cultural and personal preferences,” she said. “I’m South Asian, and when I tell my South Asian patients not to eat rice, they don’t love that, so we work with them to meet them where they are.”

Dr Paul recommends physical activity interventions, proper sleep hygiene, treatment of obstructive sleep apnea, pharmacological options, and bariatric solutions to reduce weight, improve insulin resistance, and target MASLD risk factors. For instance, recent phase 2b studies indicate semaglutide can lead to MASH resolution, with phase 3 trial data expected by the end of 2024.

In addition, resmetirom, a liver-directed thyroid hormone receptor beta selective agonist — the first Food and Drug Administration–approved drug for MASH — achieved both primary endpoints of MASH resolution and fibrosis improvement. American Association for the Study of Liver Diseases guidelines are forthcoming about who should use the drug, Dr Paul said.

“In terms of the paradigm that I think about with MASLD, we want to target other causes and diagnose advanced fibrosis, treat risk factors, and target MASH through treatment,” she said.

Considering the Community Perspective

Community-based clinicians face a unique set of challenges when addressing obesity through a multidisciplinary approach and longitudinal care, but it remains vital as more practices see increased patient loads with obesity-related GI comorbidities, said Pooja Singhal, MD, assistant professor of medicine at the University of Oklahoma Health Sciences Center, Oklahoma City, and founder/president of Oklahoma Gastro Health and Wellness.

Dr Singhal noted obesity-related associations with earlier presentations of GERD, elevated liver enzymes, MASLD, MASH, IBS, IBD, gallbladder disease, colon polyps, and GI cancers.

“Gastroenterologists, as most of us are board-certified internists, are in a unique position to offer both pharmacotherapy and endoscopic treatment,” she said. “The GI comorbidities provide an opportunity for early intervention, and we’re seeing a lot of side effects of antiobesity medications, so whether we like it or not, we are involved.”

The best practices at the community level start with a patient-centric approach, Dr Singhal said. Although clinicians are already time constrained and focused on addressing GI-related comorbidities, using the 5A’s framework can help:

• Asking if the patient is ready to talk 
• Assessing for factors contributing to obesity 
• Advising them of treatment options 
• Agreeing on goals based on shared decision-making 
• Assisting or Arranging the agreed-on plan. 

During the assessment phase, Dr Singhal suggested not only looking at medical and physical values but also secondary causes of weight gain, including the patient’s relationship with food, micronutrient deficiencies, psychosocial concerns, body image disorders, and triggers for eating.

During the advising phase, clinicians should consider multiple targets — such as diet, physical activity, and behavior — with a supervised and structured approach. Dr Singhal and colleagues include a meal plan, aerobic activity, resistance training, behavior modification of eating habits, sleep hygiene, and patient self-monitoring through smartphone apps and wearables. Pharmacotherapy may be relevant and effective for some patients but less accessible for many, she noted.

Above all, Dr Singhal recommended training through the American Board of Obesity Medicine, major GI society guidelines and conferences, American Society for Gastrointestinal Endoscopy STAR courses, and connecting with a multidisciplinary team of dietitians, coaches, physical therapists, and other GI specialists when possible.

“Most importantly, we’re dealing with decades of stigma and bias around this disease, where ‘you are what you eat,’ ” she said. “This mentality of ‘I can lose weight without help’ is a real challenge.”

This article originally appeared on MDedge.com, part of the Medscape Professional Network.