Eating Disorder

Bariatric Times • December 2016 • Supplement C C9

C ustomized care, sometimes called precision

medicine, attempts to help create specific

treatments geared to the needs of an

individual patient and this model is extremely

relevant for obesity treatment. It also allows for

the patient and clinician to intensify treatment as

needed or to change it as the patient proceeds

along the continuum of care. It allows for care to

be more or less intensive at different phases of the

patient’s journey.

There are four main domains of treatment. The

least invasive of these is an intensive lifestyle

intervention (ILI). The following can be added to

ILI: anti-obesity pharmacological therapy (second

domain), intermediate procedures (third domain),

and finally bariatric surgery (fourth domain). All

domains involve ILI, which must always be

considered the foundation, and then medications,

intermediate procedures, and bariatric surgery

may be added. Healthcare professionals involved

include the primary care physician (PCP) and

integrated health support at first, followed by

obesity specialists, and finally, in the fourth

domain, a bariatric surgeon.

INTeNSIve lIFeSTyle INTerveNTION

Intensive lifestyle intervention (ILI) is the

cornerstone of all obesity care.18 It includes a

comprehensive program of nutrition (diet),

physical activity (exercise), a psychosocial

component, sleep, and stress reduction.19 Each of

these components can be individualized for each

patient. For example, nutrition must include

caloric reduction and appropriate nutrition, but

the exact diet and special needs for the patient will

play a role and allow for the plan to be customized

as needed. For example, some patients may have

certain food allergies, need a gluten-free diet,

prefer vegetarian meals, or enjoy certain types of

foods. Patients may have physiologies that

respond better to some diet plans than others. For

example, some patients may do well on low-

carbohydrate diets while others feel lethargic on

the same diet. Special needs for individuals may

also be accommodated with meal replacements for

some patients or the use of artificial sweeteners for

others. In short, the “one size fits all” approach to

diet and nutrition is neither realistic nor effective.

The same approach applies to the patient’s

physical activities. There is a wide range of

physical exercises available including some that

are gravity-mediated and may be easier for

patients with obesity. Patients with obesity or

those with mobility issues may benefit more from

water exercises, others may experience more

benefits from vigorous strength training, while

others may need recumbent type activities to

accommodate their limited movement.

Psychosocial interventions, sleep hygiene, and

stress reduction also can be individualized to best

meet an individual patient’s needs and be most

effective.20 A sleep history may be useful for

treating patients with obesity, including not just

the presence or absence of obstructive sleep apnea

(OSA), but also sleep volume and quality. Poor

sleep habits may change hormonal levels,

Insights into the Patient Population with Obesity: Assessment and Treatment

customizing obesity treatments Deborah Bade Horn, DO, MFOMA

President, Obesity Medicine Association; Medical Director, Clinical Assistant Professor, Center for Obesity Medicine and Metabolic Performance, UT McGovern Medical School, Houston, Texas

C10 Bariatric Times • December 2016 • Supplement C

predisposing patients to fat storage, and elevating

their risk of comorbid conditions such as

diabetes.21

Once the basic ILI plan is crafted, the patient can

use this to begin the treatment. For some patients,

however, this level of intervention is insufficient,

and the next layer must be added.

IlI + ANTI-OBeSITy MeDICATIONS Anti-obesity medications (AOM) when added to

ILI represent the second domain for obesity

treatment. AOM should be used after ILI and

before intermediate procedures. AOM should be

considered in patients with a BMI >30kg/m2 or in

those with a BMI >27kg/m2 with comorbid

conditions. Before selecting pharmacotherapeutic

options, the prescriber should consider how well

the patient did using just ILI alone, how much

weight was lost, and how quickly it was lost.

There are a number of AOM available with unique

mechanisms of action.22 Prescribing choices should

be guided first by understanding contraindications

of AOMs and then by understanding the patient’s

symptoms, such as overriding persistent hunger,

specific or very strong food cravings, or a

tendency toward emotional eating. In some cases,

AOMs may help address the patient’s

comorbidities or provide additional benefits.

Patient monitoring over the course of therapy

can help confirm whether or not the prescribed

AOM is effective and if the patient is experiencing

side effects or tolerability issues. By monitoring at

around three months, it should be possible to

determine if reasonable weight loss goals have

been met and if the patient is tolerating the

medicine well.

It may benefit the patient to escalate from ILI

alone to ILI plus AOM sooner in the patient’s

continuum of care rather than later. With a large

and robust armamentarium of AOMs, there are

more options for early intervention. In many

primary care clinics, escalation to AOMs may

happen only slowly, if at all. It may be erroneously

believed that AOMs should only be considered for

the most extreme cases of obesity. In fact, AOM

treatment is prescribed to only about one percent

of patients with obesity, which indicates many

patients who would benefit from it are not

receiving it.22

IlI + INTerMeDIATe PrOCeDureS The third domain adds another layer:

intermediate procedures such as gastric balloons,

gastric emptying systems, or an electrical

stimulation system. These are not considered

surgical procedures, but rather represent

temporary devices intended to be used for a

specific but not indefinite period of time. These

procedures should always supplement an

underlying ILI foundational program and often

with AOM pharmacotherapy. There are many

considerations with this domain including

tolerability issues (not all patients can tolerate

these systems) and efficacy.23

Gastric Baloon. Gastric balloon systems are

appropriate for patients with a BMI ≥ 30kg/m2.

The gastric balloon is placed in the patient

endoscopically although in the future, it may be

possible for the patient to simply swallow the

balloon. It occupies space within the stomach

which stimulates the hormones that provide the

patient with the sensation of fullness and

satiety.24,25

Gastric emptying System. A gastric emptying

system is appropriate for patients over age 22 with

a BMI in the range of 35 to 55kg/m2. This system

requires surgical placement that uses an internal

tubing system, a port or valve in the skin, and an

external pump to remove substances out of the

stomach.26 The device is activated by the patient,

who affixes a tube to the port to empty the

stomach. To be effective, the system must be used

within 30 minutes of taking in a meal. The gastric

emptying system can remove about 30 percent of

the caloric content of the meal.

electrical Stimulation System. An electrical

stimulation system should be used in patients

either with a BMI in the range of 35 to 39kg/m2

with one comorbid condition or a BMI ≥ 40kg/m2.

The concept of an electrical stimulation system is

that nerve activation can blunt signals of hunger

and encourage signals of satiety.27

Insights into the Patient Population with Obesity: Assessment and Treatment

Bariatric Times • December 2016 • Supplement C C11

IlI + BArIATrIC SurGery

The most invasive form of intervention is

bariatric surgery—gastric band, gastric sleeve, or

gastric bypass.28 This intervention should always

rely on ILI as the foundation and it should be used

in patients who have tried or may still be utilizing

AOM pharmacotherapy. The main criteria for

bariatric surgery is that the patient have a BMI

>40kg/m2 or a BMI >35kg/m2 with comorbidities.

The gastric band is surgically placed to go

around the stomach, which restricts the stomach

space and thus limits food intake. The gastric band

may be considered the least invasive of the

bariatric surgeries. The gastric sleeve removes part

of the stomach but it does not re-route any of the

bowel system. The most invasive procedure is

gastric bypass which both removes a portion of the

stomach and re-routes the bowel system.

The role of AOM with bariatric surgery is

evolving. Some patients need even more signal

interruptions to be successful with weight loss

than are available with bariatric surgery alone.

Some of the new medications may work well to

provide bariatric surgery patients with this added

support.

Bariatric surgery is not utilized as much as is

indicated. Early intervention can be particularly

helpful for patients with type 2 diabetes mellitus

as it may have a beneficial effect on the course of

the disease. In fact, it may be helpful to think of

bariatric procedures as metabolic surgeries rather

than obesity surgeries. PCPs should be aware of

the important role of bariatric surgery and when it

is indicated—which may be at lower BMI values

than many expect. Many patients under the care of

a PCP might be appropriate candidates for

bariatric surgery, but are not being informed about

this option. It is not necessary for the PCP to

understand the nuances of the individual

procedures or to provide highly specific

recommendations to the patient. A bariatric

surgeon can be consulted and help advise the

patient.

FuTure DIreCTIONS IN weIGHT lOSS

AND weIGHT CONTrOl

The heritability of an individual’s BMI has been

estimated to be about 40 to 70 percent,29 which

roughly translates to the fact that about half of the

differences in body weight can be traced to

genetics and the other half to environment. The

issue of genetics poses questions but may also

offer future answers to better obesity management.

Genetic variations have been associated with the

relative success of ILI efforts, bariatric surgery

effectiveness, and the variations in the

macronutrient composition of diet. Genetics may

also help clinicians prescribe the most effective

weight loss strategies and therapies for an

individual patient.

It is now thought that areas of genomic

influence/customized care, such as control of

energy expenditure, appetite control and food

intake, and adipogenesis and lipid metabolism,

may be key components to weight loss.30 How the

body takes in energy and stores it varies by

individuals and this information may be useful in

finding the best weight loss strategies for the

patient.

In addition to genetics or genomics, epigenetics

should be considered in that these describe the

interactions between the patient’s environmental

factors and his or her genes. Epigenetics can allow

clinicians to find the best individualized and

customized care regimen. For example, physical

activity and high-fat diets may alter DNA

methylation, which, in turn, may affect the energy

homeostasis in skeletal muscles and adipose

tissue. Muscle tissue sends very specific signals to

adipose tissue. Thus, specific physical activity

plans can change the messaging of muscle to

adipose tissue and, in that way, encourage weight

loss.31

Epigenetics has opened up new ways of

clinically understanding weight loss, weight gain,

and weight maintenance, the latter being a

particularly challenging aspect of weight control.32

By understanding the genes that regulate energy, it

may be possible to find a more sustainable

approach to weight loss and weigh maintenance.

There are currently consumer tests available that

Insights into the Patient Population with Obesity: Assessment and Treatment

C12 Bariatric Times • December 2016 • Supplement C

look at genetics and epigenetics, but work is

ongoing to better understand how these will

impact clinical practice.

The gut microbiome is another important part of

individualized/customized care. The microbiome

in the gut changes compositionally and

functionally with external and internal influences.

It is believed that the gut mechanisms have a

direct effect on obesity by modulating energy

balance and by regulating inflammation. In fact,

the gut microbiome may be considered an

epigenetic regulator, mediating through “back

signaling” how the environment and genetics

interact.32

Inflammation and obesity are closely associated.

Many diseases, particularly those with an

inflammatory component, have an association

with obesity. Understanding the connection

between obesity and inflammation may help guide

future treatment of obesity. For example, glycogen

accumulation in adipose tissue may be a key

feature in inflammation-associated metabolic

stress syndromes of obesity.33

A number of genes, including the FTO gene,

have been identified as potential risk factors for

obesity. The question arises as to how patients

might respond upon learning that they had this

potential risk factor—would it change their

behavior? Patients who learned that they had the

genotype that put them at risk for obesity and who

also at the same time got information about weight

management strategies, were more likely to accept

treatment than those who did not get this genetic

information.34,35 When patients knew they had the

FTO genotype, they were more likely to

contemplate or take action about their weight than

patients who did not have this genetic

information. This propensity for action was more

pronounced if the patient already had overweight

or obesity; those who got genetic information and

already had overweight or obesity were more

ready for change than those with genetic

information but at normal weight. Readiness to

change behavior occurs on a continuum—from

pre-contemplation to contemplation to taking

steps and then finally to maintaining the changes.

In this study, FTO genotype information and the

patient’s overweight or obesity status made them

more ready to change, but in terms of actually

taking steps, the groups had similar rates. In other

words, genetic information and current weight

caused the patient to contemplate change but not

necessarily to implement it. This intriguing study

has caused clinicians to consider what might be

the next steps to causing change, such as

identifying resources to help the patient lose

weight, actionable education, self-monitoring of

obesity-related variables, and progress evaluation.

In particular, a risk scoring system that allows

patients to evaluate, monitor, and understand their

individual risks with obesity may be helpful.

Insights into the Patient Population with Obesity: Assessment and Treatment

u

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