Summarizing Consensus Guidelines on Obesity Management

Obesity is a chronic disease, characterized by both abnormal and/or excess body fat accumulation, that is multifactorial in origin and influenced by various genetic, behavioral, and environmental factors1 This state of hyperlipidosis adversely affects someone’s health, increasing their risk for a range of comorbid conditions and premature mortality, and reducing their overall quality of life.2 Life-altering and oftentimes life-threatening comorbid conditions that have been empirically linked to obesity include type 2 diabetes mellitus (T2DM),3–5 cardiovascular disease,5–8 sleep apnea,9,10 chronic kidney disease,11,12 and at least 13 distinct forms of cancer that, among others, include breast, colorectal, hepatocellular, ovarian, and pancreatic malignancies and multiple myeloma.13,14 More recently, obesity has been empirically documented to be an independent risk factor for adverse health outcomes, including death, in persons with coronavirus disease 2019 (COVID-19).15–18 For all these reasons, obesity is now considered a leading cause of chronic disease, disability, morbidity, and both direct and indirect health care costs worldwide. Tragically, prevalence rates for obesity are increasing globally and in all age groups, including children and adolescents.19–22 This said, how quickly these rates have been increasing over the past decade has varied geographically. Consequently, geographical origins and ethnicity are considered important factors in the pathophysiology of obesity and its associated diseases, and interventions targeting obesity and its comorbidities must take such links into consideration to optimize their effectiveness.23 Much of the diminished general health and life quality that individuals living with obesity experience stems from this extensive array of comorbid health conditions that influence virtually every organ system and both physical and psychological health. Besides T2DM, cardiovascular disease, sleep apnea, renal disease and cancer, such conditions include metabolic syndrome,24,25 liver disease,26–28 gallbladder disease,29,30 pancreatitis,29,30 venous thromboemboli,31 urinary stress incontinence,32,33 idiopathic intracranial hypertension,34,35 osteoarthritis,36 and psychiatric disorders like depression and anxiety.37–41 It is crucial that such conditions are recognized for several reasons that include (a) their potential for severe and even life-threatening consequences, and (b) how many of these conditions, including diabetes and cardiovascular disease, have been documented to improve or even abate altogether following successful metabolic and bariatric surgery (MBS) or bariatric endoscopy. In contrast, certain other conditions, like the risk of certain cancers, may or may not decline after MBS. Diagnosing, managing, and monitoring comorbid conditions are among numerous valid arguments for health care practitioners to adopt a multidisciplinary team approach to managing patients with obesity. Another is that the management of obesity has changed dramatically in recent decades with the emergence of a broad array of procedural (eg, surgical and endoscopic) therapies that have proven more effective than conservative therapy alone—with respect to achieving and maintaining weight loss, reducing comorbidities, and improving patients’ overall quality of life.42–45 Yet another rationale for multidisciplinary management is that the presence of obesity-associated physical and psychiatric conditions, their severity, and how well they are being controlled can all influence decisions both about whether surgical therapy is indicated and safe for a given patient, and which operative procedures to consider. It was with this in mind that a multidisciplinary board of advisors—including members of both the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the World Gastroenterology Organisation (WGO)—was created in the latter part of 2020 for the primary purpose of constructing and ultimately publishing consensus guidelines for the management of obesity and its associated comorbid conditions. Drafting these guidelines relied on (a) a thorough literature review conducted by a multidisciplinary team—consisting of bariatric surgeons and endoscopists, internists specializing in either endocrinology or hepatology, nutritionists/dieticians, and psychology/behavioral health care professionals—all members having extensive experience in obesity management; (b) a 3-stage, online consensus (Delphi) survey to identify areas of consensus and nonconsensus in obesity management among 94 international experts spanning all the fields of expertise listed above and 6 continents; and (c) the drafting of guidelines, by the same multidisciplinary team. A full copy of the guidelines and all Delphi survey results have been published on both the IFSO (https://www.ifso.com) and WGO (https://worldgastroenterology.org) websites. A paper summarizing the Delphi survey’s design and results has also been published elsewhere.23 This paper summarizes the main points of the consensus guidelines. INITIAL ASSESSMENT OF PATIENTS WITH OBESITY For obesity management to be successful, a multidisciplinary approach to both its assessment and treatment is required2,46–48; and such a multidisciplinary approach should begin with a comprehensive evaluation of each patient’s physical health and fitness, psychological health, nutritional health, dietary practices, and personal beliefs, goals, and expectations. Such is true whether patients are being considered for conservative therapy (eg, diet, exercise, counseling, medication) alone or combined with either an endoscopic or surgical bariatric procedure. Through these evaluations, patients typically learn about and are determined to be either eligible or ineligible for bariatric surgery by designated medical, psychology/behavioral health, and nutrition specialists. Since patients are expected to schedule and attend appointments at which they will be interviewed and examined and may undergo procedures to determine if they are healthy enough to withstand bariatric surgery,49 this evaluation period also may help to predict their likely compliance and success in their obesity management program. A trained psychotherapist, preferably with considerable expertise managing patients with obesity, should play a major role in this initial assessment. Such a psychological evaluation has several purposes. Among them is identifying dysfunctional eating behaviors—like binge-eating disorder, emotional eating, and food addiction—that could undermine the effectiveness of any therapeutic approach.50 Though the concept of “food addiction” remains unproven and controversial,51 since obesity manifests many of the same symptoms, it also is important to assess for behavioral factors that might place patients at elevated risk of developing problems associated with alcohol and/or other substances and/or behavioral abuse over the course of treatment, especially if a more invasive and permanently life-altering approach like MBS is being considered.52 Patients with a severe psychiatric disorder, like schizophrenia or bipolar disorder, must have it identified. However, the presence of such a condition, in itself, is not an absolute contraindication to MBS. Rather, it is the severity of psychiatric symptoms and how well they are being controlled that predict bariatric surgery outcomes, in terms of both weight loss and mental health consequences.53 In other words, even patients with a major psychiatric diagnosis like schizophrenia can be considered for MBS, if their psychiatric symptoms are well controlled. Early psychological evaluations also need to assess each individual’s perceptions of their obesity and how stigmatized they feel because of it. This is because weight bias, obesity stigma, and discrimination all are experienced by a sizeable percentage of persons with obesity,54,55 even within general health care settings.56,57 Even health care providers who provide obesity management often hold biased beliefs and attitudes about obesity and people with obesity.58 To combat this, every member of an obesity management team must treat obesity as the chronic disease it is now recognized to be, both to counter patient perceptions that it is merely the result of weak willpower and to reinforce to patients the importance of regular, lifelong follow-up and adherence to treatment. Such health care providers must be especially vigilant regarding their own potential weight bias and recognize that patients who perceive such bias might become averse to adhering to ongoing follow-up and the overall treatment plan. It is also important for health care professionals performing initial psychological assessments to help patients establish realistic goals for weight loss and other outcomes—like diabetes control—early on, lest failure to achieve unrealistic levels of weight loss leads to later discouragement and either reduced patient compliance with, or dropout from, the treatment plan. Obesity management also requires a detailed nutritional assessment and prolonged nutritional follow-up, even if surgery is elected as the cornerstone of therapy. As with psychological assessments, there are several reasons for this. First, as adjunctive therapy, dietary measures enhance surgical outcomes. Second, potentially life-threatening nutritional deficiencies may occur in patients who elect either for or against MBS.59–62 Several recent clinical practice and best practices guidelines have been published that encompass nutrition care in patients who either intend to undergo or already have undergone MBS, including recommendations for a preoperative medical workup and having a registered dietitian perform a nutritional assessment and provide education and ongoing monitoring.49,59,63–66 It also is well established that the care of any patient undergoing MBS must begin preoperatively and that this must include preoperative screening for micronutrient deficiencies if excellent patient outcomes are to be achieved.59,63,64,66 Obesity management should, therefore, begin with a thorough assessment of every patient’s nutritional status and dietary practices and any nutritional deficits that are identified must be corrected before MBS. Exercise is another essential component of therapy, even if MBS is undertaken, as it induces health benefits like weight loss, reduced blood pressure, improved physical function, enhanced lipid profile, lower fasting glucose levels, improved mental health, and better overall quality of life.67–69 Studies also have revealed a 16% to 30% reduction in all-cause mortality risk in moderately active individuals, versus those who are sedentary, irrespective of a patient’s body mass index (BMI) and waist circumference. Consequently, like their psychological and nutritional status, patients’ current level of physical fitness, exercise interests, and capacity for different exercise regimes must be assessed early on. As a general principle and, again, irrespective of whether surgery is selected or rejected, all aspects of nonsurgical management must be tailored to each individual patient, as no one diet, behavior, exercise program, or medication will be accepted by or effective in all patients, and none has been documented as first-line or superior to all others. Long-term and preferably lifelong monitoring of all nonoperative components of obesity management also is required to continuously assess the effects of treatment, identify treatment nonresponse and/or intolerance, and detect any adverse effects that might have arisen from the treatments chosen. Associated diseases—including T2DM, obstructive sleep apnea, hypertension, and dyslipidemia—also must be identified, be evaluated for severity, and have appropriate treatment initiated preoperatively. Since obesity is a common risk factor for 13 different types of cancer, the importance of cancer screening should be reinforced, in accordance with national guidelines.46,47,49,70 In patients considering MBS, a preoperative upper gastrointestinal (UGI) endoscopic evaluation also is recommended if either a history or symptoms suggestive of gastroesophageal reflux disease (GERD) or other UGI pathology is reported, or if patients are on chronic antiacid therapy.71 In present times, a patient’s COVID-19 status also is considered crucial,23 given the findings of several studies that have identified obesity as a significant, independent determinant of COVID-19 severity.72–76 Two special patient populations that warrant further discussion are seniors and adolescents, as elaborated in the next section. SENIORS AND ADOLESCENTS Several observational studies have demonstrated that the overall risk of bariatric surgery in seniors is low, in terms of mortality and other severe outcomes.77,78 However, the literature is contradictory regarding whether that risk is increased relative to that observed in younger adults. For example, in one meta-analysis of nine studies encompassing 4391 individuals who underwent Roux-en-Y gastric bypass (RYGB) (366 and 4025 >60-y-old and ≤60-y-old, respectively), significant rate elevations were detected among seniors for both morbidity (odds ratio=1.88; 95% CI: 1.07, 3.30; P=0.03) and mortality (odds ratio=4.38; 1.25, 15.31; P=0.02).79 In contrast, another meta-analysis uncovered comparable complication rates in patients older than 60 versus 60 or younger, independent of the type of procedure performed.80 Certain specific complications may be more common among seniors, including some nutritional deficiencies,81 rendering close, long-term follow-up a necessity. And though data are scarce comparing the different bariatric procedures, in terms of both efficacy and safety, numerous studies have identified laparoscopic RYGB as a viable option in elderly patients.79,82–85 Interestingly, though total weight loss may be less in older versus younger patients, the reverse appears to be true for metabolic response and comorbidity amelioration rates.86 According to statistics published by the World Health Organization (WHO), >340 million individuals 19 years old or under are currently affected by either overweight or obesity, including 39 million children under the age of 5.20 As in adults, obesity in childhood is empirically linked to several adverse physical and mental health outcomes, including T2DM, steatohepatitis, sleep apnea, cardiovascular disease, and polycystic ovary syndrome,87–89 as well as to negative societal outcomes, like poor self-esteem, reduced academic performance, depression, and decreased quality of life.88,89 In addition, most adolescents with obesity continue to live with obesity as adults,90 with severe obesity in youths a particular concern. Risks of severe obesity during adolescence include several-year reductions in both life expectancy and quality years of life.91 With respect to treatment, short-term studies have shown that the results of MBS in adolescents are like those achieved in adults, in terms of efficacy, major complications, readmission rates, and mortality.23 Durable weight loss and improvements in both obesity-related comorbidities and quality of life are often achieved. Laparoscopic sleeve gastrectomy is the procedure most commonly in adolescents, by and gastric bypass are not recommended in this age a sizeable body of published MBS as the most effective therapy for severe obesity in adolescents, the of MBS procedures in adolescents is the increasing prevalence of severe obesity in this age and and the of published long-term results on MBS in adolescents the of these youths for AND to bariatric surgery that may be considered in patients is which a range of procedural therapies that on one of of are gastric and upper and the of food to and the of gastric of also can be as either gastric or that gastric various of and endoscopic sleeve being in clinical current for is a from to under or a in patients with or more obesity-associated In are considered as if not than MBS, though long-term data that have over MBS are that most can be both and by their (eg, weight loss with from to of total body As they are recommended for in patients with less severe or obesity or as therapy in patients with more severe obesity More recently, the has for patients with a from to Long-term data to years weight loss of total body regarding currently procedures are and in rate status and at with of at in or older and endoscopic at 6 over a to with of a at 6 in or older with a for and at with of with may be to or to at symptoms in or older with for and at for with of Obesity Surgery of the of the of the or gastric body at at and in the clinical of the of the the of the to a at in for in gastric A to a and at the at in of A with and to 30% of at severe in or older bypass A at the and at the and at currently under the clinical of the a with currently the clinical body mass endoscopic metabolic and bariatric and not adverse total weight from and are by in to this must be both from the of the in the and from the of in the or the various by the most has been published for with both clinical and significant weight loss and rates of adverse most commonly and rationale for treatment is with to be less well in this In contrast, in one meta-analysis comparing and were linked to and more weight loss than Several have already been by the and and a endoscopic of the of the another approach to the achieved both and In several comparing against the laparoscopic sleeve findings less weight loss a not adverse with the This said, meta-analysis have recommended the of to patients with to or less for gastric and gastric procedures and their remains though specific to both procedures have To has been to any bypass procedure. 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