“Mrs. ABC, 50 years old, visited our clinic seeking advice for the management of obesity. Her weight was 95Kg and the body mass index of 39 Kg/m2. She had diabetes mellitus on insulin, hypertension requiring two medications, and obstructive sleep apnea. She started gaining weight after her second pregnancy 10 years ago. She has changed four jobs in the last five years because of difficulty in walking. She has tried several measures to lose weight but has failed. She has heard unpleasant stories about bariatric surgery and is afraid of going under the knife. She underwent endoscopic sleeve gastroplasty and lost 25kg in two years. Her life has transformed drastically now….”
Obesity is a disease that has reached epidemic proportions in the Middle East and across the globe. The healthcare cost involved in treating obesity has inflated exponentially. Compared to people with normal weight, it has been shown that overweight and obese are at increased risk of developing diabetes mellitus, hypertension, cardiovascular disease, stroke, and obstructive sleep apnoea. They are also at higher risk of 13 different types of cancers and increased mortality. Besides, the quality of life and productivity of obese individuals are shown to be very low.
Obesity is a multifactorial disease with a complex pathophysiology. There exists a strong link between genetic, environmental and social factors, and obesity development. However, among the public and healthcare professionals, it is often considered as a self-inflicted problem, and people with obesity are generally stigmatised and discriminated against.
This has considerably discouraged patients from discussing their weight during the consultation or even seek medical attention for obesity. Studies have demonstrated that individuals delay at least six years before consulting a physician for obesity. More often, these patients are eschewed away with “eat less and exercise more” advice than having a concrete long-term care plan.
It is high time that we change our practice and healthcare policy and start recognising obesity as a chronic disease and design treatment with clear outcome goals similar to other chronic diseases. Currently, several treatment options are available to treat obesity. This includes the modestly effective medical therapy to the most effective surgeries. Despite the availability of such effective treatment options for several decades, we have not been able to penetrate and treat more obese patients successfully. To date, studies have demonstrated that only 1-2 per cent of obese patients undergo surgery because of fear of complications, invasiveness of the procedure, cost, and irreversibility. This has created a big void in obesity treatment.
What is new in obesity treatment?
The field of interventional endoscopy has experienced a monumental change in the last decade where the course for many gastrointestinal diseases has been changed dramatically. A new discipline called bariatric and metabolic endoscopy is evolving with numerous innovations and treatment options targeting different pathways of obesity and its comorbidities. We have several space-occupying devices to restrict the food intake, change the motility of the stomach, and induce weight loss. More than ever, we are now able to reduce the gastric volume similar to surgery without resecting a portion of the stomach.
The endoscopic sleeve gastroplasty (ESG) and the primary obesity surgery endoluminal (POSE-2) narrows and shortens the size of the stomach significantly and induces weight loss. From our extensive experience performing these procedures, we have demonstrated that the total body weight loss is significant and sustained with continued follow-up.
Other researchers have also shown improvement in metabolic comorbidities after these gastroplasty procedures. The beauty of the endoscopic procedures are it’s a) effective, b) minimally invasive in nature, c) leads to short hospital stay (24hours), d) negligible complication rate, and e) repeatability. Recently, techniques like the duodenal mucosal resurfacing and duodenal-jejunal bypass liner are being studied to treat diabetes mellitus, and the early results are promising.
How can we enhance results?
The endoscopic treatment options now open the door for many obese patients to seek treatment at a lower risk. However, the patients should not approach it as a “one-stop and done” attitude. The success of the procedure depends on regular follow up, setting up realistic goals and expectations, and adhering to the multidisciplinary advice. From our research, we have repeatedly demonstrated that the weight loss is augmented and sustained with long term follow up and sub-optimal in those who take less responsibility in adhering to the post-procedure instructions.
How to train in Bariatric and Metabolic Endoscopy service?
Training in obesity management requires a three-pronged approach – 1) understanding the basic concepts of obesity and its pathogenesis, b) building a multidisciplinary collaboration to manage obesity, and c) becoming proficient and well-versed in different endoscopy techniques. Unlike general endoscopy training, there are only a handful of centres around the world that can offer in-depth fellowship training in obesity. Most of these advanced endoscopic procedures have a steep learning curve and requires dedicated training to understand the concepts, and learn to manage the complications. Our dedicated bariatric endoscopy unit in HM Sanchinarro University Hospital, Madrid, offers a multitude of bariatric procedures including intragastric space-occupying devices, endoscopic gastroplasty (ESG and POSE-2), and bariatric surgery revision procedures.
Our high-volume unit performs 30-40 procedures per month. The centre has a well-established and experienced multidisciplinary (Nutrition, Psychology, and Endocrinology) team that has a standardised follow-up protocol to achieve the best results. In addition, we organise the annual Madrid International Bariatric Endoscopy meeting bringing together world experts to discuss the new developments in obesity.
We also host small group, didactic bariatric endoscopy master class series, three to four times a year, to assist interested physicians in learning the principles of bariatric endoscopy. We strongly believe in education, training, and collaboration to disseminate the knowledge and strive to fight the obesity pandemic successfully.
It is not possible to curb the rise of obesity if we do not recognise and approach it holistically in our daily practice. Let us start taking obesity seriously and embark on treating it at an early stage using newer effective therapies to prevent the development of complications and to improve the quality of life and productivity.
From the design thinking perspective, it is a win-win situation both for the individuals and policymakers.
References available on request.