From Weight Loss To Health: Changing the Conversation About Obesity Treatment A Prospective from our Industry Partners

| April 24, 2014 | 0 Comments

by Elliott J. Fegelman, MD, FACS 

A native of Cincinnati, Dr. Elliott Fegelman trained as a general surgeon, and has nearly twenty years of surgical practice. His clinical interests focus on minimally invasive approaches to surgical disease, colon cancer, surgical treatment of obesity, and breast disease. He and his generation of surgeons came of age during the rise of minimally invasive techniques, and he has been witness to significant changes in the field. Since completion of surgical training, Dr. Fegelman has remained close to the training of future surgeons as a faculty member of the Department of Surgery at the University of Cincinnati, and then as Chief of Surgery and Program director at the Jewish Hospital of Cincinnati. He is currently the Director, Medical Affairs, of Ethicon with responsibility for the minimally invasive procedures and metabolics/obesity platforms. 

Bariatric Times. 2014;11(4):14–15.

We have reached a tipping point in the scientific discussion around obesity treatment, placing bariatric surgeons on the leading edge of a paradigm shift toward surgical solutions for chronic disease states. With mounting scientific evidence, including the recently published three-year durability data from STAMPEDE (Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently), the impact of bariatric and metabolic surgery for controlling not only obesity, but also a host of comorbid conditions including type 2 diabetes, hypertension, high cholesterol, and obstructive sleep apnea, is undeniable. Armed with that information, patients and their primary care physicians—now with bariatric surgeons—can make treatment decisions together based not just on weight loss goals, but also on broader issues of health improvement.

We now have the science to create that conversation. It’s up to us to be the catalysts to make it happen.

Bariatric surgeons are collaborating with endocrinologists, cardiologists, orthopedists, and basic scientists as never before to pioneer research demonstrating that the GI tract is not the passive tube it may have once been perceived to be. We now know this complex sensory organ surveys the caloric environment and participates in maintaining metabolic balance. Research has shown that once a person becomes obese, the body adapts to identify the higher weight as normal, establishing and then attempting to maintain a metabolic set point. Metabolism kicks into a cruise control that can be hard to break.

Only in recent years has science, including randomized controlled trials (RCTs), confirmed that bariatric surgery could have an immediate impact, not just on weight loss, but also on comorbid conditions. The STAMPEDE trial,[1] conducted by Cleveland Clinic’s Dr. Schauer, demonstrated that bariatric surgery represents a potential strategy to manage uncontrolled diabetes, and STAMPEDE’s recent three-year results2 confirmed its durable effects; Dr. Mingrone’s 2012 “Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes” trial[3] showed that bariatric surgery helped patients achieve glycemic control more effectively than conventional medical therapy in severely obese patients with type 2 diabetes; Dr. Dixon’s 2011 RCT[4] demonstrated weight loss associated with adjustable gastric banding results in diabetes remission in the majority of obese patients recently diagnosed with diabetes; and Dr. Sjöström’s 2011 prospective study5 showed that bariatric surgery reduced the risk of cardiovascular death (myocardial infarction or stroke) compared to customary intervention at 15 years. These trials offer a credible, scientific basis for the new conversation about obesity intervention.

In addition, updates from research initiatives such as MARS (Ethicon’s Metabolic Applied Research Strategy)6 are expanding our insights into the biology of obesity and its comorbidities. These insights will inform our assessment of how well each surgical option may perform for individual patients, extending to surgical and pharmacologic interventions for weight loss as well as diabetes. As outcomes from MARS emerge, they should become even more pertinent to how patients, physicians, and surgeons evaluate bariatric procedure choices. Ethicon’s investment in MARS has been key to helping the bariatric surgery discussion resonate beyond the surgical space.

Scientific and advocacy organizations are adding their voices to that discussion.

In April 2013, the American Association of Clinical Endocrinology (AACE), The Obesity Society (TOS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) co- sponsored a new set of guidelines, calling for bariatric surgery to be considered in patients with type 2 diabetes (T2DM), BMI 30–35kg/m2.7

In May 2013, the American Association of Clinical Endocrinology (AACE) updated its T2DM treatment algorithm to include bariatric surgery,[8] the first of its kind to incorporate obesity, pre-diabetes and cardiovascular risk factor management.

In June 2013, the American Medical Association (AMA) recognized obesity as a disease[9] requiring a range of medical interventions to advance treatment and prevention and to reduce the incidence of comorbidities linked to obesity, including cardiovascular disease and T2DM.

Even earlier, over the last two to three years, other leading medical societies updated their guidelines to support bariatric surgery’s promise in the treatment of poorly controlled or uncontrolled T2DM for the right patients. Those societies include the American Heart Association (AHA), the American Diabetes Association (ADA), The Endocrine Society (TES), the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the ASMBS.

We know that patients average about two years investigating if a bariatric procedure is right for them. Certainly the decision to have surgery is a serious one. Patients need time to contemplate and explore their options. But we also know that the earlier we can address these protean diseases that accompany obesity—before they wreak their havoc—the better patients will do for the long term. Also, with today’s integrated delivery systems rewarding value instead of volume as they take on risk for both quality and financial outcomes, earlier resolution offers substantial benefits to our care delivery systems.

We have a responsibility to partner across disciplines to offer the best possible patient care. Now we have the science to approach front-line healthcare professionals to include surgical intervention earlier in the obesity treatment discussion. We also now have, for the first time in bariatric surgery, the ability to leverage Big Data to communicate an individual’s potential outcomes with each bariatric procedure option. Ethicon recently launched a Bariatric Surgery Comparison Tool on based on the experience of more than 75,000 United States patients. The tool provides personalized information  about the potential outcomes, durability, and impact of bariatric surgery options on obesity and chronic disease for each patient.

Doing our part to change the conversation can be as simple as delivering this scientific perspective in a Grand Rounds or local medical society meeting. It can be as personal as talking science with a busy internist, cardiologist, or primary care practitioner who touches 50 patients a day, many of whom could benefit from surgical intervention. The sooner we get the science in front of patients, the sooner they can make a fully informed decision.

We can work to change the conversation by calling for the 1991 National Institutes of Health selection criteria for bariatric surgery to be re-evaluated in light of this new science that demonstrates bariatric surgery’s metabolic benefits.

We must also continue to emphasize the importance of collaboration among medical experts to solve the obesity puzzle, for example, offering patients teams of cardiologists, endocrinologists, and surgeons to guide patients to the most suitable treatment options for their unique conditions. To advance this cause, Ethicon has led MARS courses for multidisciplinary teams around the world.

Additionally, Ethicon has partnered with edX, the non-profit educational initiative founded by Harvard and Massachusetts Institute of Technology (MIT), to bring MARS to life as a massive, open, online course (MOOC) for surgeons, endocrinologists, primary care physicians, and any healthcare practitioners with interest in understanding more about the science of obesity and its comorbidities. The course is the first of its kind in the industry, and will be open to anyone, anywhere in the world with an internet connection and a desire to learn.

The metabolic benefits of bariatric surgery continue to gain wider acceptance in the broader medical community. We have the data and the opportunity right now to speed that process and to get this message to patients earlier than ever before. We owe it to them to change the conversation about obesity treatment—now. 

1. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366(17):1567–1576. Epub 2012 Mar 26.
2. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes—3- year outcomes. N Engl J Med. 2014 Mar 31. [Epub ahead of print]
3. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577–1585. Epub 2012 Mar 26.
4. Dixon JB, Murphy DK, Segel JE, Finkelstein EA. Impact of laparoscopic adjustable gastric banding on type 2 diabetes. Obes Rev. 2012;13(1):57–67. Epub 2011 Aug 31.
5. Sjöström CD, Lystig T, Lindroos AK. Impact of weight change, secular trends and ageing on cardiovascular risk factors: 10-year experiences from the SOS study. Int J Obes (Lond). 2011;35(11):1413–1420. Epub 2011 Jan 25.
6. The Metabolic Applied Research Strategy: Bariatric surgery: beyond restriction and malabsorption. Bariatric Times. 2012;9(9 Suppl C):1–24 .
7. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient— 2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for
Metabolic & Bariatric Surgery. Endocr Pract. 2013;19(2):337–372.
8. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE comprehensive diabetes management algorithm 2013. Endocr Pract. 2013;19(2):327–336.
9. American Medical Association. AMA Adopts New Policies on Second Day of Voting at Annual Meeting. page. Accessed March 30, 2014.

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