Penn Medicine Gastroenterology and Hepatology: Obesity Management

Obesity was there in the 1960s, of course, but not as the pervasive societal presence it is today, or as a source of clinical interest. A search for the word "obesity" in the distinguished Morbidity and Mortality Weekly Report finds its first mention in 1978, and then only as a contributing factor in trips and falls. However, there is much evidence that by the early 1970s the clinical community suspected a societal shift was occurring, and that adipose tissue was not simply the inert source of energy it was previously thought to be.

…And the Fat

Today, the term obesity is used to describe physiognomy, a medical condition, and a pandemic due (in the words of endocrinologist AR Shuldiner) to a "pervasive obesigenic environment," working in concert with genetic susceptibility. There is no end in sight.¹ According to the CDC, 14% of two-to-five-year-old children in the US are now clinically obese. The figure rises to 20% among older children and adolescents. Among US adults (and particularly the middle-aged), 40% are obese, a figure that includes the morbidly obese, who at 8% of the population, are at least 100 pounds above normal weight.

In the wake of this evolving calamity, governmental agencies, medical organizations and health care providers have been generally overwhelmed. The history of obesity management has been checkered, at best. The promise of effective, sustained long-term weight loss is beginning to be realized, however, with recent insights into physiology of weight gain and loss, according to Dr. Pickett-Blakely.

Among much else, Dr. Pickett-Blakely says, researchers are beginning to understand that weight loss alters the body's resting metabolism. Ordinarily, resting metabolism — essentially the balance between calories consumed and burned — is relatively predicable. Once weight loss begins, however, the body has the capacity to lower the resting metabolic set point, a phenomenon kn own as metabolic adaptation.

"The metabolism is dynamic," Dr. Pickett-Blakely observes. "Which means that goals for weight loss may need to be dynamic, as well."

Researchers have also gained a greater understanding of the metabolic syndrome (the clustering of central obesity with hypertension, elevated blood sugar and hyperlipidemia) and the role of genetics in weight gain.

As the causes of obesity have come into greater focus, so too have the benefits of weight loss.

"We know now that sustained weight loss of as little as 5% can have enormous benefits to blood pressure and blood sugar levels," says Dr. Saumoy.

Rising to the Challenge of Obesity at Penn Gastroenterology & Hepatology

Given the physiologic challenges of weight loss, the Program designed by Dr. Pickett-Blakely offers a comprehensive selection of options, from traditional conservative therapy to medications and endoscopic therapy and referral to surgery, made possible at Penn GI and through collaboration with a selection of partner services at Penn Medicine.

Behavioral modifications remain the mainstay of obesity therapy, with the intent of achieving diet modifications and physical activity that individuals can incorporate into daily life for lifelong maintenance of healthy body weight. The approach is comprehensive and individualized, and consists of self management of calorie intake, (now much enhanced through free online calorie-counting sites and apps), meal planning, alterations in food types and serving amounts, and moderate daily exercise. Behavior modification and nutritional counseling are available as well.

Medical therapy for obesity is available at Penn GI through a collaboration with . The objectives of medical management, says Dr. Pickett-Blakely, include decreasing caloric intake and absorption, increasing energy expenditure and the modulation of adipose tissue.

There are currently seven FDA approved medications for weight loss which may be used as adjunctive therapy for weight loss. Each patient undergoes a medical assessment to determine the safety and potential effectiveness. Thereafter medications may be utilized as adjunctive therapy in appropriate candidates.

Bariatric Surgery is the most effective means of long-term weight loss, but is generally available only to the morbidly obese (>100 lbs over ideal body weight, BMI >40 kg/m2) and to people with a BMI >35 kg/m2 with serious weight-related health issues. For otherwise healthy individuals with obesity who do not fit the indications for bariatric surgery, Penn GI offers access to other endoscopic bariatric procedures. These bariatric endoscopic procedures include intragastric balloon implantation, endoscopic sleeve gastroplasty and transoral outlet reduction.

As reported in the Fall 2018 GI News Update, bariatric endoscopy supplements a long history of forward-thinking strategies to incorporate innovation into interventional and advanced endoscopic practice at Penn GI, including per oral endoscopic procedures and duodenal mucosal resurfacing. Bariatric endoscopic surgeries are incisionless, many are temporary, and many can be reversed when necessary. In addition, these procedures do not preclude future bariatric surgery if it becomes necessary or desirable to do so.

Intragastric balloon implantation is indicated for temporary use to facilitate weight loss in adults with obesity (BMI between 30 – 40 kg/m2) who are unable to lose weight or sustain weight loss through supervised diet and exercise. The procedure involves inserting a deflated silicone balloon in the stomach with an endoscope that is then filled with saline to about the size of a grapefruit. Ideally, once the balloon is in place, individuals will experience rapid weight loss as a precedent to further medical weight loss under the care of weight loss specialists or as a bridge to bariatric or non-bariatric surgery.

"There's evidence that rapid weight loss in obese patients is associated with greater loss of weight and greater success at weight loss over the long term," Dr. Pickett-Blakely says. Rapid weight loss can also lead to improvement in hypertension and other physical benefits.

Endoscopic sleeve gastroplasty (ESG) is an incisionless, transoral, minimally invasive alternative to open or laparoscopic bariatric sleeve gastrectomy. The procedure uses a suturing platform mounted on an endoscope to place full-thickness running sutures in the stomach that close off the greater portion of the stomach's volume.

"Traditional sleeve gastrectomy removes 75% to 80% of the gastric volume by resection, but ESG leaves the stomach intact," Dr. Saumoy explains.

Following the procedure, patients can expect to lose 20% of their body weight within two years. Patients opting for ESG at Penn GI receive weight management and nutritional counseling as well as behavioral modification guidelines to ensure their success following the procedure.

Unlike the previously described bariatric endoscopic procedures, the intent of transoral outlet reduction (TORe) is to help people maintain or recover weight loss after Roux-en-Y gastric bypass (RYGB), one of the most common types of bariatric surgery.

It's estimated that about 15% of people having bariatric surgery will regain more than 50% of their original weight loss within 18 to 24 months of their procedure, almost always because the dietary habits that led to obesity in the first place were resumed. In addition to weight gain, eating more than the mandated limit leads to alterations in the gastrointestinal system reconfigured by bariatric surgery. Among these is dilation of the gastrojejunal anastomosis (GJA) created during RYGB, in part, to limit food intake.

TORe is a novel endoscopic suturing procedure that places sutures at the GJA to reduce its diameter in patients who have regained weight after bariatric surgery. In studies, TORe has proven to bring about weight loss in the majority of patients, and to benefit blood pressure and metabolic indices.

Contacting GI Nutrition, Obesity and Celiac Disease Specialists at Penn

Physicians and advanced practitioners can refer patients to Drs. Pickett-Blakely and Saumoy online or by calling our provider-only line: 877-937-7366.