Updates in Bariatric Endocrinology
Overweight and Obesity Risk Stratification, Complications, and Pharmacotherapy
April 2013
Volume 4, Issue 3

Introduction

Welcome from J. Michael Gonzalez-Campoy, MD, PhD, FACE

Overweight and obesity represent a continuum.  Together, they are a biological, preventable, and treatable disease.  The physical changes that result from the accumulation of fat mass (adiposity), the development of adipose tissue pathophysiology (adiposopathy), and the associated psychological burden—all creat significant morbidity and increase the risk of mortality in these patients.

Bariatric Endocrinology was conceived from the need to address the neuro-endocrinological derangements that cause adiposopathy, and from the need to broaden the scope of the management of its complications.  In addition to the well-established metabolic complications of obesity, including diabetes mellitus, hypertension, dyslipidemia, and gonadal dysfunction, adiposopathy leads to hyperleptinemia, hypoadiponectinemia, dysregulation of gut peptides including GLP-1 and ghrelin, the development of an inflammatory milieu, and the strong risk of vascular disease.

The principles of chronic disease state management that we apply to other chronic diseases should be applied to the management of overweight and obesity.  Those of us who have expertise in this field must emphasize that there are no short-term solutions to this chronic medical problem.  Instead of “diet and exercise,” all patients should be counseled on healthy eating with an emphasis on portion control and caloric intake reduction, be taught the skill of meal planning, and be shown how to increase physical activity throughout the day every day.  A team approach should be integral to the practice of bariatric endocrinology, including dieticians, nurse coaches, and mental health specialists. 

Pharmacotherapy needs to become an accepted standard of care for patients with adiposopathy.  There should be no term limits to the use of pharmacotherapy for adiposopathy.  And just like we continue medications when we reach treatment goals with any other chronic disease—be it congestive heart failure, epilepsy, depression, multiple sclerosis, rheumatoid arthritis, diabetes, hypertension, or dyslipidemia—the practice of bariatric endocrinology warrants continuation of pharmacotherapy for patients with adiposopathy, and even plain adiposity with physical complications of the accumulation of fat mass.  Lastly, monotherapy may not be enough, and combination therapy for adiposopathy needs to be considered.  The goals of treatment should include a reduction of fat mass, but more importantly, also a return of fat function to normal.

The concept of the “healthy obese” patient, which has been used to deter clinical interventions for overweight or obesity, should be seen in the correct light.  Like a patient with hypertension who has not yet had a stroke or heart attack needs intervention to lower risk, all patients with increased fat mass need risk stratification and risk lowering.  Their health risk should be reassessed periodically, because the expectation is that “healthy obese” will not remain so over time.

Commentaries and Take Home Messages from this EndoScan Edition

In this issue of EndoScan, we have reviewed 5 important contributions to the medical literature in the field of bariatric endocrinology.

Dual-energy x-ray absorptiometry (DXA) is now able to precisely measure body composition.  With this technique, we may now, with little radiation exposure and much lower cost, quantify fat and lean mass for individual patients, and trend them over time.  We are also now able to measure visceral adipose tissue, trend this over time, and correlate it to metabolic derangements.  DXA body composition analysis stands to add another dimension to the risk stratification of patients with overweight or obesity, as diagnosed by their body mass index.  Read about the study done to examine the usefulness of dual-energy x-ray for measuring visceral fat.

One of the complications of adiposopathy is polycystic ovarian syndrome, affecting about 5% of women.  Unfortunately, the name itself has become an obstacle to optimal patient care, since 20% of women have polycystic ovaries, leaving many women with cysts in the ovaries but no metabolic derangements.  And of the 5% of women with ovarian dysfunction and hyperandrogenism, there are many without any cysts in the ovaries.  An NIH expert panel has offered recommendations that will then require the necessary changes to translate them into more effective clinical practice, including the development of appropriate ICD-9 and ICD-10 codes to allow these patients access to care.  Read more about the NIH PCOS recommendations.

We have reviewed 3 papers on the pharmacotherapy for overweight and obesity.  Phentermine, the most commonly prescribed medication, was labeled as having the potential for being habit-forming, tolerance-building, and addictive.  We now have evidence that this is not the case.   The restrictions applied to it in the 1970s, born from the concern that phentermine could be like amphetamine, should now be abandoned given our understanding of this medication.  Read a summary of recent phentermine research.

The combination of phentermine with other agents for weight management has a tainted history.  Phentermine in combination with fenfluramine, a very effective combination that did elicit weight loss for most patients, is not available after the FDA decided to remove fenfluramine from the market.  Phentermine is now back for use in combination with topiramate in an extended release capsule.  Initial clinical trials with this combination are impressive, with improvements in adiposopathy across the board.  Read more about results of a phentermine/topiramate combination trial.

And finally, we now have lorcaserin, a novel selective serotonin 2C (5-HT2C) receptor agonist, which reintroduces this therapeutic class for the bariatric endocrinologist.  Read about lorcaserin for weight loss.

Looking Ahead in Adiposopathy Treatment

The 20th century saw the development of an epidemic of overweight and obesity around the world.  It also saw clinical inertia about this chronic disease.  The 21st century should bring increased understanding of the biology, physiology, and pathophysiology of adipose tissue.  And more importantly, it will also bring tools for the clinical endocrinologist to effectively treat adiposopathy.

First Article:
Dual-energy X-ray Performs as Well as Clinical Computer Tomography for the Measurement of Visceral Fat
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