Treating Obesity as a Chronic Condition
A review and assessment of recent literature for the clinical applications of new research in treating obesity as a disease. Plus: Extra commentary with our new podcast, After Hours.
March 2021
Volume 10, Issue 1

Introduction

By J. Michael Gonzalez-Campoy MD, PhD, FACE

Bariatric endocrinology – the evaluation and treatment of adiposopathy, overweight and obesity as an endocrine disease – did not exist in concept or in practice one decade ago. Adipose tissue dysfunction contributes to the pathogenesis of metabolic disorders. Many of these derangements of metabolism are known to be cardiovascular risk factors. The evidence for this concept began to form in the 1980s and was summarized into the recommendations of the National Cholesterol Education Program, Adult Treatment Panel III, which was published in May 2001. Dysmetabolic syndrome (or metabolic syndrome) is defined to include dyslipidemia, dysglycemia, hypertension and an increased waist circumference.

In 2001, Unger and Orci introduced the concept of diseases of liporegulation as a new perspective on obesity and related disorders. Then, in 2004, Bays and colleagues introduced the concept of adiposopathy, which they proposed as a preferred term, and a new focus for diagnosis and treatment. Thus, a focus on poundage (adiposity) is now replaced by the addition of discreet changes to the anatomy and physiology of adipose tissue. In 2008, we defined adiposopathy as an endocrine disease and the adipocyte as an endocrine cell. The first publication on bariatric endocrinology was in the context of the 2010 National Lipid Association’s consensus statement on obesity, adiposity and dyslipidemia.

These terms are now all very well established in the world literature. Although some of our colleagues are set in their ways and have been reluctant to adopt the terminology, the concept remains. There are now many practices that have adopted bariatric endocrinology as their focus of patient care. In 2018, we published the premier edition of a formal textbook of medicine entitled, Bariatric Endocrinology: Evaluation and Management of Adiposity, Adiposopathy and Related Disorders. The title omitted “obesity” on purpose. Obesity as a disease is fraught with decades of bias and overt impediments to the delivery of care for patients. The focus on adiposity and adiposopathy gets away from the historical barriers, including state laws and federal rules, which exclude, or fail to include, coverage for obesity as a disease and specifically pharmacotherapy for obesity.

The historical bias against obesity as a disease, the lack of coverage by the third-party payer system and the attitude of a generation of physicians who have practiced uneducated about obesity as a chronic disease (many of whom are now facing retirement) have all led to underutilization of available treatments. In 2016, Zhang and colleagues published the disturbing observation that less than 1% of eligible patients were treated for overweight or obesity. Further, of patients for whom prescriptions are actually written, many are terminated from coverage for any further obesity treatments under third-party payer algorithms that include responsiveness criteria for patented medications. In the package insert for the centrally acting obesity medications currently on patent, each has wording suggesting that if a percentage of weight loss is not achieved within a timeframe of 3-6 months, the medication should be stopped. These posted thresholds are made into mandates for discontinuation of coverage by the coverage algorithms.

It is not surprising that the most recent advances in bariatric endocrinology have come about in a roundabout way. Treatments have become available for the metabolic derangements that have universal agreement for treatment. Their mechanisms of action also correct the underlying pathophysiology of adiposopathy and lead to a decrease in fat mass (i.e., they treat adiposity). Newer diabetes treatments have not only a glycemic benefit. They also promote weight loss and treat adiposopathy. And most importantly, in the cardiovascular outcome trials which are now mandated by the Food and Drug Administration for diabetes and metabolism medications, these newer treatment options have a cardiovascular benefit compared to placebo.  Accordingly, consensus statements and clinical practice guidelines from around the world now include these newer treatments early on in the treatment of people with DM-2. Hypoglycemic agents like insulin and sulfonylureas are now late options.

Although they came from the diabetes market, some of these newer agents have been re-developed for treatment of obesity. This update will focus on therapeutic areas where treatment is already available and other products that are currently in development.

First Article:
Chapter 1: Treatments for Type 2 Diabetes Open Door for Treatment of Adiposopathy
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