Bariatric Endocrinology: Obesity, Adiposity and Adiposopathy
July 2021
Volume 10, Issue 3

Introduction

Adipose cells.

The adipocyte is an endocrine cell. Adipose tissue is an endocrine organ. As such, they belong in the practice of clinical endocrinology. It has now been well over a decade since we advanced the concept that adipose tissue, like any other tissue in the body, may become diseased. There are discreet derangements of structure and function of adipocytes and adipose tissue that take away from health. These changes in structure and function are properly classified as a disease process.

Defining terminology is important.  Adiposity is the accumulation of fat mass. Adiposity may be due to adipocyte hypertrophy or adipogenesis with the generation of additional fat cells. Adipose tissue is distributed throughout the body. The distribution of fat mass as adiposity develops is genetically programmed. Some individuals are more prone to develop metabolic derangements than others, and this predisposition is directly tied to the accumulation of intra-abdominal, visceral fat.

Adipose tissue dysfunction may develop at different degrees of adiposity. Leptin levels rise and adiponectin levels drop with increasing fat mass. Adipose tissue develops insulin resistance. Adiposopathy (or sick fat, in lay terms) encompasses adiposity and the changes in adipose tissue structure and function that then contribute to the genesis of metabolic diseases including gonadal dysfunction, hypertension, dyslipidemias and hyperglycemia. Adiposopathy is now a defined treatment target for clinical endocrinologists. The treatment goal for patients in the continuum of overweight and obesity is to return adipocyte and adipose tissue function and structure to normal. It is no longer a primary focus on poundage, which has been the approach to date. 

We now have to contend with the legacy of over half a century of rules, regulations, policies and public expectations which continue to define success based on the pounds on the scale. Even the operating definitions of overweight or obesity, which are based on the risk of death by body mass index, need to be challenged. At any given BMI the risk is dependent on waist circumference, which is a clinical sign for the degree of visceral adiposity. Racial background may shift the BMI risk down, as is the case in populations with genetic ascendancy in the Asian subcontinent and southeast Asia. For them, metabolic risk starts at a lower body mass index than for Caucasian populations. The most recent clinical practice guidelines recognize this. The American Association of Clinical Endocrinology now accepts that a BMI of 25 kg/m2 is diagnostic of obesity if complications are present. Thus, the threshold for interventions is not solely determined by the BMI, but also by how adiposity and adiposopathy affect an individual. 

The US Food and Drug Administration (FDA) still approves treatments for BMI of 30 or more, using the antiquated definition of obesity. And it defines effectiveness for approval of new treatments, as achieving 5 to 10 percent weight loss from baseline. More recently, the FDA has required pharmaceutical companies to include discontinuation guidelines if thresholds of effectiveness for weight loss are not met in a period of time, also called responsiveness criteria. No consideration is given to what constitutes the weight on the scale. It is assumed that it is all fat weight. Concomitant factors that may blunt the response to these medications, such as recent steroid injections, inactivity from joint pain, edema states or other medications that drive the weight up, are not included in the discontinuation guidelines. And no consideration is given to the metabolic benefits that may derive from the use of these medications irrespective of the degree of weight loss.

Bariatric endocrinologists are leading the way in overcoming obstacles to optimal patient care through advocacy and education. At a time in the history of medicine when overweight and obesity are universally recognized as a continuum of a disease, with two-thirds of the American population affected, the vast majority of patients are not prescribed medications for overweight or obesity. The current standard of care is still focused on the treatment of the metabolic complications of overweight or obesity. And it still does not include a focus on management of adiposopathy. 

With the inception of bariatric endocrinology and the acceptance of bariatric medicine over the past decade, there are now medical centers dedicated to the medical treatment of adiposopathy, overweight and obesity. There is also increasing knowledge that leads to new therapeutic options.

First Article:
Chapter 1: Multifactorial Approaches to Treatment
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