according to a series of presentations during the American Gastroenterological Association (AGA) Postgraduate Course held at Digestive Disease Week® (DDW) in May.
Gastroenterologists can step up as part of a multidisciplinary response to provide treatment — with a range of lifestyle interventions, pharmacological options, and bariatric endoscopic possibilities — based on a patient’s needs and preferences.
Dr. Andres J. Acosta
“Obesity is in our clinics. We’re usually the first line of obesity, and that’s why we need to know it, learn how to manage it, and understand the complications,” said Andres Acosta, MD, an associate professor of medicine and gastroenterologist at Mayo Clinic, Rochester, Minnesota, and principal investigator of Mayo’s Precision Medicine for Obesity Laboratory.
Obesity tops the charts as the most significant chronic disease in the world, affecting 130 million patients in the United States and 1 billion globally, he said, and those numbers will only climb higher in coming years. By 2030, the United States is projected to have an obesity prevalence of 50% and overweight prevalence of 80%, with every state having a prevalence greater than 35%.
The alarming prevalence rates matter not because of aesthetics or personal preference, he noted, but because of the major associations with premature death, cardiovascular disease, stroke, type 2 diabetes, numerous cancers, and 280 other diseases.
“Choose the organ you like, and obesity is a major contributor to its most important disease,” Dr. Acosta said. “Obesity affects every single disease and every single organ in the gastrointestinal system, so it’s essential that we actually manage this.”
Based on current recommendations focused on body mass index (BMI), diet, exercise, and behavioral therapy are suggested for a BMI of 25 or higher, followed by pharmacotherapy for a BMI greater than 27 with comorbidities, endoscopic procedures for a BMI greater than 30, and surgical options for a BMI greater than 40 or BMI greater than 30 with comorbidities. At each step, clinicians can start shared decision-making conversations with patients about the best options for them.
“We’re moving from a pyramid approach where we tell patients to choose one intervention toward multidisciplinary programs where we offer interventions in combination,” Dr. Acosta said, recommending AGA’s POWER - Practice Guide on Obesity and Weight Management Education and Resources . Other AGA resources for physicians treating patients with obesity include the AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity , and the Obesity Resource Center on the AGA website .
Progress in Pharmacotherapy
In recent years, developments focused on glucagon-like peptide 1 (GLP-1) receptor agonists, such as semaglutide and tirzepatide, have “changed the conversation about obesity,” Dr. Acosta said. For the first time, medications not only reduce weight but also cardiovascular disease risks, which were previously only observed with bariatric surgery.
Additional GLP-1 options are in research pipelines. During the next 3 years, for instance, more medications will focus on how the gut signals to the brain through intestinal hormones, targeting GLP-1, glucose-dependent insulinotropic polypeptide, and other receptors. Leading the pipeline, Eli Lilly’s retatrutide shows promise, with weight loss and comorbidity improvement reported similar to or better than tirzepatide. Additional data from phase 3 trials are forthcoming.
In clinical practice, major conversations remain about gastrointestinal side effects, particularly gastroparesis, that may pose a risk for aspiration in upper endoscopy. Gastroenterologists should feel comfortable about managing these types of side effects when starting patients on these medications, Dr. Acosta said, but also continue to ask questions about side effects and the latest research developments.
Of course, major obstacles remain regarding patient access, insurance coverage, cost-effective options, and heterogeneous patient responses. At the Mayo Clinic, Dr. Acosta and colleagues are researching and targeting obesity phenotypes — such as the “hungry gut” or “hungry brain” — to improve weight loss outcomes and patient adherence.
Ultimately, he said, the most important obstacle is our healthcare system. “We cannot afford to manage obesity with expensive procedures or expensive medications.”
