Transcript
Dr. Buch:
This is GI Insights on ReachMD. I'm Dr. Peter Buch, and today I'm joined by Dr. Devika Umashanker to discuss how we can integrate medical and surgical approaches in the treatment of obesity. Dr. Umashanker is the Program Director of the Obesity Medicine Fellowship at Hartford HealthCare and an Associate Professor of Internal Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University.
Welcome back to the program, Dr. Umashanker.
Dr. Umashanker:
Thank you for having me again. It's a pleasure to be back.
Dr. Buch:
It's our delight. To set the stage for our discussion, Dr. Umashanker, why aren't lifestyle interventions and medical therapies enough for some patients to achieve sustained weight loss?
Dr. Umashanker:
With lifestyle interventions and medical therapy, I think the biggest challenge we experience is the changes patients and individuals have with satiety cues and craving cues that make it very difficult to sustain the weight loss that they achieved. Many times, we see changes in hunger hormones that make us feel full that go in lower amounts as people continue to lose weight, and the hunger hormones, for example, ghrelin, increase significantly when someone loses weight. So biologically, it's very different due to that dysregulation of hormone that patients experience to sustain the weight loss that they achieved, whether it be through lifestyle interventions or pharmacotherapy, even with the newer GLP-1 medications that we are now using with our patients.
Dr. Buch:
And as a follow-up for that, Dr. Umashankar, what effect do you think screen time has with regard to this entire process?
Dr. Umashanker:
I think many times with screen time, we know that there are challenges with the sedentary lifestyle that impacts weight loss outcomes and weight loss maintenance. Many times, when patients are enrolled in our program and we are talking about medical therapy and nutrition and physical activity, we see that physical activity tends to be the more challenging lifestyle intervention to sustain over time.
But the complexity of that is when people do not engage in a physical activity program, the weight loss that they achieve is very difficult to sustain. And now what we are also noticing, especially with these more powerful medications that are available, such as GLP-1 therapy or incretin therapy, is it starts affecting body composition. And unless you have a physical activity element or program involved in your weight management treatment program, even if you're losing weight, you may not be losing the correct body composition. It may potentially be muscle mass and not necessarily fat mass, and that's what we're hoping to achieve when we are thinking about weight management and weight loss therapies.
Dr. Buch:
When you're evaluating patients with obesity, are there circumstances in which you consider proceeding directly to surgery rather than trying medications first?
Dr. Umashanker:
Absolutely. When I think about treatment options, I try to think of it less like a ladder approach, where it's medical therapy, and if that fails, then do surgical interventions. I think of it more as a multimodal approach where we can use medical therapy and bariatric surgery to get the best outcomes. Of course, there are patients, for example, who may have higher BMIs who would benefit from surgical intervention as first-line therapy and use medical therapy as adjunctive to their treatment plan, or even individuals who may have specific weight-related comorbidities such as type 2 diabetes or severe reflux, who just may benefit from surgery as the first line versus medical therapy as the first line.
Dr. Buch:
That's a perfect segue to our next question. For patients who are candidates for surgery, how do sleeve gastrectomy and Roux-en-Y gastric bypass compare, and how can we determine which procedure may be more appropriate for an individual patient?
Dr. Umashanker:
Both such powerful procedures. Sleeve gastrectomy in general gives about 20 to 25 percent total body weight loss, where 80 percent of the stomach is removed, and the stomach that is in that portion is more of a banana-shaped intestine. And that weight loss that people achieve is pretty significant. With Roux-en-Y gastric bypass, people lose about 30 to 35 percent, and a pouch is formed as well as rerouting of intestines.
And when you think about both procedures and which may benefit, I think you go back to individualized therapy and their medical history. So for example, someone with severe reflux may not benefit from a sleeve gastrectomy; they may just do better with a Roux-en-Y gastric bypass. Lots of literature has been published around people with type 2 diabetes and remission with Roux-en-Y gastric bypass. I've also seen patients with higher BMIs, and when I think about higher BMIs, I'm thinking about 50, 60, 70, that may benefit from a Roux-en-Y gastric bypass and sleeve gastrectomy.
So when we think, as physicians, about which surgery procedure may be beneficial, I think it comes down to medical history. I think it comes back down to individualized therapy and collaborative decision-making with the surgical team in terms of what would be the best option for the patient.
Dr. Buch:
For those just joining us, you're listening to GI Insights on ReachMD. I'm Dr. Peter Buch, and I'm speaking with Dr. Devika Umashanker about medical and surgical approaches to caring for patients with obesity.
So Dr. Umashanker, how often do patients undergoing bariatric surgery also need medications for weight management?
Dr. Umashanker:
I think it's becoming very common in our clinical practice. We see it in two parts. The first part is we see preoperative weight loss. And when we think about surgical interventions or surgical management, we see it not only in bariatric surgical patients, but we also see it in our orthopedic surgical patients, where having a certain BMI is helpful in terms of improving post-op complications and getting the patient more optimized for surgery in itself.
But in addition to preoperative weight loss where we utilize medical therapy, it's become a common practice also to use it post-operatively for patients to maintain the weight loss that they achieved. And once again, we see this even in our bariatric patients or patients for orthopedic intervention, and sometimes even in some of our transplant patients where we are looking to see where we have seen utilizing these medications can be quite helpful in maintaining the weight loss that they achieved.
Dr. Buch:
Thank you. So moving on, under what circumstances do you consider medications other than GLP-1 based therapies?
Dr. Umashanker:
I think that's such an important question because now, many times we are seeing people talk about GLP-1 medication so often. I sometimes feel like the first-generation medications like phentermine, topiramate, naltrexone, and bupropion are forgotten. And these medications were quite effective before GLP-1 came into the landscape. It's these medications that I was trained with and was taught by my directors on appropriate usage of prescribing methods.
There are times that we consider these medications when GLP-1 is not appropriate. It could be, for example, side effects that they may have experienced on GLP-1 medications or based on medical history and family history. For example, if someone was to have family history of medullary thyroid carcinoma, it may not be appropriate to use GLP-1, so that helps us stratify other medications to utilize. And also, we look at medical history. That's really what it comes down to in patient's previous experience. But I think if I don't talk about insurance coverage and cost, it would not be practical in terms of what we're experiencing on the clinical end of how sometimes that ends up governing what we decide as treatment options for our patients.
Dr. Buch:
Thank you so much. We're in the last few moments of our conversation, Dr. Umashanker. Do you have any additional thoughts you'd like to share on this topic?
Dr. Umashanker:
Yeah. As obesity medicine has changed over the years I've been in practice, one thing I can share with you is GLP-1 medications have really brought into the forefront the treatment of obesity. But when we think about obesity treatment, I think it's important to get away from specific numbers and what's on the scale, but rather look at it more broadly in terms of how weight loss is improving weight-related comorbidities, how this is improving body composition, and really coming back to the science of obesity medicine, which is where I think everything starts from to begin with.
Dr. Buch:
Dr. Umashanker, thanks so much for this very informative conversation. It was great having you on the program again.
For ReachMD, I'm Dr. Peter Buch. To access this and other episodes in this series, visit GI Insights on ReachMD.com, where you can be part of the knowledge. Thanks for listening and looking forward to learning with you again very soon.