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Trea%ngObesity:TheWayForward
JosepVidalEndocrinologyandNutri0onDepartment
Ins0tutdeMalal0esDiges0vesiMetabòliquesHospitalClínicBarcelona,Spain
“EUObeseSubjectsBox”
HealthataGlance:Europe2016
Trea0ngObesity:TheWayForwardPrevalenceObesityinEUMemberStates
Thepreven0on
strategy
2011 2014
HealthataGlance:Europe2016
PrevalenceObesityinEUMemberStates
2011 2014
Thetreatmentstrategy
Trea0ngObesity:TheWayForward
Condi%onsassociatedwithobesity
Upto195condi0onshavebeenassociatedwithobesity
Trea0ngObesity:TheWayForward
Thesecondi0onswouldbelesscommonshallobesitybeless
prevalent
TheEndOrganDamageApproach
CurrentApproachtoObesityRelatedCondi0ons
Therapeu0cAlgorithmforType2DiabetesEuropeanAssocia%onsfortheStudyofDiabetes(EASD)
• Focusondrugcombina%onsforglycemiccontrol• Considera%onofweightlossasdesirablesideeffectofhypoglycemicdrugs• Nospecificstrategiesforweightloss
TheEndOrganDamageApproach
CurrentApproachtoObesityRelatedCondi0ons
Isthisthelogicalapproach?
TheCommonGroundApproachImpactofMODESTweightlossonobesity-relatedcomorbidi%es
(%weightlossassociatedwithimprovementofdifferentcondi0ons)
WeightlossandObesityRelatedComorbidi0es
0 2 4 6 8 10 12 14 16
MetabolicsyndromePre-diabetesT2diabetes
HypertensionNAFLD
OSAAsthma
Urinaryincon0nence
Weightlossrela0vetobaselineGarveyetal.EndPrac:ce2016
WeightlossandObesityRelatedComorbidi0es
Obesity-relatedcancersIncidenceandmortalityreduced
Doesn’tthisop%ondeservefurther
aZen%on?
TheCommonGroundApproachImpactofLARGEweightlossonobesity-relatedcomorbidi%es
WeightLossat1YearwithHigh-IntensityLifestyleInterven%onsorPharmacotherapyCombinedwithLow-to-Moderate-IntensityLifestyleCounseling.
HeymsfieldSB,WaddenTA.NEnglJMed2017
NotapprovedbytheEMA
NotapprovedbytheEMA
CurrentOp0onsforaWeightCenteredApproach
TheLookAheadTrial(RCT:intensiveLIIversuscontrolgroupin5145subjectswithT2D,andBMI36kg/m2)
HighIntensityLifestyleInterven0oninpa0entswithDiabetes
WeightChanges
Ini0albenefitsofcurrentlifestyleinterven0onsaredifficulttosustainTheLookAheadResearchGroup.NEngJMed2013
FitnessChanges
TheLookAheadTrial(RCT:intensiveLIIversuscontrolgroupin5145subjectswithT2D,andBMI36kg/m2)
HighIntensityLifestyleInterven0oninpa0entswithDiabetes
DMremissionover4years
Posi0veimpactofWLbutlimitedbecauseofweightregain
GreggEWetal.JAMA2012
IsMODESTweightlossworthlessinT2D?
TheLookAheadResearchGroup.NEngJMed2013
ChangesintheincidenceofCVdisease
TheLookAheadTrial(RCT:intensiveLIIversuscontrolgroupin5145subjectswithT2D,andBMI36kg/m2)
HighIntensityLifestyleInterven0oninpa0entswithDiabetes
Post-hocanalysisbasedontheachievementof>10%WLirrespec%veofthestudygroup
TheLookAheadResearchGroup.Lancet2016
0.4
0.6
0.8
1
1.2
1.4
1.6
<2%loss 2-5%loss 5-10%loss >10%loss
p=0.034Adjusted
Hazardra%o
(95%
CI)
IncidenceofCVDat10y
WeightLossCategoryat1yfollowup
1.00 1.08 1.16
0.79
0
10
20
30
40
50
<2%WL 2-5%WL 5-10%WL >10%WL
Distribu%onofWLcategories%ILI18%47%75%92%%cont82%53%25%8%
• Posi0veimpactofWLonCVD,if>10%WLisachieved• Importanceofiden0fyingrespondersandfactorsassociatedwith↑likelihoodof>10%WL
Fujiokaetal.Diabetologia2014;57(Suppl.1):Abstract904-P
63.1
27.133.1
10.6
49.6
23.724.8
9.9
0
20
40
60
80
Liraglu0de Placebo
>5%WL-12m
>10%WL-12m
>5%WL-36m
>10%WL-36m
ScalePrediabetesTrial
An0-ObesityDrugsStud
ySubjects(%
)
• Effec0veinfacilita0ngtheachievementofWLgoals
WeightLossat1YearwithBariatricSurgeryandLifestyleInterven%onsasComparedwithLifestyleInterven%onsAlone.
BariatricSurgery
HeymsfieldSB,WaddenTA.NEnglJMed2017
BariatricSurgeryandType2Diabetes
-0.6±2.5%
-2,5±1,9%
-2,5±2,1%
STAMPEDETrial-ClevelandClinic:3yearsFU(n=137,Age48y,BMI36,5kg/m2,HbA1cpreQ9,3%,DMdura0on8,3y,InsulinRx43%)
Schaueretal.NEngJMed2014
TimecourseofHbA1cTimecourseofBodyMassIndex
SjostromL,JIntMed2013
SwedishObeseSubjectsStudyControl,n=2037;BariatricSurgery,n=2010(>10yearsfollowup)
1. Majorandsustainedweightlosscomparedtoconven0onaltreatment
2. Reduc0onofallcausemortality
3. Reduc0onofcardiovascularmortalityandincidenceof1stCVevent(fatalornofatal)
4. Preven0onandremissionofdiabetes
5. Reduc0onoftheincidenceofmyocardialinfarc%oninsubjectswithT2D
6. Reduc0onofobesity-relatedcancerincidenceandmortality(inwomen)
7. Improvedqualityoflife
8. Reduc0onofhealthcosts(upto20yearsfollowup)
HealthBenefitsAssociatedwithBariatricSurgery
ApproachinganoverwhealmingtaskToomanypa0ents!
BMIintheobesityrange
HealthImpact
ConcentrateonThosewiththeGreatestHealthImpact
Trea0ngObesity:TheWayForward
Summary
• Tacklingtheobesityepidemicsrequiresac0onbeyondpreven0on• Trea0ngobesityisaneffec0vemeanstoimproveobesity-related
comorbidi0es• Effortsshouldbemadetomakeeffec0vetherapiesavailableto
obesesubjectswithobesity-relatedcomorbidi0es– Althoughhigh-intensitylifestyleinterven0onsareeffec0ve,researchis
neededtobeleruonhowmaketheseinterven0onsfeasible– Moreresearchisneededtosubstan0atethebenefitsofdrug-assissted
weightloss– Effortsshouldbemadetomakebariatricsurgerytoeligiblepa0ents