On the last day of the 8th Annual Obesity Symposium here in Norderstedt, Germany, Marco Bueter from the University of Zurich presented a fascinating series of studies (just published in Circulation), demonstrating the “weight-independent” benefits of gastric bypass surgery on endothelial function (using an animal model).
Besides showing that 8 days after bypass surgery rats with diet-induced obesity had higher plasma levels of bile acids and GLP-1, that were associated with improved endothelium-dependent relaxation, not seen in sham-operated weight matched controls, but also that these effects could be prevented by blocking GLP-1 receptors with exendin 9-39.
In contrast, similar effects to those seen on vascular function in bypass rats were seen in sham-operated rats treated for 8 days with the GLP-1 analogue, liraglutide, or as the authors describe it,
“liraglutide restored NO bioavailability and improved endothelium-dependent relaxations and HDL endothelium-protective properties, mimicking the effects of RYGB”
Together these studies suggest that GLP-1 may well play an important causal role in the improved vascular function seen in patients undergoing gastric bypass surgery.
These findings are all the more interesting as liraglutide has now been approved for obesity treatment in the USA, Canada and Europe.
While these data are certainly not enough to describe liraglutide as “surgery in a pen”, they are indeed promising in terms of potential benefits of this treatment that may well be weight independent.
All the more reason to anticipate the outcome of the ongoing LEADER trial, which is currently evaluating the effect of liraglutide treatment on cardiovascular outcomes in patients with type 2 diabetes.
Disclaimer: I have served as a paid consultant and speaker for Novo Nordisk, the maker of liraglutide.
Getting reliable blood pressure readings in patients with obesity can pose a problem, even when extra-large cuffs are available. An often discussed alternative is the use of forearm readings using a regular cuff, but the reliability of these readings remains unknown.
Now a study by Marie-Eve Leblanc and colleagues from the University of Laval, Quebec, Canada, published in Blood Pressure Monitoring, shows that forearm measurements with an oscillometric device can be reliably measured and are highly predictive of intra-arterial blood pressure measurements in patients with sever obesity.
The study involved 25 participants with an average BMI of 50.9kg/m2. Overall, sensitivity (0.98) and predictive values (0.93) for the presence of systemic hypertension were excellent, indicating that the forearm approach is a promising alternative to systemic hypertension diagnosis in severe obesity.
This may well simplify blood pressure measurements in patients presenting with severe obesity, where upper arm measurements may be difficult.
Even, if one were to limit more intense obesity management (such as behavioral, pharmacological and/or surgical treatments) to those with more severe obesity (Edmonton Obesity Staging System 2+), this would still overwhelm the capacity of existing tertiary care systems.
Thus, as William Dietz and colleagues point out in their recent article in the 2015 Lancet Obesity Series, even the majority of severe (or complicated) obesity will still need to be managed in primary care.
“Care for adults with severe obesity has generally been delivered in tertiary-care centres. Although such programmes are efficacious, they are poorly suited to address the number of patients with severe obesity. Alternative approaches for the management of adults with severe obesity include primary-care settings or community settings to deliver care.”
“Transition from efficacy to effectiveness will require substantial and challenging changes in how primary care is delivered. Practices often lack the organisational structure, such as patient registries and methods for systematic tracking to assess clinical interventions, care teams to manage patients with chronic illnesses, or health information systems that support the use of evidence-based practices at the point-of-care to provide longitudinal care for chronic illnesses.”
Where they exist, these structures are already at capacity dealing with other chronic diseases including diabetes, hypertension, COPD and other lifelong disorders.
Even if many of these problems are directly related to excess weight (or would at least substantially improve with weight loss), most primary care practitioners have yet to take on the challenge of managing obesity (not just the obese patient).
Surely enthusiasm for obesity management will increase in primary care settings as more effective obesity treatments become available – making these available to those who stand to benefit, needs to be a key priority of health care system planners and payers.
The fact that many payers chose not to cover obesity treatments by delegating this to the category of “lifestyle”, shows that they have yet to take obesity seriously as a chronic disease in its own right.
It may also demonstrates their biases and discrimination of people living obesity – after all the same payers have no problem shelling out billions of dollars to treat other “lifestyle” disorders like strokes, heart attacks, type 2 diabetes or COPD.
This is where health policies can and should make a difference to people living with obesity – the sooner, the better.
For all my Canadian readers (and any international readers planning to attend), here just a quick reminder that the deadline for early bird discount registration for the upcoming 4th Canadian Obesity Summit in Toronto, April 28 – May 2, ends March 3rd.
To anyone who has been at a previous Canadian Summit, attending is certainly a “no-brainer” – for anyone, who hasn’t been, check out these workshops that are only part of the 5-day scientific program – there are also countless plenary sessions and poster presentations – check out the full program here.
To register – click here.
It would hardly come as a surprise to regular readers that I would be delighted to see the Edmonton Obesity Staging System featured quite prominently in the article on obesity management by Dietz and colleagues in the 2015 Lancet series on obesity.
Here is what the article has to say about EOSS:
“The Edmonton obesity staging system (EOSS) has been used to provide additional guidance for therapeutic interventions in individual patients (table 1). EOSS provides a practical method to address the treatment paradigm. In principle, EOSS stages 0 and 1 should be managed in a community and primary care setting. Recent data from the USA suggest that 8% of patients with severe obesity (BMI ≥35 kg/m²) account for 40% of the total costs of obesity, whereas the more prevalent grade 1 obesity accounts for a third of costs. These findings suggest that greater priority should be accorded to EOSS stages 3 and 4, resulting in greater focus on pharmacological and surgical management delivered in specialist centres.”
These recommendations are not surprising, as EOSS was specifically designed to provide a much better representation of how “sick” a patient is rather than just how “big” she is.
This is why EOSS has now found its way not just into the 5As of Obesity Management framework of the Canadian Obesity Network but also into the treatment algorithm of the American Society of Bariatric Physicians.
To download a slide presentation on how EOSS works click here.