Martin Fried

Management of Obesity in Adults: European Clinical Practice Guidelines

The development of consensus guidelines for obesity is complex. It involves recommending both treatment interventions and interventions related to screening and prevention. With so many publications and claims, and with the awareness that success for the individual is short-lived, many find it difficult to know what action is appropriate in the management of obesity. Furthermore, the significant variation in existing service provision both within countries as well as across the regions of Europe makes a standardised approach, even if evidence-based, difficult to implement. In formulating these guidelines, we have attempted to use an evidence-based approach while allowing flexibility for the practicing clinician in domains where evidence is currently lacking and ensuring that in treatment there is recognition of clinical judgment and of regional diversity as well as the necessity of an agreed approach by the individual and family. We conclude that i) physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment, ii) treatment should be based on good clinical care and evidence-based interventions and iii) obesity treatment should focus on realistic goals and lifelong management.

Interdisciplinary European guidelines on metabolic and bariatric surgery

In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Inter-disciplinary European guidelines on surgery of severe obesity.

In 2005, for the first time in European history, an extraordinary Expert panel named ‘The BSCG’ (Bariatric Scientific Collaborative Group), was appointed through joint effort of the major European Scientific Societies which are active in the field of obesity management. Societies that constituted this panel were: IFSO – International Federation for the Surgery of Obesity, IFSO-EC – International Federation for the Surgery of Obesity – European Chapter, EASO – European Association for Study of Obesity, ECOG – European Childhood Obesity Group, together with the IOTF (International Obesity Task Force) which was represented during the completion process by its representative. The BSCG was composed not only of the top officers representing the respective Scientific Societies (four acting presidents, two past presidents, one honorary president, two executive directors), but was balanced with the presence of many other key opinion leaders in the field of obesity. The BSCG composition allowed the coverage of key disciplines in comprehensive obesity management, as well as reflecting European geographical and ethnic diversity. This joint BSCG expert panel convened several meetings which were entirely focused on guidelines creation, during the past two years. There was a specific effort to develop clinical guidelines, which will reflect current knowledge, expertize and evidence based data on morbid obesity treatment.

Interdisciplinary European Guidelines on metabolic and bariatric surgery.

In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity - European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present presidents together with EASOs OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the subsequent changes that have taken place in patient eligibility criteria. The expert panel composition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

European Guidelines for Obesity Management in Adults

Obesity is a chronic metabolic disease characterised by an increase of body fat stores. It is a gateway to ill health, and it has become one of the leading causes of disability and death, affecting not only adults but also children and adolescents worldwide. In clinical practice, the body fatness is estimated by BMI, and the accumulation of intra-abdominal fat (marker for higher metabolic and cardiovascular disease risk) can be assessed by waist circumference. Complex interactions between biological, behavioural, social and environmental factors are involved in regulation of energy balance and fat stores. A comprehensive history, physical examination and laboratory assessment relevant to the patients obesity should be obtained. Appropriate goals of weight management emphasise realistic weight loss to achieve a reduction in health risks and should include promotion of weight loss, maintenance and prevention of weight regain. Management of co-morbidities and improving quality of life of obese patients are also included in treatment aims. Balanced hypocaloric diets result in clinically meaningful weight loss regardless of which macronutrients they emphasise. Aerobic training is the optimal mode of exercise for reducing fat mass while a programme including resistance training is needed for increasing lean mass in middle-aged and overweight/obese individuals. Cognitive behavioural therapy directly addresses behaviours that require change for successful weight loss and weight loss maintenance. Pharmacotherapy can help patients to maintain compliance and ameliorate obesity-related health risks. Surgery is the most effective treatment for morbid obesity in terms of long-term weight loss. A comprehensive obesity management can only be accomplished by a multidisciplinary obesity management team. We conclude that physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment. Treatment should be based on good clinical care, and evidence-based interventions; should focus on realistic goals and lifelong multidisciplinary management.

Effects of biliopanceratic diversion on type 2 diabetes in patients with BMI 25 to 35.

Objective:Biliopancreatic diversion (BPD) resolves type 2 diabetes in near totality of morbidly obeses [BMI (body mass index) ≥35 kg/m2]. However, studies of BPD effect in BMI range 25.0 to 34.9 kg/m2, including about 90% of diabetic patients, are lacking. Materials and Methods:If BPD effects are independent of weight changes, they should be maintained in patients who, being mildly obese or overweight, will lose little or no weight after operation. Thirty type 2 diabetic patients with BMI 25 to 34.9 were submitted to BPD and monitored 12 months. Thirty-eight diabetic patients selected from a large database, kept 1 year on medical therapy, served as controls. Results:Nineteen male and 11 female. Mean age 56.4 ± 7.4 years, weight 84.8 ± 11.1 kg, BMI 30.6 ± 2.9 kg/m2, waist circumference 104 ± 9.4 cm, diabetes duration 11.2 ± 6.9 years, HbA1c 9.3±1.5. Twelve patients on insulin. Fifteen (2 F) with BMI < 30 (mean: 28.1). No mortality or major adverse events occurred. BMI progressively decreased, stabilizing around 25 since the fourth month, without excessive weight loss. One year after BPD, mean HbA1c was 6.3%±0.8, with 25 patients (83%) controlled (HbA1c⩽7%) on free diet, without antidiabetics, and the remaining improved. Acute insulin response to intravenous glucose had increased from 1.2 ± 2.9 to 4.2 ± 4.4 &mgr;IU/mL. Diabetes resolution correlated positively with BMI. HbA1c decreased at 1 year in the control group, along with an overall increased amount of antidiabetic therapy. Conclusions:BPD improves or resolves diabetes in BMI 25 to 35 without causing excessive weight loss, its action being on insulin sensitivity and beta-cell function. The strikingly different response between morbidly obese and low BMI patients might depend on different beta-cell defect. ClinicalTrials.gov Identifier: NCT00996294

Interdisciplinary European guidelines on surgery of severe obesity.

In 2005, for the first time in European history, an extraordinary expert panel named BSCG (Bariatric Scientific Collaborative Group), was appointed through joint effort of the major European scientific societies which are active in the field of obesity management. Societies that constituted this panel were: IFSO – International Federation for the Surgery of Obesity, IFSO-EC – International Federation for the Surgery of Obesity – European Chapter, EASO – European Association for Study of Obesity, ECOG – European Childhood Obesity Group, together with the IOTF (International Obesity Task Force) which was represented during the completion process by its representative. The BSCG was composed not only of the top officers representing the respective scientific societies (four acting presidents, two past presidents, one honorary president, two executive directors), but was balanced with the presence of many other key opinion leaders in the field of obesity. The BSCG composition allowed the coverage of key disciplines in comprehensive obesity management, as well as reflecting European geographical and ethnic diversity. This joint BSCG expert panel convened several meetings which were entirely focused on guidelines creation, during the past 2 years. There was a specific effort to develop clinical guidelines, which will reflect current knowledge, expertise and evidence based data on morbid obesity treatment.

Literature review of comparative studies of complications with Swedish band and Lap-Band.

Background: Gastric restriction is a treatment option for morbid obesity. Currently there are several types of adjustable gastric bands available, with two leading but conceptionally different systems, not just from a technical point of view but also from the long-term complication rates. Methods: A literature search of articles published from January 1997 to December 2002 dealing with prospective or restrospective studies comparing results of treatment with the Swedish band and LapBand® was carried out. Results: 7 comparative studies fulfilled inclusion criteria, with a total of 1,031 patients in the Swedish band (41-597) and 1,305 patients in the Lap-band® groups (34-821). Pouch dilatation/slippage and/or erosion in Swedish vs Lap-band® were reported in the studies as follows: 1 vs 2 in study group 1, 0 vs 9 in study group 2, 0 vs 3 in 3, 3 vs 38 in 4, 0 vs 64 (slippages) and 4 vs 4 (erosions) in group 5. In study 6, 3 vs 3 dilatations and 0 vs 1 erosions were reported. Study 7 found 12 vs 42 long-term complications of this origin. Port-site infections, total reoperation rates and length of hospital stay were also compared. Conclusion:The results of this meta-analysis reveal that fall in BMI is similar with both laparoscopic bands. Long-term complication rates, despite the fact that they have been defined in a similar way in all the included studies, may be higher with more reoperation rates in Lap-band® patients.

Assessment of the Outcome of Laparoscopic Nonadjustable Gastric Banding and Stoma Adjustable Gastric Banding: Surgeon's and Patient's View

Background: The results of nonadjustable gastric banding (NAGB) and stoma adjustable gastric banding (SAGB) in the treatment of morbid obesity are compared. Of 300 patients operated laparoscopically with NAGB since 1993 and of 25 with SAGB since 1994, 65 in the NAGB and 11 in the SAGB group were available for a 3-year follow-up study. Methods: For assessment of the outcome of our laparoscopic approach in terms of weight loss, length of hospitalization, immediate and late postoperative wound complications, postoperative changes in the band and pouch area, were compared in patients from both groups. The patients opinion on the outcome of the operation and the quality of postoperative digestion was recorded. Results: There was no significant difference in the length of hospital stay and wound complication rate in the two groups or the weight loss at 36 months after surgery. There was a statistically significant lower incidence of postoperative food intolerance and vomiting and a lower rate of immediate and long-term reoperation rate in the SAGB group. Conclusion: SAGB is a method with less postoperative complications in food intolerance and vomiting in comparison with NAGB.

Does the Laparoscopic Approach Significantly Affect Cardiac Functions in Laparoscopic Surgery? Pilot Study in Non-Obese and Morbidly Obese Patients

Background: Laparoscopy in bariatric surgery represents a modern method generally associated with lower morbidity and mortality,compared with the traditional surgical approach. However, in patients with impaired cardiovascular function, the laparoscopic approach is limited by the potential adverse hemodynamic impact.We assessed the influence of some laparoscopic procedures on selected cardiac functions in significantly obese patients and in subjects with normal body weight, using transesophageal echocardiography (TEE). Patients and Methods: Six subjects with normal body weight (mean BMI 25.3 ± 3.6 kg/m2), and six patients undergoing laparoscopic gastric banding for morbid obesity (mean BMI 45.8 ±7 .5 kg/m2) were studied. Heart rate (HR), blood pressure (BP), ejection fraction, cardiac output (CO) and transmitral flow were measured. Parameters were recorded at baseline before the operation (BL), after installation of capnoperitoneum (CP), and after positioning the patient for surgery (SP). Results: Compared to BL, CP and SP were characterized by an increase in HR and BP in both groups of patients. As ejection fraction did not change significantly, the HR changes were accompanied by an increase in CO: (BL 5.8 ± 2.2 l/min, CP 6.5 ± 2.6 l/min, SP 6.7 ± 2.7 l/min, p<0.05 BL vs CP and SP). Transmitral flow parameters did not change significantly. Hemodynamic changes in subgroups with normal body build and in the obese patients were comparable.There was an increase in CO and pressure-rate product in obese individuals. Conclusions: Our results suggest that the hemo dynamic response to laparoscopic surgery is characterized by an increase in CO (due to increased HR) and BP. In subjects without a manifest cardiovascular disease, neither systolic nor diastolic performance was significantly affected by the introduction of capnoperitoneum and positioning of the patient for surgery. Similar results were observed in obese and non-obese subjects. Phase II of this on-going study is focusing on impact and safety of laparoscopy in obese patients with known cardiovascular disease.