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