Multiple Specialties COMMiT to Managing Obesity

At a Glance

  • One in 20 adults is considered extremely obese.
  • A multidisciplinary team at NewYork-Presbyterian came together to offer patients a range of expertise related to obesity under one umbrella of care to can help them achieve their weight loss goals.
  • Researchers focus on the neurohormonal regulation of body weight, appetite, and glucose homeostasis­ with forms of weight reduction, including diet and bariatric surgery.

“People describe obesity as though it is a single disease, but it isn’t. If we can identify factors that contribute to an individual’s obesity, we can then target the right therapy for them.”

Judith Korner, MD, PhD

“Obesity is a chronic disease with many health consequences of which diabetes, cancer, liver and kidney disease, and sleep apnea are but a few examples,” says Marc Bessler, MD, Chief of the Division of Minimal Access/Bariatric Surgery and the Director of the Center for Metabolic and Weight Loss Surgery at NewYork-Presbyterian/Columbia University Medical Center. “Its incidence is startling. More than one-third of the American adult population is obese. One in 20 adults is considered extremely obese.”

To address this multifaceted public health issue, Dr. Bessler and his colleagues in GI surgery and interventional endoscopy, endocrinology, psychology, nursing, and nutrition have come together to create COMMiT – Comprehensive Obesity and Metabolism Management and Treatment – to offer patients a range of expertise related to obesity under one umbrella of care and to integrate the newest medical, endoscopic, and surgical treatments that can help them achieve their weight loss goals.

“There are almost as many reasons why people become overweight as there are people who are overweight,” says Dr. Bessler. “The COMMiT team understands the social, emotional, and behavioral factors in an individual’s life and environment that can affect their weight and their health. We work with patients to develop safe and effective strategies on several fronts. In addition to promoting healthier nutrition and lifestyle choices, we can recommend the latest medications, nonsurgical procedures, or minimally invasive surgery.”

The Endocrine Connection

“People describe obesity as though it is a single disease, but it isn’t,” says Judith Korner, MD, PhD, an endocrinologist in the Division of Endocrinology and Metabolism and Director of the Weight Control Center at NewYork-Presbyterian/Columbia. “If we can identify factors that contribute to an individual’s obesity, we can then target the right therapy for them.”

Dr. Korner’s research – both NIH and industry funded – is focused on the neurohormonal regulation of body weight, appetite, and glucose homeostasis­ with forms of weight reduction, including diet and bariatric surgery. “Some individuals­ can eat a slice of pizza and feel full, and some individuals need a whole pizza to feel full. This is not just a matter of willpower,” says Dr. Korner. “It may be due to a deficiency in the individual’s reward center or the hypothalamus. Researchers now realize that the gastrointestinal tract is comparable to a huge endocrine organ, with dozens of different hormones secreted from the stomach, the small intestine, and the large intestine. They not only help regarding processing food that is consumed, but hormones also regulate the brain to control hunger, satiety, metabolism, and how the body manages insulin.”

Dr. Korner explains, for example, that the ghrelin hormone in the stomach increases hunger. In the large intestine, the hormones GLP-1 and PYY signal fullness. Some of the hormones have multiple roles, so in addition to signaling fullness or hunger, they may also be related to insulin secretion and insulin sensitivity, creating an overlap between weight control and glucose control. One of the avenues of research that Dr. Korner is therefore pursuing is the relationship of bariatric surgery to metabolic benefit and, in particular, type 2 diabetes. The question she seeks to answer is: Does weight loss alone produce metabolic improvement or does the particular surgery change the types and the number of hormones that control blood sugar?

“Individuals can have the same surgery and the same surgeon, and some of them will lose a lot of weight and some will not,” notes Dr. Korner. “Likewise diabetes will go into remission with normal glucose control for some patients, while others are more resistant. Results are very individualized. So to try to identify the response of one person, either to a particular medication or a particular type of surgery, is very important. Our goal is to develop a hormone profile based on the outcomes of these surgeries to be able to triage patients to the surgery that is best suited for their metabolic condition.”

Dr. Korner also serves as the principal investigator of two major clinical trials: an NIH-funded trial to study the effects of leptin administration after gastric bypass surgery on body weight and neuroendocrine function and a multicenter randomized trial of medical management versus gastric bypass surgery for the treatment of diabetes.

Moving Toward the Minimally Invasive Arena

“The role of the gastroenterologist in bariatrics is evolving with new and exciting endoscopic weight loss procedures,” says Tamas A. Gonda, MD, a gastroenterologist at NewYork-Presbyterian/ Columbia with particular expertise in therapeutic endoscopy.

Dr. Gonda notes that in the last two years several procedures—all of which are available at Columbia—have received FDA approval. “We currently offer the intragastric balloon procedure, aspiration therapy, and endoscopic sleeve gastroplasty,” he says. “By working together with the surgeons and the medical weight loss team, we can tailor therapy to shift from an endoscopic procedure to a surgical procedure, as well as add medications or nutritional counseling.”

The FDA has approved intragastric balloons, some that are placed endoscopically and others that are swallowed and removed endoscopically. The COMMiT program offers both of these. This incisionless, non-surgical procedure is recommended for adults with a BMI of 30 to 40, with or without a weight-related comorbidity, who have tried alternative weight loss methods without durable success. “The balloon is placed in a simple, outpatient procedure that takes less than an hour and does not require general anesthesia,” says Dr. Gonda. “Patients lose about 15 percent of their starting weight, over 30 pounds on average, over a period of six months. After adapting to the balloon, more than 96 percent of patients tolerate it well, and the weight loss success rate is over 98 percent.”

According to Dr. Gonda, the balloon procedure has been performed on thousands of patients. “The balloon is in place for six months and then is completely removed,” says Dr. Gonda. “However, that has its advantages and disadvantages. There can be significant weight gain afterward if the person returns to their previous eating habits. The other procedures, which have been performed in smaller clinical trials in several hundred patients, are either permanent, like the gastroplasty, or have a longer duration.

“The aspiration device is a recently FDA approved option, and it has a wider BMI range,” continues Dr. Gonda. “In general, today’s endoscopic procedures are meant and approved for those at the lower end of the obesity spectrum. This may change as these procedures evolve and we begin to understand the benefit of repeated procedures to manage this chronic condition.”

Dr. Gonda and his colleagues also treat patients with complications from prior bariatric interventions or surgeries.

“Endoscopic management of bariatric surgical complications offers an incredible advantage over reoperations and other much more morbid interventions,” he says. “These are patients who’ve had difficult surgical situations. Repeating their surgery is not easy. However, our team has the medical knowledge and the endoscopic and surgical expertise to manage any complications.”

“The trend, in general,” Dr. Bessler says, “has been toward less invasive therapy for obesity as patients often do not want surgery.

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