A working paradigm for the treatment of obesity in gastrointestinal practice

Effect of endoscopic sleeve gastroplasty on gastric emptying, motility and hormones: a comparative prospective study

OBJECTIVE

Endoscopic sleeve gastroplasty (ESG) has gained global adoption but our understanding of its mechanism(s) of action and durability of efficacy is limited. We sought to determine changes in gastric emptying (GE), gastric motility (GM), hormones and eating behaviours after ESG.

DESIGN

A priori-designed single-centre substudy of a large US randomised clinical trial, adults with obesity were randomised to ESG or lifestyle interventions (LS) alone. We measured GE, hormones and weight loss and assessed eating behaviours. In a subset of ESG patients, we assessed GM. The primary outcome was the change in T1/2 (min) at 3 months, and secondary outcomes were changes in weight, GE, GM, hormones and eating behaviours. We used t-test analyses and regression to determine the association between GE and weight loss.

RESULTS

36 (ESG=18; LS=18) participated in this substudy. Baseline characteristics were similar between the two groups. At 3 months, T1/2 was delayed in the ESG group (n=17) compared with the LS group (n=17) (152.3±47.3 vs 89.1±27.9; p<0.001). At 12 months, T1/2 remained delayed in the ESG group (n=16) vs control group (n=14) (137±37.4 vs 90.1±23.4; p<0.001). Greater delays in GE at 3 months were associated with greater weight loss. GM was preserved and fasting ghrelin, glucagon-like peptide 1 and polypeptide YY significantly increased 18 months after ESG.

CONCLUSION

ESG promotes weight loss through several key mechanistic pathways involving GE and hormones while preserving GM. These findings further support clinical adoption of this technique for the management of obesity.

TRIAL REGISTRATION NUMBER

NCT03406975.

Intermittent Fasting and Metabolic Health: From Religious Fast to Time-Restricted Feeding

Over the past 10 to 15 years, intermittent fasting has emerged as an unconventional approach to reduce body weight and improve metabolic health beyond simple calorie restriction. In this review, we summarize findings related to Ramadan and Sunnah fasting. We then discuss the role of caloric restriction not only as an intervention for weight control, but importantly, as a strategy for healthy aging and longevity. Finally, we review the four most common intermittent fasting (IF) strategies used to date for weight management and to improve cardiometabolic health. Weight loss is common after IF but does not appear to be different than daily caloric restriction when compared directly. IF may also provide additional cardiometabolic benefit, such as insulin sensitization, that is independent from weight loss. While no specific fasting regimen stands out as superior at this time, there is indeed heterogeneity in responses to these different IF diets. This suggests that one dietary regimen may not be ideally suited for every individual. Future studies should consider strategies for tailoring dietary prescriptions, including IF, based on advanced phenotyping and genotyping prior to diet initiation.

Endoscopic Treatments for Obesity

Purpose of review Endoscopic bariatric therapy (EBT) is a rapidly developing area that has now seen FDA approval of six endoscopic bariatric devices and procedures and there are a number of other novel EBTs progressing through various stages of development with newly published findings. This paper aims to assist readers in either selecting an appropriate therapy for their patient or deciding to incorporate these therapies into their practice. This paper provides an updated review of the available data on EBTs, both FDA approved and not, with a particular focus on effectiveness and safety, as well as guidance for discussing with your patient the decision to use endoscopic therapies. Findings The authors of a large meta-analysis of Orbera concluded its ideal balloon volume to be 600-650 mL. AspireAssist has had favorable effectiveness and safety data published in a large RCT. A large study of endoscopic sleeve gastroplasty has published findings at up to 24 months showing promising durability. Elipse, a swallowed intragastric balloon not requiring endoscopy for either insertion or removal, has had early favorable results published. A magnet-based system for creation of a gastrojejunostomy has published favorable findings from its pilot study. Summary EBTs are safe and effective therapies for weight loss when used in conjunction with lifestyle changes and fill an important gap in the management of obesity. There are now six FDA-approved EBTs available and several more in ongoing trials with favorable early findings. More study is needed to understand the role of EBTs used in combination or in sequence with medications and bariatric surgery.